Change of Shift

Head on over to Doctor Anonymous for this weeks edition of Change of Shift.

ER Top Ten number 10

This is one of my favorite devices. The Level 1 Rapid infuser. At the top is two pressure devices that can squeeze a bag of blood or IV fluid in as fast as the guage of the IV or Central line will allow, often just a couple of minutes. The bottom of the device warms the fluid to body temp, important because hypothermia leads to coagulopathy and patients being infused with large volumes of fluid become cold very quickly.

Despite looking complicated, it is very easy to use, pull the tubing out of the box, spike your IV bags and the tubing pops into two places, conveniently numbered in case you forget. Open the clamp and it self-primes in a couple of seconds and you are ready to go.

Also great for hypothermia resuscitation and massive blood loss, for instance GI bleeders or in the OR.

Cell Phones and why America is going to hell in a handbasket

I hate cell phones. Nothing is so important that you have to be yakking in the damn thing 24 hours a day. I do not enjoy having the person in the bathroom stall next to me talking while peeing, I do not enjoy regularly having to dodge the idiots on the road who are dialing or text messaging instead of driving their car, I do not enjoy those who carry on cell phone conversations while sitting behind me in the movie theater. I do not enjoy hearing the details of your date last night while I am in line at Starbucks. I do not enjoy hearing about the fight you had with your husband while I am waiting for my hair stylist. GET A FUCKING LIFE. (Sorry for the language.)

But on a sadder note, every day I see parents with small children out and about and the parent is yakking on the cell phone instead of being engaged with and spending time with their child. The most precious thing in their life is being completely ignored. Do these retarded people really want their child to grow up and realize that their parent put their cell phone ahead of them?

When you think back to your childhood what are your fondest memories? I remember packing up a picnic lunch on the spur of the moment and taking a drive somewhere we'd never been and having a picnic. I remember spending the day at the lake swimming and eating cupcakes. I don't remember having a lot of things but I do remember spending a lot of time together.

What do you want your kids to remember?

And for more on this topic, read this post at Cranky Epistles. The woman has a way with words.

Lateral Violence

We have had an abnormal surge of patients, in twelve hours we have managed to see almost twice as many patients as normal and admit over 25% of them. We've worked tirelessly to get as many of them dispositioned as possible before night shift comes on and we have the department fairly emptied out when they arrive.

As I am leaving I overhear one of the night shift nurse say to another "they didn't even stock the IV carts, it's not like they are ever busy."

Why do nurses persist on back-stabbing, bad mouthing and sabotaging each other?

ER Top Ten number 9

I'm all for monitoring devices, anything that will monitor my critical patient and free me up to hang meds, titrate drips and assist with procedures is a good thing. Meet the temperature monitoring Foley Catheter. A critical patient needs a catheter to monitor urine output and these come equipped with a built in thermistor that connects to the monitor and continuously monitors my patients core temp. Very handy for hypothermia, blood transfusions, septic and patients under anesthesia. And since they have re-designed the thermistor so it doesn't break so easily, they are even better.

What is Wrong with People?

So one day I was in charge and was walking down the hall and I hear a baby wailing for all it is worth. I briefly wondered what they were doing to the poor thing when I realized that we didn't have any babies as patients right then. So I stuck my head around the curtain to see what the situation was and I see a 20ish female who is in for flu symptoms lying on the gurney with her arm draped over her eyes and across the room is a car seat with a very red-faced, angry baby. Who is just wailing away to beat the band.

I walk into the room and ask her what is the matter with the baby and she tells me she is just too sick to get up and get him. As I recall she was afebrile with a complaint of body aches and congestion. Being polite, I asked her if she was there alone or had someone come to take care of the baby. She told me her boyfriend was coming soon.

I'm a sucker for a baby so I ask if I can pick him up. When I do, he is dripping wet. Anyone familiar with today's pampers that magically turn urine into jello knows that they can hold a hell of a lot of urine before they drip so I assumed he had been in that diaper for awhile. I asked mom if she had a spare diaper and of course she didn't so I got one out of our pediatric supplies and changed him. He was still fussy and mom said he might be hungry but didn't have a bottle so I got one and fed him while waiting for the boyfriend to show up.

So while I thoroughly enjoyed playing with the baby I have to wonder, who would leave the house with an infant and not have any diapers or a bottle. Who would lay there and ignore their screaming infant?

IQ and a permit to reproduce, that is all I have to say.

Grand Rounds

Grand Rounds is hosted by Prudence MD this week, stop by and peruse the med blogosphere's weekly best.

ER Top Ten, Number 8

People who come in to the ER in severe respiratory distress sometimes can't adequately maintain their own airway, it used to be those people would get intubated and put on a ventilator. The problem with that is people with chronic lung disease are difficult to wean back off the ventilator and, as with any other invasive procedure, there are risks of infection. And it is not very pleasant for the patient, having a big plastic tube shoved through their vocal cords, it tends to make them cough and gag, that keeps the ventilator from doing it's job. That makes the patient agitated and they will grab at the tube, trying to get it out so we often have to tie their hands to prevent them from pulling it out. We try to keep them sedated but too heavy sedation interferes with weaning.

Along came BIPAP. A more sophisticated model of it's cousin, CPAP - BIPAP is a machine that is connected to a tightly fitting mask that fits over the patients nose or nose and mouth and delivers positive airway pressure to make it much easier for the patients to breathe. BIPAP has made it possible to avoid intubation in a great number of patients. Because it delivers two levels of positive pressure, a higher one during inhalation to make taking the breath easier and a lower one during exhalation to keep the airways open, it is better tolerated than CPAP that delivers the same amount of pressure all the time.

By helping support patients with compromised airways without having to intubate, BIPAP is one of the best therapies to come to the ER. Non-invasive airway management.

This is the closest I have ever come to barfing from reading. Bleah.

ER Top Ten, number 7

Back in the old days, we used a Sengstaken-Blakemore tube for GI bleeds from ruptured esophageal-varices. As you can see from the picture, there were two balloons, the bigger ballon sat in the stomack and the smaller balloon in the esophagus to put direct pressure on the varices. The end of the tube had an aspiration port as well as the ballon inflation ports, the esophageal ballon was inflated with the aid of a manometer so you could specify how much pressure to have in the esophagus. The end of the tube was then put to some sort of traction, we used to make the patient wear a football helmet and tied the tube to the face guard.

Thankfully with the advent of Vasopressin drips and readily available endoscopy, this tube is relegated to the museum of medical artifacts. Those of us who have used it are not sorry to see it go. To me, endoscopy is one of the greatest things that ever came along for us in the ER. GI bleeds are quickly and definitively treated now and that is much better for the patient.

A Holiday Surprise

For some reason the ER is very busy around the holidays, Christmas eve is usually the worst. Between the nursing homes trying to dump some patients, concerned family members who have just arrived home to find Granny isn't doing so well since they last saw her a year ago and elderly folks that can't stand the thought of being home alone at Christmas - the ER is usually hopping.

That year was no exception. The ER was packed, the waiting room was packed, we were short staffed. Every room was full and the eight permanent hallway beds had been augmented with ten hallway chairs in an effort to get people seen and dispositioned. The staff all had extra patients and we working as fast as they can, fueled by endless Christmas Cookies and pieces of fudge, counting the minutes until we could go home to our own families

About that time, security informed us that there was an eighteen-wheeler pulled into our parking lot and the driver was at the front window, very upset. They were unable to determine the problem because he was non-English speaking. I was not too busy right then so I grabbed a pair of gloves and headed out to the parking lot with the security guard. We were greeted by a young adult male who was visibly agitated and gesturing wildly toward the truck. I could tell that whatever the problem was, it was inside the truck. He did not look in anyway threatening so I approached the truck, when I was about ten feet away I could hear a woman screaming and moaning. I sent the guard in for help and climbed up into the cab. In the sleep space behind he seats was a young woman, obviously in late pregnancy which was confirmed by one glance between her widely spread legs where an infant's head was crowning.

OH SHIT!

I may have mentioned before, ER nurses DO NOT like childbirth. There is blood from places you can't put direct pressure on and wet, slippery infants involved. *shudder*

I climbed into the sleep area, pulling on my gloves. About that time one of the other nurses had come running out. I yelled at her to get the emergency delivery pack and a doctor. I turned back to the mother in time to see the head emerge. I place a my hands underneath just in time to catch the rest of the baby who rocketed out in one push. The whole delivery probably took less than 10 seconds. And there I was, all my worst fears realized, holding a limp, slippery, dusky blue newborn who, BTW, wasn't breathing yet. Fortunately the rest of the team arrived with a suction bulb and warmed towels and receiving blankets. A little suction and a good rubdown and the limp purple baby transformed into a pink, angry, squalling baby. Happy endings all around.

Somewhere out there is a child who's birth certificate bears my signature as the person who delivered the baby. How cool is that?

AND HOPEFULLY THAT WILL NEVER HAPPEN AGAIN!

ER Top Ten, number 5 and 6

The spit hood is an invaluable tool for police, EMS and ER staff. When a patient is highly agitated they come in kicking, hitting and spitting. To avoid injury to ourselves and the patient we quickly secure their hands and feet to the gurney with leather restraints and cover their face with a spit hood.

Agitated delirium can lead to death from hyperthermia, rhabdomyolisis, heart attack etc. so these patients are quickly given a powerful dose of a sedating medication, usually an injection, to get them under control.

Hospital staff, EMS crews and police are at very high risk for injury from these type of patients, ER nurses are injured and killed every year by their patients who are often under the influence of mental illness or drugs. These tools are used to protect us and as soon as the patients are under control, are removed when it is safe for the patient and the staff.

Nothing worse

Heartbreaking, just heartbreaking.

Post Thanksgiving Bliss (and ER top ten number 4)

It was the day after Thanksgiving and all through the ER could be heard, retching and puking. Every so often a privacy curtain is yanked open and the unfortunate soul it was shielding is seen sprinting for the bathroom for another bout of explosive diarrhea. Vomit bags were the most commonly used item in the department today, closely followed by IV boluses of NS and lots and lots of Compazine and Phenergan.

The moral of the Story is......don't eat so much and don't leave food sitting out all day.

(For the uninitiated, the barf bag is a great invention that you hold up to your face and has a one way opening to prevent spills. Also great to keep in the car if you have a child that is prone to car-sickness)

ER Top Ten, number 3

Dermabond, need I say more? How much nicer to glue small lac's instead of sewing them. Especially great for the very common forehead lacerations that small children learning to walk sustain, hold them down, pinch the wound together, glue, dry, glue, dry, glue and done - thirty seconds tops! And since the advent of the pen, it is even easier to use.

Best ER inventions ever, part 2

What can be worse than a critically ill child? Even to seasoned ER professionals it is an extremely anxiety provoking situation. Pediatric doses are complicated and impossible to remember and who wants to try to be doing calculations at a time like that.

Enter the Broselow system. A laminated tape measure quickly tells you which color coded drawer to use. Each drawer is set up with the appropriately sized oxygen delivery, intubation equipment, IV supplies, urinary catheters and NG tubes. Flip the tape over and the doses for that size child are right there, quick and easy. As you can see by this site, manufactures make specialized carts and pre-made modules, but if your ER can't afford them, you can easily assemble the appropriately sized equipment into large ziplock bags and label them by color and just purchase the tapes.

No one likes taking care of critically ill or coding pediatric patients but the invention of this system takes some of the stress out of it.

Top Ten Best Inventions For Emergency Medicine - in no particular order

This is one of the best things on the market. Easy to use, great for EMS and ER personnel alike, the easy IO. It is fast, easy and safe. Every squad and ER should have it.

When I feel like having a pity party.......

When I start feeling sorry for myself I read this blog, makes me realize I don't have it bad at all. Make sure you read the whole post including the top 50 reasons.

On the other hand, it gives me a glimpse into how my son's life must be right now, which is a topic I'd rather avoid. It is much better if I just imagine him on some generic base in some non-sandy country sitting around, being bored and counting the days until he comes home.

I thought of another thing I would institute if I was queen of the universe.....You would have to take an IQ test, score above 110 and get a license before you could reproduce. To get the license you would have to provide proof of income, credit score and verification that you had some kind of family support if there was no father.

For those on Welfare, mandatory Depo shots or voluntary sterilization.

Let's give natural selection a chance. Right now it ain't working because the hard working, college educated people have 0 - 2 children while the unemployed, welfare addicted and drug addled have 3 or more. You do the math.

Get a Job

This post at Monkey Girl got me going.

I think there are too many people who don't have anything to do every day but sit and think about their problems. When you have nothing to take your mind off your real or imagined ills they start to grow in your mind until they are so huge that they obscure everything else. It's like when you wake up at 2 am and start worrying about something. Awake alone in the dare, the problem becomes monumental when in reality, and in the light of day, it is not nearly as bad.

In our society there are too many people who do not work. There is a huge group of people on welfare as well as a surprisingly large contingent of young, able bodied adults who are on disability for such things as 'back pain' and 'fibromyalgia' among others. First of all don't get me going on how they get their disability approved when there are people with real disabilities and serious medical issues get denied.

When you don't work you really don't have anything to do all day but sit around and think about how you don't have any money, your apartment is crap, your clothes are old, you don't every have any money to go anywhere, your car is breaking down. Before you know it you are depressed, often without realizing it. People who are depressed often develop somatic symptoms such as......headaches and back pain. Imagine it, a friend suggests they go to the ER for their pain and they get the magic shot that takes away their physical and mental pain, makes them relaxed and floaty and all their problems magically go away. That's a pretty powerful thing. When the drug wears off their are some pills that do close to the same thing but after a couple of days they are gone and your problems are all back again. It is easy to imagine how people get caught up in this.

I think our society is making a big error in not making people work for their money. Years ago, welfare was time limited and mostly given to people with small children, young able bodied adults were only able to get the dole for a few months. Why did it change? How did an eighteen year old male get to be declared permanently disabled for chronic back pain? Unless it was from some kind of serious accident it just cannot be.

Our society needs to make people work, there is something every one can do. No one should get something for nothing. No one should be allowed to be on welfare for generations, they should have to be in work training or do some kind of work in return for their benefits. All disabled people should be reviewed every three months to determine that they still are truly disabled. Their needs to be more scrutiny of the doctors that are saying these people are disabled.

Before you say what a horrible person I am and how I 'Just don't understand what it's like'..... I have rheumatoid arthritis, I hurt all the time. Funny though, as soon as I get to work and get busy, I don't even think about it. Work makes me feel good, it gives me a sense of self worth. If I was sitting home all I'd be doing is thinking about poor, pitiful me.

Attention: This is the year 2007, you can buy six bars of soap for a dollar at the dollar store, public restrooms abound, most cities have homeless shelters where you can shower and do laundry, if not - there are plenty of streams and rivers.

THERE IS NO EXCUSE FOR BEING DIRTY.

I have sat in triage with people who obvious have not bathed or washed their clothes in months. Jeans that have been worn for so long that the persons body oil has completely soaked through them to give a shiny appearance - usually shiny black from filth. That comes accompanied by the smell of rancid oil and BO. Hair greasy, lank ropes. How do they stand it? Imagine being shut in a small ER room with someone like that. And invariably the chief complain is some sort of discharge from some unwashed part. ER docs, you amaze me with your fortitude. I can stand over to the side with some Vicks under my nose while you are planted square in front of the offending body part.

The most offensive thing to me is when they bring in their babies. Babies not even walking with rings of dirt in their neck folds and suppurating rashes from not having their diapers changed properly. I have seen infants with lice!

How can anyone think that this is OK? Can you really be so lacking in IQ that you don't realize it is not acceptable?

That thing is a BUG?

I found this in my garage today, it was 3" long and clearly in its death throes. I have NEVER seen anything so incredibly disgusting in my life. I screamed so loud that I scared the dog. He spent the rest of the day following me around to ensure that I was OK. His idea of following is to walk three inches behind me so that whenever I change direction I either a)step on him or b)trip over him. Now I am afraid to go out into the garage. As a matter of fact, I'm kind of afraid to go outside either. I'm calling my bug guy first thing in the morning.

Change of Shift

Kim at Emergiblog is hosting Change of Shift this week so head on over there and check out the best posts of the week.

I'm not as dumb as you think I am

I was reading my comments lately and someone cautioned me to watch my apostrophes. I got a good long laugh out of that one. It has been a looooonnnnnggggg time since English and punctuation was never what I would call my strong suit anyway. So let me apologize about not knowing for sure where to put that dang apostrophe, not knowing when to use a semi-colon or a colon and for my tendency to engage in run on sentences. I must drive cranky professor insane!

But seriously. Everyday at work I encounter people who tell me stories that are so patently ridiculous that I can only assume that a) They are complete idiots or b)they think I am a complete idiot.

For instance, I recently triaged a man who came in with a complaint of flank pain, possible kidney stones. During the triage he let it slip that he had been seen at hospital X across town. I asked him why he had not returned there and he told me he had called them and they told him that they wait was very long and told him to go to our hospital. Riigghtt. I often tell people to go see our competitors. So now I'm thinking that he is either lying like a dog or was so horribly obnoxious when he was there that they did suggest he go to another hospital.

Then there is the patient with a migraine who drives 50 miles and bypasses two hospitals to come to ours. When asked why, she states she "doesn't think they know what they are doing" at those hospitals. Sure. So they told you no more narcotics huh?

And the guy with the gunshot in his left buttock who said the gun went off while he was cleaning it. how the heck were you cleaning it behind your back? I think the guy who's store you were robbing probably would tell a different story.

The teenager with abdominal pain who swears she's not pregnant even as the babies head is crowning.

The guy with back pain and 22 ER visits last year for the same thing tells me he didn't get his pain meds filled because he lost the prescription. Or the girl who claims her roommate stole her meds (maybe so but too bad.) Or I accidentally knocked the bottle over and they went down the drain.

I hear all kind of stories but I take a lot of them with a grain of salt. It's not my first day on the playground.

I Hate This

Do managers take special, secret classes in how to best aggravate and stress out their their staff members?

I'm home on my day off, which happens to be a Friday, I've been out running errands and get home after five. I check the answering machine and I have a message from work. It is my manager: "We need to meet on Monday to discuss and issue, please come to my office before I start my shift." Arrrgh! Did you mean to leave that late Friday afternoon so there is no way I can get in touch with you and have to stew and worry all weekend? Of course you did.

So I stew all weekend. What have I done? I thought I was being especially good, I haven't pissed off any of the floor nurses, my patients have all thanked me, I haven't dispositioned too many people to jail so what have I done? Did I make a med error and not realize it? I am fanatical about quadruple checking everything but it is always possible, oh my God, is the patient OK. Now I am freaking out. I don't sleep well either night and my mind is going round and round on the same track. I am cranky with the family and totally stressed out. I have a horrible weekend.

Monday morning I show up way before my shift and spend a half an hour tracking my manager down. I'm so upset my stomach is in knots and I have had several bouts of diarrhea from the stress. We go into the office and she shuts the door. My heart is palpitating. What have I done? Am I going to get fired?

"We have to collect data on pediatric moderate sedation's for PI and I immediately thought of you as I know you have a special interest in that area, would you consider taking that on."

I sit staring at her, blinking in a stupefied fashion as my brain tries to get out of the endless track it has been on for two and a half days. What? You had to call me at home and leave an ominous sounding, cryptic message on Friday for THIS? Do you know how stressed out I have been all weekend? I thought I was in trouble for something for crying out loud.

But do I say any of that? no, I'm too stunned. I agree to take on the PI project and go out to go to work.

Check this guy out, what an imagination. Thanks Mielikki.

Being a rebel

I never get up with the idea that I'm going to cause trouble, I swear I don't, but sometimes I just can't help it.....it's like the devil just moves on in and takes control.

Take today for example. I got up and went to work like any other day. The ER nurses have been a little up in arms lately since we found out that the administration have decided to give the critical care nurses a 5% premium. We were told we are not critical care. Despite the fact that we routinely care for incredibly sick and unstable patients that we STABILIZE before they go to the ICU. Despite the fact that we routinely hold ICU patients because of lack of beds. Some nights it looks like ICU south. But apparently we are not qualified to do so. Fine. We are fighting that one with the union.

So an hour into my shift we get in a trauma patient who is well and truly FUBAR'd. He is so messed up that he can't even go to the OR. The ER is slammed, the waiting room is full and we are on diversion. Another nurse and myself had been working with the Trauma Doc for over an hour to get the patient stabilized. Now he was doing better, with semi stable vital signs but they decided to wait to take him to surgery for his orthopedic injuries. We are going to take him to the ICU when the ICU doc informs us he is "Too unstable to go to the ICU." Huh? I was under the impression that the ICU took care of critically ill people, apparently better than the ER since we aren't "critical care nurses." So of course I said something along those lines to the doc. He was not amused. Neither was my boss who wasted no time telling me so.

I don't go out of my way to agitate and cause trouble, but sometimes I just can't help it. Tomorrow is another day.

For all those who have served in the past and for all those who are currently serving our country my humble and heartfelt thanks.

Thank you for all that you have done, the sacrifices made by you and your families to ensure that I can walk out in public with my face bare, my hair how I want it, my legs exposed when it is hot. Thank you for fighting and dying for this country so that I may bad mouth the government if I so choose without fear of torture or imprisonment. Thank you for the freedom to go to what ever church I believe in without fear of another religious group exterminating me. Thank you for a country where I can work, own a home, have plenty to eat, be college educated.

Sure, our country has problems, but all in all - we have it really good. I've never known hunger, torture, government sanctioned rape or murder, religious sanctioned torture or murder, genital mutilation, being sold into marriage when I was a child. I'm not considered less than a servant by the males in my community or family. I have the freedom to think and say what I want without retribution or punishment.

THANKS VETERANS FOR ALLOWING ME TO BE FREE!

On a non-nursing note

What is the problem with people that they all feel free to treat the world as their garbage can? I was driving down the freeway today and all along the side of the road is garbage. Cups, paper, boxes, buckets, bottles etc. etc. etc. It looks awful. And cigarette debris. I think it is a fairly well known fact that California is an inferno waiting to happen in the summer, the grass is so dry that you could set a fire by looking at it wrong and yet that doesn't stop people from tossing lit cigarette butts out the window and setting fires by the thousands. Every so often you'll come across a blackened patch, sometimes small, sometimes many acres. Hello you morons, just because you are too lazy to use an ashtray you are putting peoples homes and lives at risk.

So in ERnursey's world the penalties would be:

Tossing anything out the window that could start a fire: Pulled out of your car and shot on the side of the road and left there to rot. A couple of those and everyone else would think twice about doing that again.

Littering: 1st offense - 300 days of picking up litter on the side of the road wearing a bright orange vest that says 'I am a moron.' 2nd offense- see above.

Drunk driving - 1st offense (as long as you didn't cause harm to another)1000 days of picking up garbage on the side of the road wearing a bright orange vest that says 'DRUNK DRIVER.' 2nd offense - see above.

If there were actually some real penalties for peoples misbehavior, they would stop. In our country people know there are no swift, sure penalties so they feel free to do whatever they want.

The Draft

After a night of drug seekers and malingerers we got to talking about what will happen if they reinstate the draft. After the question was posed we looked around the ER, which was filled with 18 - 30 somethings, most of whom had never known a day of work and all of whom listed Vicodin, Oxycontin, Klonopin, Ativan and Soma in various combinations on their med lists, and decided our country was screwed.

I think our perceptions get skewed by what we see on a daily basis and I truly hope these people are not an actual representation of that age group. Surely there must be some gainfully employed, non drug addled adults out there somewhere.

This isn't my definition of ecstasy

Late one evening we got a call from EMS that they were bringing in a 20 year old female having seizures. When they arrived the patient was still seizing, the report was that it had been going on off and on for over 20 minutes. (At that time I lived in a community with no paramedics and mostly volunteer rescue squads)

We swung into action, one nurse put oxygen on the patient and another started looking for an IV site, a third placed her on the monitor while I went and grabbed some IV Ativan, a medication like Valium that we give to people having seizures.

When I got back to the room, the monitor was on, the patients HR was 180 and her BP was 224/130! As if that wasn't bad enough, a rectal temp was taken and it was 107! What the hell? We figured some sort of Amphetamines were involved, was she seizing from the high temp? We gave several doses of Ativan with no effect, the seizure continued unabated.

Prolonged seizure can lead to massive muscle breakdown known as rhabdomyolysis. When muscle breaks down, large molecules are released into the blood and can clog up the filtering tubules in the kidneys causing kidney failure. We decided to paralyze, deeply sedate and intubate this patient. After intubation we started her on an IV beta blocker to bring down her HR and BP. We also started cooling her to get her body temp down. About that time her lab work came back with a serum sodium of 109, which is critically low - probably causing her seizures. Now we started sodium replacement and prepared to transport her to a tertiary facility.

It was our first encounter with Ecstasy. A popular stimulant taken at clubs and parties to give the user a feeling of endless energy and well being. Overdose can lead to hyperthermia and cardiovascular collapse. Often the user feels thirsty which leads them to drink large amounts of fluids which causes dilutional hyponatremia and seizures.

It's not enough that several children's toys have been found to have high levels of lead, now you can give your kid GHB too. What in the world is the matter with people that they think it is okay, in this day and age, to use these ingredients. It is not like it is a new thing that lead is bad for people, I believe that fact is fairly well known.

I think we need to ban the export of all foreign goods, other countries seem to be viewing that as a cheap sneaky way to get rid of a few Americans.

On the other hand, I bet there is a rush by the club crowd to buy these beads before they are completely yanked off the market.

Hey!

I just found out that...........


IMPACTED NURSE IS BACK!!!!!!!

A new approach to ER overcrowding

Actually this is a very good idea but I imagine there are hospital administrators that are getting out the tar and feathers.

h/t Scalpel

Trauma Center

The first edition of the new blog carnival, Trauma Center, is up at Straight Talk from the Stanford ER. This is an ER themed carnival and the next edition will be in two weeks. You can use the blog carnival thingie on my sidebar to submit.

Watching Mama die

The ETT is left in place but the ventilator is gone, along with the noise. The room is silent, the nurses motions are slow, gentle and hushed. Morphine has been given to allay any pain or air hunger.

The lights are dim.

In the distance the noise of the ER has receded like the dull roar of the surf, heard only faintly in the subconscious. All that matters is here, Grandmother to twelve, mother to four, beloved wife. Collapsed suddenly at lunch, CT shows brain full of blood, no hope of recovery or any sort of meaningful life the family has chosen to let her go.

The children and elderly husband have gathered at the bedside, silent tears rolling down their cheeks.

on the monitor, which is turned away from the families view the spikes grow further and further and further apart until they stop.

The doctor pronounces time of death and expresses her condolences. The family wants to know if she knew what happened and did she suffer. We tell her that we don't think so, the injury to her brain was so sudden and devastating that she probably didn't know what happened.

The family says their good byes and leaves. The nurse removes the tubes and IV's and prepares the body for the funeral home. While she works her own tears fall, her own mother is aging and someday in the future she knows she will on the other side of the bed. Plus it is very difficult to see other peoples grief and anguish and remain untouched.

Are you on the phone or just nuts?

Ok, the freaking bluetooth earpieces are ridiculous. What is so important that people have to be yakking on the cellphone every minute of the day. But it has enabled me to come up with a new game to entertain myself when I am waiting in lines and whatnot.....when I see someone yakking away, apparently to themselves, I try to guess if they are wearing an ear piece or if they are psychotic. It can be endlessly amusing.

Burnout and Death with no dignity whatsoever

Came across a new blog today and read this. Reminded me of why I left the ICU setting, I am a firm believer in death with dignity. When I first started in the ICU, we went all out on those that could benefit and did comfort care on those that couldn't ie the patients with no hope of recovery. Over time I noticed that we were doing more and more on people that were going to die anyway and it began to feel like an endless torture of sick, elderly people. I saw doctors overturn patients DNR's when the family asked (when the patient was not able to speak for themselves) because they were afraid to get sued. I've participated in the intubation, insertion of multiple invasive lines and tubes in people with severe heart disease, diabetes, multiple amputations and strokes confined to a nursing home in their 90's for god sakes because the family 'wanted everything done.' At what point did medicine become 'have it your way' instead of what is medically indicated. Anyway, I couldn't take it anymore and left to go to the ER. Sigh.

So check out this new blog, I suspect most of us have been in some form of burnout at one time or another, and with all the burdensome rules, regulations and paperwork - it'll only get worse.

California says HAH!

It was sunny and eighty degrees out today. I was wearing shorts and got a sunburn. For those of you that live in places where it didn't get above fifty today........HAH! Bet you aren't laughing at us now.

Politics Explained

FEUDALISM: You have two cows. Your lord takes some of the milk.

PURE SOCIALISM: You have two cows. The government takes them and puts them in a barn with everyone else's cows. You have to take care of all of the cows. The government gives you as much milk as you need.

BUREAUCRATIC SOCIALISM: You have two cows. The government takes them and put them in a barn with everyone else's cows. They are cared for by ex-chicken farmers. You have to take care of the chickens the government took from the chicken farmers. The government gives you as much milk and eggs as the regulations say you need.

FASCISM: You have two cows. The government takes both, hires you to take care of them and sells you the milk.

PURE COMMUNISM: You have two cows. Your neighbors help you take care of them, and you all share the milk.

RUSSIAN COMMUNISM: You have two cows. You have to take care of them, but the government takes all the milk.

CAMBODIAN COMMUNISM: You have two cows. The government takes both of them and shoots you.

DICTATORSHIP: You have two cows. The government takes both and drafts you.

PURE DEMOCRACY: You have two cows. Your neighbors decide who gets the milk.

REPRESENTATIVE DEMOCRACY: You have two cows. Your neighbors pick someone to tell you who gets the milk.

BUREAUCRACY: You have two cows. At first the government regulates what you can feed them and when you can milk them. Then it pays you not to milk them. Then it takes both, shoots one, milks the other and pours the milk down the drain. Then it requires you to fill out forms accounting for the missing cows.

PURE ANARCHY: You have two cows. Either you sell the milk at a fair price or your neighbors try to take the cows and kill you.

LIBERTARIAN/ANARCHO-CAPITALISM: You have two cows. You sell one and buy a bull.

SURREALISM: You have two giraffes. The government requires you to take harmonica lessons.

Etiquette

Whitecoat Rants has a funny rant about cell phones. I hate it when a patient or their family member is talking on the cell phone when I am in the room but you know what I hate more? Nurses that carry a cell phone and have an audible ringer and answer the damn thing when the are supposed to be working. What in the heck is the matter with people?

I obviously was raised in a different age, or by different parents anyway. I was taught that when you are at work you are working. And when your own work is done there is always someone that needs help or something that can be cleaned or sorted or tidied. You don't sit on your duff at work, you don't make or receive personal phone calls except in dire circumstances. You don't call in sick unless you really are sick because it causes a burden on your co-workers and employer.

Most of the time that isn't the case. I see people everywhere on the phone when they should be doing something else. For instance, one day I was at Wally world trying to buy a new watch. The one I wanted to see was locked up and the jewelry counter person was standing with her back to the customers talking to her boyfriend about their upcoming date and what she should wear. I waited patiently for about five minutes before I went in search of the manager to tell him that they had lost a sale and all my further business because of poor customer service. At my own job, you will see one or two nurses running their asses off while some slacker does the minimum patient care and then sits at the computer answering email. That really steams me.

Sometimes I wish I could go back to live in the fifties when people had some manners and some sort of a work ethic. Back before the welfare generation and the age of entitlement. But then I realize I may very well have been stuck being a housewife. ICK!

How to go wrong with an Epi pen

Wow, here's a new one on me, courtesy of Straight Talk From the Stanford ER.

Change of Shift

This week's Change of Shift is hosted by Mother Jones at Nurse Ratched's. I love the pictures and I bet you will too. Check it out!

Keep Quiet or Else

The more things change the more they stay the same. Head on over to see what Girlvet has to say about it.

Do they think they are the first?

Mental health patients are going to be dumped on ER's in Austin. Hmmmm. That certainly sounds familiar. A few months ago our county legislature, in their infinite wisdom (not), decided that it would help balance the budget if they closed the psychiatric hospital. So now, all the patients in psychiatric crisis come to one of the local ER's while we try to locate a bed for them elsewhere in the state, often fruitlessly. It is nothing for a patient to spend their whole 72-hour hold in the ER. When the 72-hours is up we have to let them go. In the meantime they have received no treatment and are in no better condition than when they arrived. Sickening.

Some of these patients are a danger to staff and other patients. They are disruptive and upsetting to the sick and dying patients who are also in the ER. Staff have been hurt, several have quit in disgust. While the psychiatric patients are being held that is a room that can't be used to treat the ever growing backlog of ER patients.

The ones that are placed are often sent to a hospital hours from their community and families. Some of them are discharged in worse condition then they were admitted in.

The mentally ill are America's forgotten citizens. Our lawmakers find it easy to ignore them when handing out funds. Many have been de-institutionalized in a misguided effort by government to 'make things better.' Many are homeless, lost and mistreated.

Why do we allow this to happen?