Your Tax Dollars at Work

When we came on today we inherited a patient that had come in around 10 pm. She had been brought in by the police for being 'suicidal.' Her real problem was that she was extremely drunk and kept crying nearly incoherently "I just want to die." She had been incontinent of urine and stool as well as vomited all over herself. The night shift nurse, wonderful soul that she is, had bathed her from heat to toe, sent her clothing to the incinerator and found clean stuff from our closet where we keep clothes for the homeless. Now it is 7 am and her BAC is finally under 0.2 and she has told the psych resident that she is not suicidal, never has been - she must have just said those things because she was so out of it.

Since she is denying suicidal thoughts we can't hold her so we call the police and they take her away for being 'drunk in public.'

At noon we get an EMS report that one of the squads are coming in with a patient who was found by a passerby, passed out on the sidewalk. She is agitated, combative, incontinent of urine, stool and covered in vomit.

Guess who?

You got it.

The police won't deal with these people until they've been deemed medically stable. We don't dare say they are until they are worked up for more sinister things - like head bleeds from falling. Each ER visit costs you, the taxpayer, several hundreds of dollars.

But, we mustn't interfere with their right to drink themselves into a stupor.

My Last Shift

I signed into the computer 42,784 times because every time I stop to answer a family question or answer the phone it logs me off. 10111 of those times I typed my password, which is a combination of numbers and letters - some capitalized, wrong and had to do it again.

The computer I was using froze up or crashed a total of 14 times requiring a reboot which takes two or three minutes each time. That is about a half-hour of wasted time.

So tell me again how much this EMR is going to streamline documentation and increase my job satisfaction.

We've been notified by management that we can no longer call the computer on wheels 'cows' because a patient complained that she thought staff were talking about her when the nurse said she had to "go get the cow."

People are retarded.

Munchausen's by Proxy

Unfortunately I've seen a lot of child abuse working in the ER. Munchausen's by Proxy is a rare form where a parent or caregiver induces illness in their child. Here is one example.

It can go on for a long, long time before someone starts to suspect. The child's caregiver seems to be very concerned and loving, not the typical picture of the abuser.

I was involved in a case where an infant was repeatedly brought to the ER for vomiting and failure to thrive. The baby was repeatedly hospitalized for hydration and the symptoms would quickly improve. After awhile the nurses noticed that the child would have vomiting after the mother came and did the feeds, even that at first didn't cause any suspicion. It took almost twenty admissions before someone became suspicious enough to put the baby in a room with a camera and monitor the mother. She was found to be putting a substance in the babies bottle that turned out to be ipecac. Twenty admissions and untold ER visits with blood draws and IV starts, painful procedures for an infant that wasn't sick.

Sadly (or happily depending on your point of view) I have nothing to say. I am exhausted so I'm going to bed early - right after a real, long bubble bath.

Nighty-nite

More public health issues

Parents, if you suspect your child has chicken pox do not bring them to the ER or, for that matter, your pediatricians office. If you do, you will expose a lot of people who shouldn't be exposed - people with weakened immune systems for which chicken pox can be fatal, Pregnant women, the elderly and other children.

treat fever if your child is uncomfortable, give them plenty of fluids, oatmeal baths or calamine lotion for itching. It is an emergency if your child can't keep down fluids, if they are lethargic, complain of a bad headache or stiff neck, seizures, have difficulty breathing or the rash involves an eye. Also seek medical attention if the pox appear infected.

If you do feel you need to seek medical attention, please call ahead to the ER or pediatricians office and let them know you are coming so we can properly isolate your child, chicken pox is EXTREMELY contagious.

Public Health Issue

Dear Nurse Practitioner, The next time you think you have a child with measles please do not tell the mother to go to the ER where she and said child will sit with 200 other people in the lobby for several hours to be seen for the "rash" because mom isn't very fluent in English. When it is discovered that said child does have the measles public health becomes involved to try to track down all the people who may have come in contact with the child while sitting in the lobby, a rather daunting and time consuming task.

So consequently public health is not happy, the ER staff is not happy and all the people who had to have a dose of immune globulin are definitely not happy.

Great job.

In the future, if you suspect a communicable disease please contact public health where you will find a nurse on call, 24/7 to guide you in how to handle things without causing a public health disaster.

Your friendly ER staff, some of which now have sore asses

Grand Rounds

Grand Rounds is hosted (hostessed?) by Val Jones MD this week. Head on over.

A Nation that can't say NO

When did we become a nation that can't say no?

From infancy the parents are taught the extreme importance of bolstering a child's self-esteem. Don't ever tell them they are bad because it will give them bad self-esteem. Children today have no rules, they are never made to behave and grow up to be horrible little brats who can 'do no wrong' in their parents eyes.

So from early childhood the sense of entitlement has become well instilled.

In my job I see it all the time. A patient calls an ambulance because they have an ear ache. The ambulance must go, they must transport the patient to the hospital. The EMS crew cannot tell the patient that they don't have an emergency and to find their own ride. They are not allowed to even educate the patient that it is inappropriate to call an ambulance for an earache. God forbid we upset the patient or make them unhappy.

So off to the ER they go. Is the ER allowed to tell the patient they don't have an emergency or that it is inappropriate to call an ambulance for an earache? No, of course not, we don't want to upset them or make them unhappy - it might affect our patient satisfaction scores after all.

Now there is talk that reimbursement will be tied to patient satisfaction scores. The very idea makes me want to vomit. Let's completely take away the doctors ability to practice medicine and turn them into Vicodin prescribing machines. Drug seeking, that's okay - come on over, we'll give you what you need. We only want satisfied customers and if Vicodin is the way to get them, we're all over that.

And why bother toiling your way through medical school? Your ability to diagnose and appropriately treat an illness are being taken away by the petty bureaucratic meddling of imbeciles with NO MEDICAL KNOWLEDGE! Brought to you by the folks that dictated that pneumonia patients have blood cultures drawn which has no evidence based benefit but does increase your medical bill.

Since most patients have little or no medical knowledge they don't know if they are getting good care of not. If you come in with acute appendicitis and I give you pain medicine and nausea medicine and you feel better you might mistake that for good care, not knowing that failing to blood work, other tests and surgery could very well kill you. You are satisfied with they symptoms being relieved.

Sometimes patients need to be told NO. No an Xray is not indicated. No, you've had 15 visits for dental pain in the last few months - we're not going to give you any more narcotics. No you cannot have an MRI today, you can wait for your outpatient appointment next week. No you cannot have an antibiotic for your bronchitis.

Those are all patients that need to be told no. By the same token, these are all the patients that will call administration to complain when told no. This is the kind of non-sense that clogs up ER's world wide. This is what the government wants to perpetuate.

Here's a real rocket scientist

A little faux pas

A post on nurse K's blog reminded me of a funny thing that happened one time (in sort of a dark, sick way.)

It was the weekend in upstate NY and it was hazy, hot and humid. Peoples tempers rose in direct correlation to the heat index and we were experiencing a sharp upswing in shootings, stabbings and assaults.

It was 8 pm and the ER was slammed to the rafters, all hallway beds full, two gunshot wounds in the trauma bays and a code going on in the critical section. There were about a thousand cops, nurses, residents, attendings and ancillary staff running around the ER in barely controlled chaos.

The code was called. Before we could even get our breath we got the call that there was a five car pile up on the interstate with approximately 10 criticals and 5 minors. Since we were the trauma center we knew we'd get at least three of the most critical. The problem was that there was nowhere to put them.

Out of desperation we quickly did post mortem care on the code patient. There was no family there and none expected so we pushed the patient around into the outpatient center down the hall while we waited for the funeral home to pick him up. The department was closed for the weekend so we pushed the gurney into one of the rooms and locked up the department.

In the chaos of the next few hours we never realized what went on but we sure heard about it later. Apparently the weekend cleaning staff went into clean that department and were startled to find a patient in there. Surprise turned to shrieking when they realized the patient was dead. A great deal of confusion and chaos followed.

In retrospect it may not have been the best idea but we did the best we could at the time.

Unfortunately every time I imagine that scene I giggle.

Dear staffing office

If you ever call me at 4 pm on Monday afternoon and tell me you didn't 'get to' finding some staff for nights on MONDAY when they are going to be three nurses short......

I will have a psychotic episode.

Don't say I didn't warn you.

Whooping Cough

The baby was 9 months old, his birth weight was 8 lbs 5 ounces. At six months he weighed just shy of 20 pounds. Today he weighed 15 pounds - he was a skeleton and he was dying.

Mom had brought him in after treatment by his naturopath had failed. Constant coughing had made it impossible for him to take in adequate nutrition and starvation, coupled with a raging bacterial pneumonia were conspiring to shortly end his very short life.

We worked feverishly. Intubation, IV boluses, major antibiotics, vasopressors. All futile.

At 9:03 pm, after 30 minutes of cardiopulmonary resuscitation we pronounced him dead.

This boy had pertussis. His mother choose not to vaccinate him. I won't enter that debate. Anyone who has ever watched a child die or become permanently disabled from a preventable illness supports vaccination.

From Pkids.org:

• Babies may bleed behind the eyes and in the brain from coughing.
• The most common complication is bacterial pneumonia. About 1 child in 10 with pertussis also gets pneumonia, and about 1 in every 50 will have convulsions.
• Brain damage occurs in 1 out of every 250 children who get pertussis.
• Pertussis causes about 10-20 deaths each year in the United States.

I received an email today about the website Pkids and I urge you to visit it. I've seen one death from pertussis and I hope to never see another.

Red Flag

When you have had 47 ER visits this year and they are all for back pain, migraine and dental pain...........



IT'S KIND OF A RED FLAG!

And in case you are wondering what causes ER overcrowding, this is one of the reasons.

feeling sorry for myself?

I got to feeling sorry for myself the other day.

Then I was surfing the 'net and read about people in other countries that live in one room shacks, dirt floors, no running water or plumbing and having to cook over an open fire on the floor.

Kind of puts things into perspective doesn't it?

This is what nursing is

Go read this incredibly powerful, moving story of caring for a dying man and his family. Caring for the patient is only part of the job.

Six Word Meme

My friend, Whitecoat Rants, has tagged me for a meme.

Here are the rules:

1. Write your own six word memoir.
2. Post it on your blog and include a visual illustration if you want.
3. Link to the person that tagged you in your post and to the original post if possible so we can track it as it travels across the blogosphere.
4. Tag at least five more blogs with links.
5. Leave a comment on the tagged blogs with an invitation to play.

I'm not tagging, feel free to play.

My six words are......

A day without a book.....SUCKS!

No Death with Dignity Here

This picture speaks a thousand words.

More on the idiocy that is JCAHO (with a little Press-Gainey thrown in)

A couple of great anti-JCAHO rants today.

The first is found at MDOD, 911 Doc you are my hero.

Then for a little bit more check out this post at Respiratory Therapy 101.

As much as I hate the idiocy that is JCAHO, what really is frightening me is the talk that reimbursements are going to be tied to patient satisfaction scores. I can see how that is going to be..."I want a prescription for Vicodin." says the patient that was in two days ago for the same bullshit complaint. "OK" says the poor doctor who has been threatened with his job if he doesn't keep patient satisfaction scores up.

Doctors and nurses will be leaving the profession in droves. Perfect.

Dear Doctor

If you come out of a patients room and walk past the supply cart and come all the way out to the nurses station to write an order to give the patient a urinal

I WILL BE TEMPTED TO CHOKE THE LIFE OUT OF YOU.

It is not beneath you to hand the patient a urinal.

READ THIS

Eloquently said.

Nursing 101

I know I sound like a hardened old bitch but I actually work very hard to make sure that my patients are as clean, dry, wrinkle free and comfortable as possible. When I went to nursing school we were taught how to be a nurse which is a lot more that being able to read EKG's and titrate drips. The high tech stuff is important, it's what makes our patients get better but it won't mean a thing to them if they are laying in a pile of wrinkled linen with no blanket.

So in case you missed nursing 101:

keep the linens wrinkle free. Have you ever been sick and laying in a damp wrinkly bed, it makes you feel worse. When your patient comes back from a test is in the rest room, take 5 seconds and straighten out and tuck in the sheet. If it is damp, throw it in the linen hamper and grab a new one.

Keep them warm. ER's are cold and the patients are scantily clad. Bundle them up. I am a 50ish, post-menopausal in full hot-flash city but when I had to go to the ER I was freezing! Those warm blankets were the best thing in the world. A great deal of our patients are elderly and frail people who are cold all the time any way.

Keep them dry. Nothing peeves me worse than to go into another nurses room to answer a call light and find the patient laying in sopping wadded up sheets.

Give them food and fluids if they can have it, tell them what is going on, what to expect and an estimate of how long things are going to take, if there are delays let them know why. This only takes seconds and means the world to someone. You are NEVER to busy to poke your head in and tell someone that the place is falling apart, they have not been forgotten but the doctor is tied up with a critical patient so there will be a delay.

Keep them comfortable. I don't mean drugs either. Find them a pillow. Get them into a hospital bed if there is a delay going to a room. ER stretchers SUCK!!! I laid on one for 4 hours and it killed me. I'm well padded, a lot of our patients a frail elderly.

Floor nurses - when I give you report have the damn room ready. when I tell you the patient is on 4 liters of oxygen to keep his sat 93% then you probably need to have an oxygen set up in the room. What do you people do with the christmas trees off the flo-meters anyway? Why do you take them off? Move the furniture, have an IV pump and be in the room to greet the patient as soon as they arrive.

Little things that they don't see - label you different IV tubings. I hate to go to a code on the floor and the patient has two or three things running with no labels so I don't know what line I can use to push meds without spending extra time untangling them, put a little tape on the end where they connect to the primary.

Have suction ready in your rooms. I routinely take patients to the floor and there are no suction buckets set up in the room. What do you plan to do if your patient starts vomiting and aspirating? That is not the time to run to the clean utility room and find one. Pretend you are a boy scout and be prepared.

Know your patients labs. If your patient has a high potassium or a low 'crit - you should know, unacceptable to not know.

I know we all get busy but most of these things take seconds or a few minutes at most and they are the things that our patients and families will remember.

Have you ever wondered........

Have you ever wondered why a woman with a complaint of vaginal discharge comes to the ER with her three kids? I mean, what does she think we are going to do with them during the pelvic?

Have you ever wondered why the men who are all pierced and tattoo'd are the ones most likely to vagal out when getting stitches?

Have you ever wondered why all the mandatory meetings are scheduled at 1pm which is the equivalent of 1 am to the night shift?

Have you ever wondered why your boss will call you in on your day off because you didn't complete some form but won't let you know you have a subpoena waiting until you come back from your stretch of days off and find out you missed a court date?

Have you ever wondered if your patients really think you believe them when they tell you their Vicodin prescription blew out the window of their car/got stolen by their girlfriend/got eaten by the dog?

Have you ever wondered what your patients home looks like when they come in with filthy hair and clothes? (ewwww)

Have you ever wondered if their is some billboard outside that says 'Tell the triage nurse you have chest pain and you'll get right back?'

Have you ever wondered why someone would design a forty bed ER with one patient bathroom?

Have you ever suspected that the EMS guys who pick up a drunk passed out on the street automatically think 'hmmmm, a stinky drunk - let's take him to Hospital X (your hospital'

Have you ever wondered if the guy who was shot by 'sumdood' really thinks you believe him when he tells you he was just 'walking along, minding my own business.'

Have you ever wondered if the aluminum foil hat really works? Or if the crazy people are really the one's that are OK and it's us that have the problem?

More Idiocy from the Governator

Oh yeah, and medi-cal reimbursements are going to be delayed, half a month in July and the whole month of August.

Since over half of our income comes from Medi-cal payments imagine what that is going to do to our hospital.

Change of Shift

Change of Shift is hosted by the fabulous Nurse Chapel (of Star Trek fame) via Nurse Ratched. How I envy nurse Chapel, working in a time when all you have to do is run the scanner over the patient and it tells you what is wrong with them, no more 4 hour workups!

California Follies

California is going to cut Medi-cal reimbursements to physicians 10%. Medi-cal reimbursements already lag behind most of the rest of the country which means that most doctors and almost all the specialists refuse to accept Medi-cal. For instance, in our area if a medical patient breaks their wrist, the only orthopedic surgeon that will take care of them is 2 hours away. It also means that my hospital, which is largely Medi-care, Medi-cal patients is finding it increasingly difficult to get specialist to be on call for the ER. It also means that up to 1/4 of the patients we see every day are Medi-cal with no primary care physicians.

Our Governor is an IDIOT.

Many more dollars could be spent if the program had some sort of limits and oversite.

Every day in my ER we see patients who have been in the ER 4 or more times a month for non-emergent issues. Many of them are at the other hospitals in the surrounding areas when they are not at our place. This abuse costs the program gazillions of dollars. Why not start fixing that problem first?

Or how about this, Medi-cal stopped covering Albuterol inhalers which are cheap and now only cover Xopenex inhalers which cost about three times as much.

By cutting reimbursement to physicians more patients will be force to the ER which is much more costly.

where is the sense in that?

Once again, our Governor is an idiot.

Go and Read This

The April fool that isn't a fool at all, it's all too real. Sadly.