I was reading this post at Moving Meat. I can't wait for the rest of the story of how his hospital went from being at the very bottom of the heap to where they are today. When you are reading the story pay careful attention to the last paragraph, the part where it says:

'Hospitals that view ER performance as an ER problem routinely fail to solve their problems. The ER is largely dependent on the institution for its success or failure, and without an institution-wide performance improvement plan, the prospects for meaningful reform are bleak'

Wow. What a profound statement. In other words, the ER is not an island even though many facilities persist in treating it like one. A facility cannot decide to improve things in the ER without being truly committed to make changes throughout the facility. Any attempts without that commitment will fail. All the gimmicks in the world won't change that.

How to really impress your patients

I was taking care of a nice woman who had a badly fractured wrist from slipping on the ice. We had sedated her and reduced and splinted the fracture and sent her home with her equally nice and attentive husband. They had just left the department and I was cleaning the room when I found her pain medicine prescription under the end of the gurney, they must have dropped it and not noticed. That was a nasty fracture and is going to hurt like a bastard tonight so I decide I will run out and see if I can catch them in the parking lot. I dash out the ambulance doors and spot them half way across the lot. I call them and they turn around just in time to see me hit my own patch of ice, fly up in the air and come down flat on my back, nearly knocking myself out cold.

Great. Nothing like impressing your patients with your cool professionalism.

Grand Rounds

Grand Rounds is hosted by Kim at Emergiblog this week. She has chosen the Beatles as the theme so head on over there and check it out.

Exciting news

I've received a proposal of marriage!!!!!!!




Of course he was about 60, toothless, reeking of alcohol and a complete stranger to soap and water but hey, at my age how picky can you be.

Where do candy hearts come from

OMG! I love this guy, what an imagination. And in case you ever wondered where candy hearts come from.....here's the answer.

RANT

Today I get this ambulance. I'm trying to triage the patient and I am going to put her on the monitor, only someone has taken my monitor cable (I guess they think they are more important) so I have to go find one, I look in all the usual drawers but I can't find one so I go room to room, finally in the tenth room I find two so I take the extra. I start back to the room, looking for a thermometer but all the wall-mounted holders are empty so back I go on the room to room search until I finally find one. I go back to the room, put my patient on the monitor and get a temp. I put her information in the computer and go to get her a warm blanket only to find the blanket warmer AND the linen cart empty. This is the part where I lose it a little.

JUST ONE TIME, ONE MEASLY LITTLE TIME I WOULD LIKE TO HAVE THE BASIC FREAKING EQUIPMENT I NEED TO DO MY JOB.

ARRRRGGGGGHHHH!!!!!

Your Diagnosis Might Be.........

Fever, Chills, Muscle aches, Coughing, fatigue.......You might have the flu.

Guess what? Antibiotics don't help the flu - it's a virus. You are going to be sick for a week or so. Drink lots of fluids and take some Tylenol and stay in bed until you feel better.

And next year get a flu shot.

Don't come to the ER and demand antibiotics, they won't help. Yes you'll feel better after a 10 day course, you'd feel better after 10 days anyway. Fever and feeling like shit does not constitute an emergency. Sorry. You'll be much more comfortable in your own bed than sitting on a hard waiting room chair for several hours.

Don't go to work and infect everyone you work with. You are not that important. The flu can, and does, kill thousands of people every year.

This post does not constitute medical advice

Leave it to California

Anyone who has seen the Body Worlds or Universe Within exhibits knows what an amazing exhibit it is. Donated bodies, in various stages of dissection and plasticized give us a never before seen view of the wonders of the human body.

Bad language follows.

Well leave it to the state of California to fuck it up. Assemblywoman Fiona Ma (D-San Francisco) has introduced a bill to ensure that the people who donate their bodies have consented to be gawked at by the public. Sadly, said bill was passed by 50-4 in the assembly and is now on its way to the Senate.

How much is this folly costing state tax payers? No wonder Arnold has to cut funding to State Parks, Schools and Libraries to balance the budget when our elected officials are spending millions of dollars with this CRAP! It is often embarrassing to say you live in California.

That being said, I saw the Universe Within exhibit when I was visiting another state, DO NOT MISS the opportunity to go. It was the most amazing thing that I have EVER seen. The human body is a complex work of art, simply amazing.

GOD BLESS OUR TROOPS

You stay up for 16 hours

He stays up for days on end.

You take a warm shower to help you wake up.

He goes days or weeks without running water.

You complain of a 'headache', and call in sick..

He gets shot at as others are hit, and keeps moving forward.

You put on your anti war/don't support the troops shirt, and go meet up with your friends.

He still fights for your right to wear that shirt.

You make sure you're cell phone is in your pocket.

He clutches the cross hanging on his chain next to his dog tags.

You talk trash about your 'buddies' that aren't with you.

He knows he may not see some of his buddies again.

You walk down the beach, staring at all the pretty girls.

He patrols the streets, searching for insurgents and terrorists.

You complain about how hot it is.

He wears his heavy gear, not daring to take off his helmet to wipe his brow.

You go out to lunch, and complain because the restaurant got your order wrong.

He doesn't get to eat today.

Your maid makes your bed and washes your clothes.

He wears the same things for weeks, but makes sure his weapons are clean.

You go to the mall and get your hair redone.

He doesn't have time to brush his teeth today.

You're angry because your class ran 5 minutes over.

He's told he will be held over an extra 2 months.

You call your girlfriend and set a date for tonight.

He waits for the mail to see if there is a letter from home.

You hug and kiss your girlfriend, like you do everyday.

He holds his letter close and smells his love's perfume.

You roll your eyes as a baby cries.

He gets a letter with pictures of his new child, and wonders if they'll ever meet.

You criticize your government, and say that war never solves anything.

He sees the innocent tortured and killed by their own people and remembers why he is fighting.

You hear the jokes about the war, and make fun of men like him.

He hears the gunfire, bombs and screams of the wounded.

You see only what the media wants you to see.

He sees the broken bodies lying around him.

You are asked to go to the store by your parents. You don't.

He does exactly what he is told even if it puts his life in danger.

You stay at home and watch TV.

He takes whatever time he is given to call, write home, sleep, and eat.

You crawl into your soft bed, with down pillows, and get comfortable.

He tries to sleep but gets woken by mortars and helicopters all night long.

If you support your troops, send this to 7 people.

If you don't support your troops well, then don't send this out. You won't die in 7 days, your love life won't be affected, and you won't have the worst day ever.

You don't have to email this. It's not like you know the men and women that are dying to preserve your rights.

REMEMBER our Troops, and do not forget them LATER

Ack! This is terrible.

This is terrible. No excuse. None. And the hospitals response? 'It's not worthy of a lawsuit.' Grrrr. They threw this woman's dead child in the laundry! Lawsuit? I wouldn't be happy until nothing was left of the hospital but a pile of smoldering rubble and the idiots that made statements like that were tarred and feathered.

h/t At Your Cervix

It's Raining, It's pouring, ERnursey soon will be snoring!

Raining, raining, raining, raining. Sigh. I have a stretch of days off and a bunch of outside projects to do and it is supposed to rain every single day. Currently it is raining so hard that my front walk is covered with two inches of water.

So. Fire? Check. Jammies? Check. Old movie? Check. Hot cocoa? Check.

having a reasonable excuse to be lazy? Priceless.

Something is a little off

ER nurses see a large variety of patients. Young, Old, happy, angry, sad, crazy and everything in between. Sometimes we don't realize at first that the person isn't quite what they seem.

One day I received an elderly woman by ambulance and I was examining her. She was complaining of lower abdominal pain. I listened to her bowel sounds which were normal. She said she moved her bowels regularly with no constipation. I asked her about her urination, did it hurt to go? Did she have frequent urges, any odor to the urine? No, no and no. I palpated her abdomen and did not note any focal tenderness.

I asked her if anything made the pain worse and she holds out a closed fist and says "here." Without thinking I hold out my hand and she drops a dried up, black thing that sort of looked like a piece of stick, but not quite. I am standing there looking at it thinking to myself "what the hell is that?" So I ask, and she tells me that she masturbates everyday with a banana and that is the stem and the pain gets worse when she masturbates. Ack! I kind of fling the object back onto the gurney and quickly squirt some hand sanitizer into my palm and vigorously clean my hands. While I am doing this she is telling me how she is pregnant with a banana vine and it is the vine growing that is causing the pain and she is too old to be a mother so she wants the vine cut out. My first random thought is "I think bananas grow on trees." But then I come to my senses and fall back on my generic "hmm, I see. Well let's get you seen by the doctor then."

As I leave the room for a thorough wash I marvel on how a person can seem perfectly normal until you start talking to them and then you realize that something is a little off.

Change of Shift can be found this week at Pixel RN. Go check it out!

This sucks the life out of me

my last patient of the day has had 107 ER visits to our ER in the last three years. That is just my ER, a friend that works across town told me he is a frequent flyer there also. His visit history reads; back pain, dental pain, arm pain, pain, pain, pain. If you take the time to go through the charts he has been told 8 times in the last three hears that he will be given no more narcotics and yet on the very next visit he will be give a 'script for Vicodin.

We are contributing to his slow death.

This is not why I went into nursing. I did not intend to be turned into a drug dealer. I don't like it and it sucks the life out of me. We are not doing these people any favors, just the opposite in fact.

Tonight played out like this:

He came in with acute narcotic withdrawal. He ran out of Methadone three days ago and he had a visit to our ER that day for dental pain for which the NP gave him 20 Vicodin. Obviously he has used those all up, he sits in the triage room vomiting into a basin, covered in goosebumps. We offer him IV fluids, anti-nausea medicine and clonidine to block some of the symptoms but he refuses. All he wants is drugs. The doctor is firm, no drugs. He becomes enraged and flings the basin of vomit at the doctor. A security alert is called and the police summoned. He is dragged from the ER in handcuffs, screaming threats on the way out.

While all this is going on there are families with small children, elderly ladies with chest pain and a dying grandfather in the adjacent room. Real patients with real problems who are cheated of the care they deserve by toads like this man. I would hate him but we helped to create him.

Another example of VA care

I worked in a trauma center years ago and the residents also covered the VA hospital up the hill from us.

One evening the neurosurgery resident was in the ER placing a ventriculostomy and a Codman drain on a patient with a head injury so I was holding his beeper and answering his pages.

First I get one from the VA. A nurse up there is calling to say she needs him to come and verify NG tube placement on a patient she had placed a NG tube in. WTF????? For the uninitiated, an NG tube is a naso-gastric tube. It is a long, flexible tube that is inserted through the nostril, down the throat, into the esophagus and the end sits in the stomach. It can be used to suction stomach contents out or the put tube feedings and meds into the stomach. Placement is checked to make sure it isn't in the lung as putting formula etc. in the stomach is NOT good. This is a nursing task. You check by injecting some air and listening for a gurgle over the stomach and by aspirating some stomach contents. You can also get an x-ray. So, I'm confused. I ask her, "You don't check your own tube placement." She tells me no. And this tube is going to be used for feeding. So you are putting stuff into the tube and not checking yourself for placement before each use? Are you crazy. So you don't check placement and infuse tube feeding into someone's lung which will surely kill him? Not to mention the fact of the prolonged delay in starting nutrition, which is crucial to healing, while you wait for the one resident in the hospital to have time to trot all the way over there and do that for you. I am flabbergasted but tell her I will pass on the message.

Before too long I get another call from another nurse on another floor there at the VA. She has a patient that is post op from back surgery and she can't find his orders. Well come to find out, the patient came out of surgery nine hours ago! The patient has been on the floor for NINE hours and no one has looked for the orders until now? Once again, WTF?

My dad told me awhile back that he was going to try to sign up for VA benefits so that he could save some money on his meds. I looked them over and almost all of them were on Wal-Marts $4 prescription list and two of the others could be changed to ones on the list. I talked him out of signing up for VA hell.

This is how the country is treating it's Veterans, what a crime.

Ahem....Attention Staffing Office

Attention, staffing office. If I am in charge and the ER is holding 10 admits and we have every other bed full and 8 people in the hall and 37 people waiting in the lobby to be seen - some of which have been there for more than six hours and there are 12 more people waiting to be triaged and I call you because a night shift nurse called in sick and you tell me that you are busy staffing the floors but you will "try to get to it." It will cause me to have a psychotic break.

'k? Thanks.

More Governmental Stupidity

Just when I thought the government could not aggravate me any further I came across two posts at The Happy Hospitalist.

Medicare, in their infinite wisdom (NOT) have come up with the brilliant idea that if you are a medicare patient and are ready for discharge and you feel you don't want to be discharged you can challenge the decision and it will be reviewed by some doctor somewhere who is employed by the government (the same idiot's that brought you JCAHO.) How does that work in practice? About as badly as you might expect.

The second post deals with the VA. I have come to realize that the VA system is a colossal monument to waste, obstruction of any progress and stupidity. It is like every joke about bureaucracy every coined. Let me give you one example. I recently had a patient in the ER who had been discharged from our facility three days prior with CHF. The VA does not accept prescriptions by outside doctors so when a patient is discharged he needs to call his doctor at the VA and get him to order any necessary prescriptions. Have you ever tried to contact a real live human being at a VA facility? Yeah. Voice mail hell. So, here's our patient three days after discharge, he still has not gotten in touch with his VA doc so he has not had Coreg, Lasix, Zaroxolyn, Digoxin and Potassium since discharge. He is indigent and cannot pay out of pocket. Now is in Pulmonary Edema and barely escapes intubation. This is by far an isolated incident.

I really love his blog, but sometimes after reading it I'm feeling anything but happy!

I was just watching a show where a patient coded and they shocked him three times but never did any kind of CPR or ventilations and then they called it. After 15 seconds! I certainly hope if I ever code in front of someone that they will work me a little longer than that.

But seriously, if you are going to spend several million dollars making a TV series or a movie - hire a real live, practicing, medical advisor. PLEASE!!!

The Family Visit

I pull the next triage ticket and realize it is a group of 3 - mom and two kids with colds. I sigh and mentally feel defeated before I even start.

I bring them in the room, Mom and five kids. It takes a long time to get them triaged, the kids are brats - opening drawers and running around screaming while mom sits there oblivious.

I get them all done and start to usher them out the door when the mom decides that "as long as we're here, might as well get the other two checked out two." even though they have no complaints.

In the 45 minutes I spent triaging this family, none of which were suffering anything other than mild coughing and snotty noses, 4 more people had signed in and had been waiting with more serious complaints than 'colds.'

ER's Have Longer Waiting Times

So there is a study out that shows that ER's are suffering from increased wait times and the problem is going to get worse.

Duh. Really? How much did that study cost? Any ER staff member could have told you that for free.

ER's are closing, ER visits are increasing. The population is aging, the economy is collapsing. More primary care physicians are refusing to take Medicaid patients. JCAHO and CMS are coming up with more idiotic and burdensome regulations requiring ER staff to spend more and more time on redundant paperwork. Litigation is making doctors gun-shy so they are ordering longer work-ups.
There is a nursing shortage so inpatient beds are not able to be filled.

Once again, duh. What did you think was going to happen. It's only a matter of time before our system crashes.

H/T Whitecoat Rants

Ever Wonder Why Nurses Burn Out?

The last two days have been simply dreadful. Critical patient after critical patient, stroke, MI, septic shock, major trauma, gunshot, head bleed and on and on and on. Running, running, running from bed to bed trying to keep everyone alive long enough to go to the ICU's and trying desperately to get everything done without making a mistake. Coming home to collapse exhausted in bed only to dream all night long that I am at work and everything is going to hell.

We work short every day. The patients are sicker and sicker. Higher acuity, higher volume of visits with less staff to care for them. And now, the insurance companies are not going to pay for some things that only adequate staffing can prevent. When the hospitals aren't getting reimbursement what will they cut? Bedside staff of course, always the first to go when money is tight. Do you see where this is going?

I'm overwhelmed and burnt out with no end in sight. I suspect a lot of my fellow nurses are right there with me.

And here's a post by Mother Jones. She was assaulted by a patient and is expecting a call from her boss, not to express concern and caring but rather blaming her for the problem. If you think this kind of experience is rare, let me assure you it is not.

Heartbreaking

Some patients really capture our hearts......and break them. For two excellent posts about this read these posts:

Part 1

Part 2

Thanks, John for this story.

Blah

I'm tired, the news is boring and nothing interesting happened at work. I can't even think of any exciting or interesting stories. I'll try again tomorrow. Sorry.

For those of you in the snow belt - it was sunny and 67 here today.

Medical Transcriptionists are Da Bomb

You have to admire anyone that can hear this:

Doctor dictating on the dictaphone: 40-year-old Female mumble, mumble, mumble, snort abdominal mumble mumble mumble mumble (hey hand me those labs) history of mumble, mumble, mumble gravida mumble, mumble please add Caucasian before female mumble mumble mumble (did you need something? OK give her 1 mg of Ativan PO)mumble diverticulitis mumble


And turn it into this:

40-year-old Caucasian female with a two day history of RUQ abdominal pain occurring after meals accompanied by nausea, vomiting and diarrhea. The patient is gravida 4, PARA 3 currently pregnant 36 weeks. Previous medical history is negative except for one episode of diverticulitis occurring earlier in this pregnancy.

I stand in awe of your talents.

Need a Gift for the ER Nurse in Your Life

I want this for my birthday.

Good news!

These are probably not work safe but i have a little too much time on my hand and came across these:

I've finally found a way to keep my glasses from sliding down my nose.

And, I've found the man I want to be my son-in-law.

That's my manicurist, second from the right.

And for more choices when blowing your nose.....

This just defies belief.

For those of us who are a little saggy, this has possibilities.

Ever bit your tongue? Now imagine how this felt.

And my kids think I embarrass them.

And for those that find a necklace is not enough.

We're guaranteed not to ever get a job.