To any state contemplating nurse to patient ratios, please learn from California's mistakes.
Old way: Med-surg floor with 32 patients would be staffed with a charge nurse, a unit clerk, two or three aides and 4 RN's. Each RN would have 8 patients but would have a clerk to answer phones and take off orders, aides available to answer lights, help with baths, transferring patients and passing trays. The charge nurse was also available to help with lifting and moving along with helping the nurses with med's and stuff.
New Way: Same floor. 4 RN's each with 5 patients, the other twelve-bed's sit empty because there is no staff. There are no ward clerk, no aides. There is a charge nurse that covers two units . No one to answer the phones, no one to help you with baths, lifting and transferring, passing trays or implementing orders. The charge nurse is supposed to be the break nurse. She is responsible for breaking 9 people whose break time amounts to 11.25 hours - not including her own.
If you are contemplating nurse to patient ratios make sure you include ancillary help into your ratios SO YOU DON'T GET SCREWED LIKE WE DID!
Saturday, May 31, 2008
Friday, May 30, 2008
Welcome to entitlement land
I was discharging a young lady who had called an ambulance because she didn't want to walk to be seen for her armpit abscess. I was reviewing the discharge instructions when she interrupted me in the middle of a sentence - "you gonna give me dressing stuff?" Now to be honest, we often do give dressing supplies for a couple of days but this girl was just too much, she had been rude when she got sent to triage, she was snotty when she had to wait for the doctor, who was in the middle of a code. She had asked for a blanket, a phone and a sandwich the minute she got put in the room. Frankly I was fed up and not inclined to give her any favors so I told her that mini pads make great dressings - which they do, we recommend those and maxi pads quite a bit - they are cheap and stick inside your clothing or stick good to tape. Then she wanted a free cab and when she was told no she snottily said "WELL......I GUESS I'll just have to WALK since you won't pay for a cab."
Yep, I guess you will.
Later on another ambulance brought in a 20 year old male with a sunburn.
Good grief.
Yep, I guess you will.
Later on another ambulance brought in a 20 year old male with a sunburn.
Good grief.
Tuesday, May 27, 2008
Message to administration
I got a letter marked CONFIDENTIAL in the inter-departmental mail today.
I opened it with a lot of trepidation. Inside was a letter informing me that it was the end of the month and I had failed to get my PPD. It went on to say that I had until Friday to get it or......I WOULD NOT BE ALLOWED TO WORK.
So, Attention Administration and employee health......
That is not a punishment!
I opened it with a lot of trepidation. Inside was a letter informing me that it was the end of the month and I had failed to get my PPD. It went on to say that I had until Friday to get it or......I WOULD NOT BE ALLOWED TO WORK.
So, Attention Administration and employee health......
That is not a punishment!
Monday, May 26, 2008
When it says on the can of lighter fluid not to squirt onto lit barbecue they aren't kidding.The resulting explosion will mean a trip to the burn center for you as well as the loss of most of your new deck and the siding on the back of your house.
You would think that would be common sense but apparently not.
BTW, have you noticed how many stupid accidents start with 'a few brewski's?'
Memoral Day
God Bless the troops.
I give my thanks to all the members of the armed forces, past and present, who have sacrificed so much to ensure we can live in a country where we are free to believe what we want and speak our minds.
Where there is always abundant food on my table.
Where I, a woman, can enjoy the same freedom as a man.
Where I can openly badmouth politicians without fear of retribution.
Please take this day as it is intended, to remember our service men and women. Visit a military graveyard, invite a troop members family to a picnic, send a care package to the troop overseas to say thanks.
I give my thanks to all the members of the armed forces, past and present, who have sacrificed so much to ensure we can live in a country where we are free to believe what we want and speak our minds.
Where there is always abundant food on my table.
Where I, a woman, can enjoy the same freedom as a man.
Where I can openly badmouth politicians without fear of retribution.
Please take this day as it is intended, to remember our service men and women. Visit a military graveyard, invite a troop members family to a picnic, send a care package to the troop overseas to say thanks.
Sunday, May 25, 2008
Ahhh, the ER. Where else do your employers expect you to take physical and verbal abuse with a smile and an offer to do more to meet the abusers needs?
How the ER Works
A previous commenter wondered what we do when we aren't in triage so I thought hey, I bet a lot of people really don't know much about the ER other than what they see on TV, which aren't very accurate.
In my ER when you come in the front door you see a 'greeter' who takes some basic info to get you into the computer - name, date of birth, social security number and why you are there. Then you see the triage nurse, this may be right away if the ER isn't busy but more likely you will have to sit and wait a bit.
Triage means to 'sort.' We use a 5 level triage system but what it boils down to is: can go to fast track or not. for the 'or not's' they can either wait or need a bed now. The triage nurse is very important, they need to have the experience to sort through all the extraneous information people give to figure out what might be going on with the patient and how sick they really are. In my ER we don't even think about putting you in triage until you have at least a full year of ER experience.
Once you go to a room you get into a patient gown and the nurse will probably put you on the monitor to monitor at least your blood pressure, oxygen level and pulse. Often we will often put your heart leads on also - especially if you are complaining of chest pain, dizziness, weakness, shortness of breath, seizures, abdominal pain or any problem that can be related to your heart. The nurse will probably start an IV and draw some blood either now or after the doctor sees you. Then you will wait for a while until seen by the doctor.
The doctor will come in and talk to you, do an exam and then order some tests to try to figure out why you are ill. If you need IV fluid, pain meds, anti-nausea meds those will get ordered also.
Then the nurse will come in and complete any of the Dr.'s orders that aren't already completed. The nurse may will be caring for several other patients at the same time and it may take awhile to get back to you, they are doing the best they can but some of the other patients may be critical. Then you wait for results, depending on what is done that can take one hour or several.
When the results are back the ER doc will re-evaluate them when he has time, the ER doctor is often juggling ten or twenty patients some of which are critical. Depending on the situation it make take awhile for the ER doc to get to you. Remember, they are doing the best they can - it is not like your doctors office where you have an appointment and he sees patients one at a time.
When you get re-evaluated you may need more tests, you may need to be admitted or you may be discharged home.
That is sort of a brief over-view of the organized chaos that is the ER.
In my ER when you come in the front door you see a 'greeter' who takes some basic info to get you into the computer - name, date of birth, social security number and why you are there. Then you see the triage nurse, this may be right away if the ER isn't busy but more likely you will have to sit and wait a bit.
Triage means to 'sort.' We use a 5 level triage system but what it boils down to is: can go to fast track or not. for the 'or not's' they can either wait or need a bed now. The triage nurse is very important, they need to have the experience to sort through all the extraneous information people give to figure out what might be going on with the patient and how sick they really are. In my ER we don't even think about putting you in triage until you have at least a full year of ER experience.
Once you go to a room you get into a patient gown and the nurse will probably put you on the monitor to monitor at least your blood pressure, oxygen level and pulse. Often we will often put your heart leads on also - especially if you are complaining of chest pain, dizziness, weakness, shortness of breath, seizures, abdominal pain or any problem that can be related to your heart. The nurse will probably start an IV and draw some blood either now or after the doctor sees you. Then you will wait for a while until seen by the doctor.
The doctor will come in and talk to you, do an exam and then order some tests to try to figure out why you are ill. If you need IV fluid, pain meds, anti-nausea meds those will get ordered also.
Then the nurse will come in and complete any of the Dr.'s orders that aren't already completed. The nurse may will be caring for several other patients at the same time and it may take awhile to get back to you, they are doing the best they can but some of the other patients may be critical. Then you wait for results, depending on what is done that can take one hour or several.
When the results are back the ER doc will re-evaluate them when he has time, the ER doctor is often juggling ten or twenty patients some of which are critical. Depending on the situation it make take awhile for the ER doc to get to you. Remember, they are doing the best they can - it is not like your doctors office where you have an appointment and he sees patients one at a time.
When you get re-evaluated you may need more tests, you may need to be admitted or you may be discharged home.
That is sort of a brief over-view of the organized chaos that is the ER.
Saturday, May 24, 2008
Ouch, my aching back
Healthcare is hard on our backs.
There is a lot of lifting and moving of people that aren't able to assist us. People are heavier than ever - it used to be a rarity to have a patient over 300 pounds and now we see several every day. Many employers pay lip service to 'no lift policies' but do they really provide the equipment?
For instance, in my hospital there is supposed to be a special, slippery sheet placed under every patient to help scoot them up in bed. These sheets have to be laundered after each patient. We might be able to scrounge up five. We see 250 patients a day. You do the math.
We are supposed to have a lift belt. We have 78 employees in our department. We have no lift belts. You do the math.
We are supposed to have a hoyer. We do, it has 1 sling that has to be laundered after each patient. You do the math.
Patients have to be moved several times every day, in and out of bed, on and off the toilet, ambulated, turned, scooted up in bed and so on. Healthcare staff are aging. Wouldn't it be a little cheaper to provide the equipment and staff we need to move the patients safely than to pay workmans comp and disability to those of us who get hurt on the job.
I would think so but what do I know?
There is a lot of lifting and moving of people that aren't able to assist us. People are heavier than ever - it used to be a rarity to have a patient over 300 pounds and now we see several every day. Many employers pay lip service to 'no lift policies' but do they really provide the equipment?
For instance, in my hospital there is supposed to be a special, slippery sheet placed under every patient to help scoot them up in bed. These sheets have to be laundered after each patient. We might be able to scrounge up five. We see 250 patients a day. You do the math.
We are supposed to have a lift belt. We have 78 employees in our department. We have no lift belts. You do the math.
We are supposed to have a hoyer. We do, it has 1 sling that has to be laundered after each patient. You do the math.
Patients have to be moved several times every day, in and out of bed, on and off the toilet, ambulated, turned, scooted up in bed and so on. Healthcare staff are aging. Wouldn't it be a little cheaper to provide the equipment and staff we need to move the patients safely than to pay workmans comp and disability to those of us who get hurt on the job.
I would think so but what do I know?
Thursday, May 22, 2008
SPAMMED!
I seem to have been spammed by someone annoying but not trying to sell anything. I've turned the word verification on for a bit, sorry - I know that feature is annoying but I hope it won't keep you from commenting.
Monday, May 19, 2008
Burnout Meme
Monkeygirl created a new meme and I've nominated myself to play.
Six things that are causing me to burnout:
1. JCAHO
I've explored this subject to death but their self-procreating idiocy and it's attendant reams of paperwork to prove that you are doing excellent patient care without taking into account that nurses now spend all their time charting instead of actual patient care. To meet all their requirements most hospitals have a nurse to administrator ratio of 1:1 - complete twaddle. Take the clipboards away and take care of the patients for crying out loud.
2. Not having the equipment to do my job.
Today I had a shocky patient and needed to do a manual BP but there was not one working cuff in the department. Last week the hospital was out of pediatric IV catheters - what in the hell do you want me to use? a 16 guage on that neonate?
3. Lazy ass co-workers
Stock your fucking rooms. I'm busy too but I get it done. If you take the last blanket out of the blanket warmer fill it. If you take the last form, make some copies. Don't leave your trash on the nurses station desk/med room counter/break room table etc. Make your patients comfortable - if they are wet change them, if they are cold give them a blanket. Give them a pillow, turn down the lights. I work with one nurse that will have two floats doing her orders and she'll be on the phone with her boyfriend. Enough already.
4. 20 year olds that are on disability for back pain.
5. Lazy ass housekeepers.
This is a hospital, it shouldn't be visibly filthy for the love of God. Why does no one but me see this as a problem?
6. Drug seekers and the entitlement crowd.
Six things that are causing me to burnout:
1. JCAHO
I've explored this subject to death but their self-procreating idiocy and it's attendant reams of paperwork to prove that you are doing excellent patient care without taking into account that nurses now spend all their time charting instead of actual patient care. To meet all their requirements most hospitals have a nurse to administrator ratio of 1:1 - complete twaddle. Take the clipboards away and take care of the patients for crying out loud.
2. Not having the equipment to do my job.
Today I had a shocky patient and needed to do a manual BP but there was not one working cuff in the department. Last week the hospital was out of pediatric IV catheters - what in the hell do you want me to use? a 16 guage on that neonate?
3. Lazy ass co-workers
Stock your fucking rooms. I'm busy too but I get it done. If you take the last blanket out of the blanket warmer fill it. If you take the last form, make some copies. Don't leave your trash on the nurses station desk/med room counter/break room table etc. Make your patients comfortable - if they are wet change them, if they are cold give them a blanket. Give them a pillow, turn down the lights. I work with one nurse that will have two floats doing her orders and she'll be on the phone with her boyfriend. Enough already.
4. 20 year olds that are on disability for back pain.
5. Lazy ass housekeepers.
This is a hospital, it shouldn't be visibly filthy for the love of God. Why does no one but me see this as a problem?
6. Drug seekers and the entitlement crowd.
Sunday, May 18, 2008
Music to my ears
We had a float from the telemetry floor today that had never been in the ER so she got buddied up with me.
That being said, we had the worst day I think I have ever had in the ER - and I've had a lot of them.
At 5 pm there were 14 hallway patients, 42 people waiting to be seen in fast track and the main ER and 4 ambulances waiting to unload patients. The ER nurses had been working like dogs all day but not making any headway against the never ending tide of sick and injured. No one had a break, a lunch or even a pee.
I could go on and on about how awful it was but you can use your imagination. It was about that time that the float nurse said "I get it now." Having seen it with her own eyes she finally understood why we were so pushy about getting the patients to the floor.
Music to my ears.
That being said, we had the worst day I think I have ever had in the ER - and I've had a lot of them.
At 5 pm there were 14 hallway patients, 42 people waiting to be seen in fast track and the main ER and 4 ambulances waiting to unload patients. The ER nurses had been working like dogs all day but not making any headway against the never ending tide of sick and injured. No one had a break, a lunch or even a pee.
I could go on and on about how awful it was but you can use your imagination. It was about that time that the float nurse said "I get it now." Having seen it with her own eyes she finally understood why we were so pushy about getting the patients to the floor.
Music to my ears.
Saturday, May 17, 2008
Triage
Let me start by saying I hate triage.
But everyone has to have their turn and today it was mine. So with only a little grumbling I headed up to "the box."
The first card I pick up says "lump." I call the patient in and it is a twentish male who states he has had a lump on his neck for 3 years. Yes he has a doctor. No he has not gone to his doctor about this problem. No nothing has changed recently. I want to say, but I don't-"so let me get this straight. you've had this lump for three long years. In all those three long years you never thought to go see your doctor about it. Nothing is new or different today but you have suddenly decided, after three long years, that it is an emergency and has to be looked at right away." Like I said, I want to, but I don't. Out to the waiting room he goes.
The next patient has dental pain. I see from the visit history in our hand electronic medical record that she has had 42 visits in the past two years for dental pain, migraines and back pain. One of the residents gave her 20 Vicodin 3 days ago. I wanted to say, but I didn't "So, did you ever consider going to a dentist instead of just coming here for pain medicine." Out to the lobby she goes.
The next patient has shortness of breath, ohhhh! Potentially a real sick person. The patient is nineteen and REEKS of cigarette smoke along with the smell of BO and rancid body oil that has soaked through their clothes from not bathing or changing. Their respiratory rate is under twenty and their oxygen saturation is 99% which is normal. During the triage he mentions that he has chest pain. Since we became a 'chest pain center' we have seen an influx of patients with 'chest pain' which they figure will get them whisked right back to a room.
The next patient is 999years old, well- really only 93 but they look that old. The complaint is dizziness so I take her back to a room. Dizziness could be anything from stroke, slow heart rate, dehydration along with several other worrisome things.
The next patient is an infant with diarrhea which he demonstrates by pooping all over the exam table and the wall. He got to go straight back to a room for some IV fluids and ultimately an admission.
Then there was a party of three, mom with back pain and two of her children with colds. During the endless triage process she decided to get the third child checked out "while we're here."
The 19 year old with shortness of breath has a girlfriend with him, she is probably in her twenties and already has no teeth. Every time I go out she accosts me to ask how much longer he is going to have to wait. The patient himself has been on the cell phone continuously. How can one afford a cell phone when they apparently cannot afford soap.
By noon I have triaged 43 people and only 8 of them were sick. Short of breath boy left an hour ago, girlfriend in tow, screaming obscenities at all and sundry. Helpful hint, if you are screaming you are not short of breath.
The rest of the day is more of the same. The end of the shift is a welcome respite. And it'll be about a month before my number comes up again. Thank God.
But everyone has to have their turn and today it was mine. So with only a little grumbling I headed up to "the box."
The first card I pick up says "lump." I call the patient in and it is a twentish male who states he has had a lump on his neck for 3 years. Yes he has a doctor. No he has not gone to his doctor about this problem. No nothing has changed recently. I want to say, but I don't-"so let me get this straight. you've had this lump for three long years. In all those three long years you never thought to go see your doctor about it. Nothing is new or different today but you have suddenly decided, after three long years, that it is an emergency and has to be looked at right away." Like I said, I want to, but I don't. Out to the waiting room he goes.
The next patient has dental pain. I see from the visit history in our hand electronic medical record that she has had 42 visits in the past two years for dental pain, migraines and back pain. One of the residents gave her 20 Vicodin 3 days ago. I wanted to say, but I didn't "So, did you ever consider going to a dentist instead of just coming here for pain medicine." Out to the lobby she goes.
The next patient has shortness of breath, ohhhh! Potentially a real sick person. The patient is nineteen and REEKS of cigarette smoke along with the smell of BO and rancid body oil that has soaked through their clothes from not bathing or changing. Their respiratory rate is under twenty and their oxygen saturation is 99% which is normal. During the triage he mentions that he has chest pain. Since we became a 'chest pain center' we have seen an influx of patients with 'chest pain' which they figure will get them whisked right back to a room.
The next patient is 999years old, well- really only 93 but they look that old. The complaint is dizziness so I take her back to a room. Dizziness could be anything from stroke, slow heart rate, dehydration along with several other worrisome things.
The next patient is an infant with diarrhea which he demonstrates by pooping all over the exam table and the wall. He got to go straight back to a room for some IV fluids and ultimately an admission.
Then there was a party of three, mom with back pain and two of her children with colds. During the endless triage process she decided to get the third child checked out "while we're here."
The 19 year old with shortness of breath has a girlfriend with him, she is probably in her twenties and already has no teeth. Every time I go out she accosts me to ask how much longer he is going to have to wait. The patient himself has been on the cell phone continuously. How can one afford a cell phone when they apparently cannot afford soap.
By noon I have triaged 43 people and only 8 of them were sick. Short of breath boy left an hour ago, girlfriend in tow, screaming obscenities at all and sundry. Helpful hint, if you are screaming you are not short of breath.
The rest of the day is more of the same. The end of the shift is a welcome respite. And it'll be about a month before my number comes up again. Thank God.
Friday, May 16, 2008
Hot
It was 103 degrees today in Sunny Califonia! HOT, HOT, HOT!
There are a lot of wonderful things about living in California, summer isn't one of them. We have 9 wonderful months where you can do all kinds of wonderful outdoor activities and then comes summer. From mid-June through September it just sizzles and we scurry from air conditioned place to air conditioned car to air conditioned place.
It's a little early in the year for such heat. I sure hope it goes away.
Wednesday, May 14, 2008
Who's in charge here anyway?
I was discharging a 3 year old with strep throat and giving the discharge instructions to the parents. I was going over the prescription for Amoxicillin when the mom says "Oh, I can't get him to take medicine."
WTF? He's three. Who is the parent in this relationship. If you don't have some control over your three year old your life is going to be HELL when they get older.
When did parents stop being parents and turn into a bunch of namby-pamby pussies? Children don't know what is good for them and what is dangerous. It is up to you, their parents to make rules to keep them safe and healthy and ensure they grow up to be responsible, productive adults and you are FAILING MISERABLY!
Yet another reason why people should have to take a test before they are allowed to reproduce.
WTF? He's three. Who is the parent in this relationship. If you don't have some control over your three year old your life is going to be HELL when they get older.
When did parents stop being parents and turn into a bunch of namby-pamby pussies? Children don't know what is good for them and what is dangerous. It is up to you, their parents to make rules to keep them safe and healthy and ensure they grow up to be responsible, productive adults and you are FAILING MISERABLY!
Yet another reason why people should have to take a test before they are allowed to reproduce.
Tuesday, May 13, 2008
Tachycardia
It always amazes me how the people with a cold will call an ambulance but the really sick people will make their own way to the ER and sit patiently in the lobby until they are called for triage. They often give a vague, non-specific complaint when they sign in so the greeter doesn't catch that they need immediate attention.
We were short staffed one morning so we didn't have a triage nurse, we were all busy with patients in the back so when they called from up front for a lady with "weakness for a week" it took a minute for one of us to break away and get out front.
It happened to be me. The lobby was already full, when I called her name no one got up. I was about to give up when someone mentioned casually that they thought she was sitting next to them. I went over to check it out and found a woman slumped over minimally conscious, pale and diaphoretic with no palpable pulse. (Gives you an idea of the usual ER clientele that no one out there was worried about how she looked.)
We quickly got a gurney and rushed her to the back where she was found to be in V-tach, with a blood pressure of 48 by doppler. We quickly applied some electrical therapy in the form of cardioversion which converted her to sinus rhythm. Anti-arrhythmics, vasopressors, fluid boluses and eventually a trip to the cath lab which led to a 4 vessel CABG. She made a full recovery and made it home two weeks later.
Her story eventually filtered back to us. She had probably had an MI earlier in the week which was why she had been feeling bad, ischemia and necrosis made the heart irritable. She was feeling worse and worse but didn't want to be a bother to anyone. She called her doctor but couldn't get an appointment so she stayed at home until she couldn't take it any more and decided to drive herself to the ER. (In V-tach with no blood pressure!)
We had gotten three ambulances prior to her arrival, a 44 year old with nausea and vomiting for an hour, a chronic back pain and a sprained ankle. Ironic, isn't it.
picture credit
Monday, May 12, 2008
A Good Day
I had the best day today.
All of my patients we nice and thanked me for all I did for them.
We weren't balls to the wall so I had time to talk to them and explain what was going on and even do some teaching.
My kidney stone patient go 30mg of Toradol IV and went from pale, sweaty, writhing and vomiting to pink, dry and smiling. I believe if he could have a statue erected of me he would have done it, he was that thankful.
I got a bouquet of flowers from my son in the Air Force, a belated mom's day present.
I triaged a delightful 99 year old man with no medical problems AND on no medications that still lived alone independently and volunteered at the homeless shelter once a week. And he asked me out on a date.
I took care of a pale, lethargic, sick looking baby that perked up and looked like new after a couple fluid boluses. I was able to spend enough time with the mom to put her mind a little bit at ease.
My boss got a thank you letter from a previous patient of mine with praise.
The doctors bought us pizza for lunch.
We got the STEMI patient to the cath lab in 19 minutes! Go us!
All four of my favorite ER MD's were on today.
Why can't all our days be like this?
All of my patients we nice and thanked me for all I did for them.
We weren't balls to the wall so I had time to talk to them and explain what was going on and even do some teaching.
My kidney stone patient go 30mg of Toradol IV and went from pale, sweaty, writhing and vomiting to pink, dry and smiling. I believe if he could have a statue erected of me he would have done it, he was that thankful.
I got a bouquet of flowers from my son in the Air Force, a belated mom's day present.
I triaged a delightful 99 year old man with no medical problems AND on no medications that still lived alone independently and volunteered at the homeless shelter once a week. And he asked me out on a date.
I took care of a pale, lethargic, sick looking baby that perked up and looked like new after a couple fluid boluses. I was able to spend enough time with the mom to put her mind a little bit at ease.
My boss got a thank you letter from a previous patient of mine with praise.
The doctors bought us pizza for lunch.
We got the STEMI patient to the cath lab in 19 minutes! Go us!
All four of my favorite ER MD's were on today.
Why can't all our days be like this?
Sunday, May 11, 2008
Friday, May 9, 2008
You Know It's Gonna Be a Bad Day
I went in to see my first patient at the beginning of the shift only to find he had been incontinent of urine - the entire bed was soaked. I rounded up all the linen and bathing supplies and got one of the other nurse to help me. She rolled him over and I washed his back and bottom and pushed the dripping wet linen underneath him, usually I would start the dry linen but his old stuff was so wet we elected to roll him completely off of it to avoid getting the clean stuff wet. I reached across him and grabbed his shoulder and hip and rolled him to face me. He was kind of a big guy and ER gurneys are notoriously narrow so I had to roll him up against me to give the other nurse enough room to get the linen under him. Suddenly I felt a warm flood going down my leg and into my shoe. He was peeing and it was running off the mattress and all over me.
The sad thing was the rest of the day was so bad being peed on was the high point.
The sad thing was the rest of the day was so bad being peed on was the high point.
Thursday, May 8, 2008
Happy Nurses Week
It's nurses week and the blogosphere is full of tales of gifts received from employers, pens, coffee cups, fleece jackets and so on.
So what did my fine institution do for their nurses this year?
Not a damn thing!
So what did my fine institution do for their nurses this year?
Not a damn thing!
Wednesday, May 7, 2008
"We Need Some Help Out Here!"
We got the panicked call from the ER greeter - "There's a mom here with her baby and it's having trouble breathing - I think you better get right out here."
Our greeters are a very seasoned bunch and tend to not overstate things so we went right out there. Mom was about 20 and crying holding a limp, gray, grunting infant. I just grabbed the baby right out of her arms and headed to the 'crash' room without even looking to see if she was following. As I ran by the nurses station I yelled for help.
Not only was she not breathing well she was having some sort of seizure activity. Like a well oiled machine the team swung into action. One nurse started assisting respiration's with an ambu bag while another searched for an IV site, a third put on the monitor leads which showed a HR of 210 and a pulse ox of 79%. Cap refill was delayed and the abdomen was hard as a rock.
"What happened?" the doctor asked the mom, who was hovering in the doorway.
She came home from work and found the baby like this, dad had been home with the child. She was a normal healthy child but had been suffering from colic and was fussy.
Hearing this story a sick suspicion entered all of our minds. This baby had probably been beaten. We quickly intubated and started some fluid resuscitation then rushed off to CT scan. As we scanned the pictures coming up on the screen told the devastating story, traumatic sub-arachnoid hemorrhage and ruptured spleen spoke of violent shaking and violent blunt trauma to the abdomen - probably from being punched.
The baby was whisked off to surgery to remove the spleen. She survived the surgery but the neurologic damage was too great and the family elected to remove life support three days later. She was 3 months old.
Our greeters are a very seasoned bunch and tend to not overstate things so we went right out there. Mom was about 20 and crying holding a limp, gray, grunting infant. I just grabbed the baby right out of her arms and headed to the 'crash' room without even looking to see if she was following. As I ran by the nurses station I yelled for help.
Not only was she not breathing well she was having some sort of seizure activity. Like a well oiled machine the team swung into action. One nurse started assisting respiration's with an ambu bag while another searched for an IV site, a third put on the monitor leads which showed a HR of 210 and a pulse ox of 79%. Cap refill was delayed and the abdomen was hard as a rock.
"What happened?" the doctor asked the mom, who was hovering in the doorway.
She came home from work and found the baby like this, dad had been home with the child. She was a normal healthy child but had been suffering from colic and was fussy.
Hearing this story a sick suspicion entered all of our minds. This baby had probably been beaten. We quickly intubated and started some fluid resuscitation then rushed off to CT scan. As we scanned the pictures coming up on the screen told the devastating story, traumatic sub-arachnoid hemorrhage and ruptured spleen spoke of violent shaking and violent blunt trauma to the abdomen - probably from being punched.
The baby was whisked off to surgery to remove the spleen. She survived the surgery but the neurologic damage was too great and the family elected to remove life support three days later. She was 3 months old.
Monday, May 5, 2008
How to tell if you have a problem
So we have this doctor in town, there is one in every town, we call him doctor feelgood. All of his patients are on some cocktail of Oxycontin, Vicodin, Soma, Klonopin and so on. But.....to give him some credit, he expects his patients to adhere to the rules, he only gives out a months supply at a time and if he finds out you are going to other doctors or ER's - you're fired from his practice.
Recently we had one of his patients that gave a history of being on high dose narcotics for back pain come in with vomiting. His story was nausea, vomiting and chills for 24 hours. On exam it was fairly obvious he was in narcotic withdrawal. When the doctor confronted him the patient admitted he had been out of his med's for two days.
Brother, you've got a problem. You've used up a month's worth of med's in 17 days AND when your doctor finds out you've been here he'll probably give you the boot.
When the ER doctor explained all this to the patient and told him that he would not give him a narcotic prescription but would give him med's to treat the symptoms the patient went BALLISTIC. It ended up with the police being called and the patient going off to jail for attempted assault on a health care worker.
Another fun moment in the ER.
Recently we had one of his patients that gave a history of being on high dose narcotics for back pain come in with vomiting. His story was nausea, vomiting and chills for 24 hours. On exam it was fairly obvious he was in narcotic withdrawal. When the doctor confronted him the patient admitted he had been out of his med's for two days.
Brother, you've got a problem. You've used up a month's worth of med's in 17 days AND when your doctor finds out you've been here he'll probably give you the boot.
When the ER doctor explained all this to the patient and told him that he would not give him a narcotic prescription but would give him med's to treat the symptoms the patient went BALLISTIC. It ended up with the police being called and the patient going off to jail for attempted assault on a health care worker.
Another fun moment in the ER.
Saturday, May 3, 2008
Too Much Sun
I. Am. Sunburned.
Too much yard work even with #50 sunblock but I made a lot of progress, got my drip irrigation set up and working so it will all be automatic now. But I'm absolutely glowing right now and sleeping tonight will be hell.
With my pale Scandinavian skin I try to be very careful, I never go out unless slathered in sunblock, wearing a hat etc. Thankfully I don't burn all that easily, which you'd never believe if you saw me - fish belly white comes to mind. Not to mention that I am getting to the age when you don't want to actively seek out anything that will contribute to your wrinkles - they are doing fine on their own. But my care with the sun comes from another reason, one patient I just can't forget.
I had a patient a few years ago that came in for vomiting. He was in his mid-forties and had metastatic melanoma. He hadn't noticed the unusual mole on his back - it was discovered after a visit to the doctor for some shortness of breath that just wouldn't go away. A chest X-ray showed multiple lesions in his lungs. Multiple rounds of treatment with remissions and relapses later he was now in our ER with a bowel obstruction from the multiple metastatic lesions in his abdomen. The lesions were also now in his brain, liver and bones.
His pain was agonizing despite massive doses of narcotics. He weighed 97 pounds. A mere skeleton covered with a frail, tissue paper coating of yellowed skin. His hair, once lush and wavy, was now just a few brittle strands. He had bedsores on his bottom. If you have ever questioned whether hell exists, it does - and this poor man was in it.
We admitted him for pain management and I heard he died later that day. I've always remembered that man. I am religious about checking my skin and go to the dermatologist regularly also. Dying from melanoma is a horrible way to go. A now I've got this sunburn...........
Too much yard work even with #50 sunblock but I made a lot of progress, got my drip irrigation set up and working so it will all be automatic now. But I'm absolutely glowing right now and sleeping tonight will be hell.
With my pale Scandinavian skin I try to be very careful, I never go out unless slathered in sunblock, wearing a hat etc. Thankfully I don't burn all that easily, which you'd never believe if you saw me - fish belly white comes to mind. Not to mention that I am getting to the age when you don't want to actively seek out anything that will contribute to your wrinkles - they are doing fine on their own. But my care with the sun comes from another reason, one patient I just can't forget.
I had a patient a few years ago that came in for vomiting. He was in his mid-forties and had metastatic melanoma. He hadn't noticed the unusual mole on his back - it was discovered after a visit to the doctor for some shortness of breath that just wouldn't go away. A chest X-ray showed multiple lesions in his lungs. Multiple rounds of treatment with remissions and relapses later he was now in our ER with a bowel obstruction from the multiple metastatic lesions in his abdomen. The lesions were also now in his brain, liver and bones.
His pain was agonizing despite massive doses of narcotics. He weighed 97 pounds. A mere skeleton covered with a frail, tissue paper coating of yellowed skin. His hair, once lush and wavy, was now just a few brittle strands. He had bedsores on his bottom. If you have ever questioned whether hell exists, it does - and this poor man was in it.
We admitted him for pain management and I heard he died later that day. I've always remembered that man. I am religious about checking my skin and go to the dermatologist regularly also. Dying from melanoma is a horrible way to go. A now I've got this sunburn...........
Friday, May 2, 2008
I'm going to buy this.
Imagine the endless entertainment I will have. Talking on the cell phone and driving 57 MPH in the passing lane? Jammed.
Endless phone call with your friend talking about the fight you had with your boyfriend last night while sitting behind me in the theater? Jammed.
Your cell phone ringing incessantly while I am trying to eat? Jammed.
Carrying on a cell phone conversation while sitting on a toilet in the ladies room? Jammed.
Talking on your cell phone in triage? Jammed.
Cell phone glued to your ear while you are at the amusement park with your kids? Jammed. Dumb ass.
I can hardly wait. I hope they have overnight delivery!
Imagine the endless entertainment I will have. Talking on the cell phone and driving 57 MPH in the passing lane? Jammed.
Endless phone call with your friend talking about the fight you had with your boyfriend last night while sitting behind me in the theater? Jammed.
Your cell phone ringing incessantly while I am trying to eat? Jammed.
Carrying on a cell phone conversation while sitting on a toilet in the ladies room? Jammed.
Talking on your cell phone in triage? Jammed.
Cell phone glued to your ear while you are at the amusement park with your kids? Jammed. Dumb ass.
I can hardly wait. I hope they have overnight delivery!
Things you hope never happen
A long time ago in a hospital far, far away.
It was January, the temperature was approaching zero and it was snowing like hell. The ER I worked in was in a resort town that was all but deserted in the winter. There was a PA and myself and we had seen a grand total of seven patients so far that day.
It was after lunch. We had two patients in the department, a lady with vomiting getting IV fluids and waiting for lab results to rule out an appy and a little old man with chest pain that was waiting for an ambulance to transfer him to bigger hospital down the road to repair his broken hip. Both were sleeping and the PA and I were finishing up charting and charges.
A car pulled up to the ambulance dock and a man helped his heavily pregnant wife out of the car. I went out with a wheelchair to help them.
"My water broke and there is something hanging out of me, I think it might be the cord."
Oh my God. My heart almost stopped. We were a half an hour away from the closest hospital that did any kind of obstetrics and this was an obstetrical emergency. A half an hour in good weather and this was anything but.
We zipped into the ER and quickly got her up on the cart, stripping off her bottoms we saw that indeed there was cord protruding from her vagina. I helped her to get onto all fours with her bottom pointing into the air and the PA quickly slipped a sterile glove on and reached inside to push the babies head up off the cord to relieve the pressure and allow blood to flow to the baby. I grabbed the doppler and auscultated fetal heart tones which were 147, in the normal range. I placed an oxygen mask on the mom.
I stepped away to quickly call the supervisor to come and help. The PA couldn't move, if he took his hand away the fetal head would compress the cord cutting off the flow of blood and oxygen. She needed a c-section right away and our hospital couldn't do one. The general surgeon arrived and discussed the options with the parents, The elected to try for a transfer to the other hospital as long as things looked OK. The fetal heart rate remained reassuring.
Thank goodness the transfer went without a hitch, the PA had to go and the surgeon also went in case he was needed, the nursing supervisor had OB experience so she rode up front in case the baby delivered.. The other hospital was alerted and was on full standby, the patient was in the OR within 5 minutes of her arrival where they delivered a healthy baby boy via c-section without incident.
I don't think I've been that scared since.
It was January, the temperature was approaching zero and it was snowing like hell. The ER I worked in was in a resort town that was all but deserted in the winter. There was a PA and myself and we had seen a grand total of seven patients so far that day.
It was after lunch. We had two patients in the department, a lady with vomiting getting IV fluids and waiting for lab results to rule out an appy and a little old man with chest pain that was waiting for an ambulance to transfer him to bigger hospital down the road to repair his broken hip. Both were sleeping and the PA and I were finishing up charting and charges.
A car pulled up to the ambulance dock and a man helped his heavily pregnant wife out of the car. I went out with a wheelchair to help them.
"My water broke and there is something hanging out of me, I think it might be the cord."
Oh my God. My heart almost stopped. We were a half an hour away from the closest hospital that did any kind of obstetrics and this was an obstetrical emergency. A half an hour in good weather and this was anything but.
We zipped into the ER and quickly got her up on the cart, stripping off her bottoms we saw that indeed there was cord protruding from her vagina. I helped her to get onto all fours with her bottom pointing into the air and the PA quickly slipped a sterile glove on and reached inside to push the babies head up off the cord to relieve the pressure and allow blood to flow to the baby. I grabbed the doppler and auscultated fetal heart tones which were 147, in the normal range. I placed an oxygen mask on the mom.
I stepped away to quickly call the supervisor to come and help. The PA couldn't move, if he took his hand away the fetal head would compress the cord cutting off the flow of blood and oxygen. She needed a c-section right away and our hospital couldn't do one. The general surgeon arrived and discussed the options with the parents, The elected to try for a transfer to the other hospital as long as things looked OK. The fetal heart rate remained reassuring.
Thank goodness the transfer went without a hitch, the PA had to go and the surgeon also went in case he was needed, the nursing supervisor had OB experience so she rode up front in case the baby delivered.. The other hospital was alerted and was on full standby, the patient was in the OR within 5 minutes of her arrival where they delivered a healthy baby boy via c-section without incident.
I don't think I've been that scared since.
Thursday, May 1, 2008
Mylie Cyrus Scandal. Not.
This IS NOT naked.
What is the matter with people? I'm sure she shows a lot more skin at the beach without people getting all in a flap.
I don't care for the makeup that makes her look like a freshly dug up corpse but other than that, there is nothing offensive about her back showing.
Give the girl a break and get yourselves a life.
Things are never what they seem
My patient was a petite, thin 16 year-old. She sat on the exam table, shoulders hunched and staring at the floor while her mother told the story.
"I found a towel saturated with blood in her hamper." I listened but mentally wondered exactly saturated was. People tend to over-estimate the amount of blood.
The girl said she had started her period and had bled more than normal. She had awakened after it started and used the towel to clean up. She said the bleeding had pretty much tapered off and showed me a half saturated pad that she said was over an hour old.
I wondered if she was pregnant and miscarried and was trying to hide it from her mom. I started an IV and drew blood for chemistry, blood counts and type and screen. I explained that we would have to do a pelvic exam. She had never had one before so I spent some time explaining the procedure and getting her ready.
The doctor, a woman, had a reputation for unshakable calm. We positioned the girl in the stirrups and she gently inserted the speculum. As she opened the speculum a huge clot came loose followed by an unstoppable torrent of bright red blood.
The doctor said to me "Get some help in here."
I hit the code button.
I'd never seen that blood coming out of a woman's vagina before - it was horrifying. The doctor was using suction to try and locate the source to no avail so she started packing the vagina. Fluid boluses were hung and pressure bagged. The patients pulse was climbing and blood pressure falling. After 2 liters of saline we hung uncross-matched blood. The OR crew arrived and stood outside the door waiting for the GYN doc to arrive.
Shortly after that he arrived. The room looked like a slaughter-house. Two 1.5 liter suction buckets were filled - more than half the patients blood volume. Uncross-matched blood was being infused via the rapid transfuser. The ER doc had her hand in the patients vagina putting pressure against many yards of vaginal packing. The patient lay limply on the stretcher, semi-conscious.
Within minutes the whole entourage was whisked up to the OR. The ER doc was gone for over an hour. When she returned she told us that the patient was slightly more stable - the GYN surgeon had found a huge, jagged vaginal laceration that had torn an adjacent artery. It was a wonder that the patient hadn't bled to death at home. But how had it happened?
The sad story emerged days later. She had gone on a date with an older boy. He became angry when she wouldn't have sex with him and raped her. He was rather a large male and she was a small, petite girl and a virgin besides and she tore inside. She was bleeding heavily when she got home but was too ashamed to tell her mother. When the bleeding stopped she hid the towel and went to bed, terrified but trying to forget the ordeal.
"I found a towel saturated with blood in her hamper." I listened but mentally wondered exactly saturated was. People tend to over-estimate the amount of blood.
The girl said she had started her period and had bled more than normal. She had awakened after it started and used the towel to clean up. She said the bleeding had pretty much tapered off and showed me a half saturated pad that she said was over an hour old.
I wondered if she was pregnant and miscarried and was trying to hide it from her mom. I started an IV and drew blood for chemistry, blood counts and type and screen. I explained that we would have to do a pelvic exam. She had never had one before so I spent some time explaining the procedure and getting her ready.
The doctor, a woman, had a reputation for unshakable calm. We positioned the girl in the stirrups and she gently inserted the speculum. As she opened the speculum a huge clot came loose followed by an unstoppable torrent of bright red blood.
The doctor said to me "Get some help in here."
I hit the code button.
I'd never seen that blood coming out of a woman's vagina before - it was horrifying. The doctor was using suction to try and locate the source to no avail so she started packing the vagina. Fluid boluses were hung and pressure bagged. The patients pulse was climbing and blood pressure falling. After 2 liters of saline we hung uncross-matched blood. The OR crew arrived and stood outside the door waiting for the GYN doc to arrive.
Shortly after that he arrived. The room looked like a slaughter-house. Two 1.5 liter suction buckets were filled - more than half the patients blood volume. Uncross-matched blood was being infused via the rapid transfuser. The ER doc had her hand in the patients vagina putting pressure against many yards of vaginal packing. The patient lay limply on the stretcher, semi-conscious.
Within minutes the whole entourage was whisked up to the OR. The ER doc was gone for over an hour. When she returned she told us that the patient was slightly more stable - the GYN surgeon had found a huge, jagged vaginal laceration that had torn an adjacent artery. It was a wonder that the patient hadn't bled to death at home. But how had it happened?
The sad story emerged days later. She had gone on a date with an older boy. He became angry when she wouldn't have sex with him and raped her. He was rather a large male and she was a small, petite girl and a virgin besides and she tore inside. She was bleeding heavily when she got home but was too ashamed to tell her mother. When the bleeding stopped she hid the towel and went to bed, terrified but trying to forget the ordeal.
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