They say I'm a great nurse and a biotch! I'm okay with that

I had an interview within the hospital system for a critical care transport gig.  I've been considering getting the heck out of my ER for the past year, but really haven't done much in planning an exit.  Earlier in the month I interviewed in a trauma center in the hood, I was offered a position, but I haven't set up a start date yet.  I guess I was weighing my options.  Do I stay in my dysfunctional ER or tough it out until after the "new ER" opens and see if the new CNO makes much needed changes?  Fortunately I was approached about a critical transport opening and a CCU opening, not to mention the other ER gig.  So I have options.

I love the ER.  I think I'm a kick ass ER nurse, and my peers, patients and docs compliment me often.  Unfortunately lately I have been utterly disenchanted.  I love the work, I love the patients, I truly love working in the ER, but I am so incredibly disappointed with the quality of care that some of my peers provide and it is frustrating.  Recently one of my coworkers told me that some of the nurses on dayshift fear giving me report.  He finds it hysterical.  I find it amusing as well. When I asked him why he told me that they are always scrambling to get things done because they know if I come in and the shits not done there will be hell to pay.  I'm not sure that I would say that I would say I'm that rough on them, but I have written people up for neglecting to give meds or start IVs that were ordered hours ago.

I guess I learned the old school military way.  You treat every patient like they belong to your family, and you make sure you do your job.

If this expectation has given me the title of biotch, so be it.  I wear it well.

I am more than happy to point out when someone does a great job, but I will not coddle a lazy incompetent person!

Jackass OBs and their little friends too

I haven't spent a ton of my nursing career in labor and delivery, but I have spent enough time dealing with egotistical OBs as well as my own experience as a patient and a support team member to other moms to offer this rant:

Dear Labor and Deliver Staff:

1) Please stop saying "you're not in labor" when a mom is having palpable contractions every 6-3 minutes.
2) Please don't be the ass who asks the mom in labor with contractions every 4 minutes, "Do you have a low pain tolerance?"  --- here's a clue if the person is having repeated contractions--- of course its painful- if its their first birth chances are it's going to be very uncomfortable.  If you have a penis ask yourself how would that feel if your penis was contracting every 4 minutes!!  If you can't imagine it please come closer and I will find a way to make you uncomfortable every 4 minutes and follow it up with "do you have a low pain tolerance?".
3) Please don't tell the mom in labor that although the monitor shows a contraction of 75, it really doesn't matter, because the numbers on the monitor are only really valid when the internal transducer is in place---  moms in pain don't give a crap about that, and it doesn't reduce their pain.
4) Please don't tell moms who are having a difficult time pushing because of an epidural that they "aren't trying hard enough".
5) Please don't tell the mom who is 37 weeks, bleeding, having strong contractions every 4 minutes and was on bed rest at 22 weeks for preterm contractions and an incompetent cervix that they can go home because there are not in labor and they shouldn't be having pain because they aren't in labor because their cervix is only 3 cm dilated.
6) Please put an IV in and hydrate the mom when she has not been able to eat or drink appropriate amounts due to pain and vomiting, within 2 hours of being at the hospital, and not 10 hours later!
7) Please do not blame the dehydrated, pregnant, scared mom who is in pain with contractions for not having plump veins.
8)  Please do the right thing for dehydrated moms in pain and find the best vein for the time being--- if its an AC vein so be it-- hydrate them, manage them with an antiemetic and pain meds, find a more suitable vein in the lower arm later after they are hydrated--- don't stick the patient 7 times when you could have inserted an IV the first time!  Take care of the patient first! find the vein that suits you better later when they are comfortable!
9)  Don't ask the support team and husband to leave the room because your IV skills, and the skill of the nursing team suck!
10)  After essentially blaming the patient for "not being in labor" and taking up a bed with symptoms of labor in a high risk pregnancy, don't try to shove them off to home or an antepartum unit, re-check the patient.  And by the way you look like a complete ass when the patient dilates to 4 from the 3 they were at and now all of a sudden they are in labor!  And when you say "I've never seen this before"… you are a liar…  it happens all of the time!  Women can be slow to dilate and have close strong contractions!  It happens all of the time!
11) To the L&D staff.  A mom that is "not in labor" is no different than another patient in the hospital..   they need to be assessed and monitored!  Waiting hours to check a set of vital signs is not appropriate!  You have that ability on your fetal monitor!  Put the cuff on!
12) L&D nurses: Advocate for your patients!
13)  Don't leave narcotic pain meds drawn up in a syringe sitting for 2 hours at the bedside until the anesthesiologist can come start the AC IV---  waste or return your meds!  Bad practice!  Very bad!
14) When a mom has been pushing for 3 hours and things are not progressing, change the approach, because when that baby is born and isn't breathing, has to be placed on a vent with a cooling cap, its hell on the family and the nice ER nurse friend is now your worst enemy!
15) When you see the meconium come out when the bag was ruptured, you need to explain to the family the significance of it right then and there, not wait  hours until the very troubled birth!  Because that C-section they requested before they fully dilated might have been a better idea than the chain of events that unfolded!

Stop Bit@hing And Do Something

The ER I work in has 4 areas.  The area I was assigned to the other day is pretty detached from the main ER.  This particular part of the ER has 10 urgent care beds for the not so sick folks and then another 12 beds for level 3 and 2 patients.  The 12 bed area gets its fair share of stroke and septic patients.  Unfortunately it is a logistical nightmare.  Not only is it minimally stocked with meds, the new flavor of the month is not to have insulin stocked in a medication refrigerator because there were issues with vials not being properly labeled with "use by" dates.  Needless to say trekking through the ER to the main ER's med room is time consuming.  Upon getting to the med room and finding no insulin one might find themselves extremely annoyed… not because they walked all the way to the main ER, but because it was a complete waste of time  when they are otherwise running around cleaning up the mess from the prior shift.

Having had this issue of no insulin in the ER in the past I called the pharmacy and offered to pick up a bottle of each type of insulin in order to restock the ER!  During my conversation with the pharmacy tech I asked why when they restocked the refrigerator they didn't check to see if we had insulin.  The tech informed me that it wasn't something they did.  Knowing that they stock the refrigerator with other refrigerated meds it just seemed like a simple request…. but I wasn't getting anywhere.  The only explanation I was given was that someone must have been stealing the meds.

After hanging up the phone on of my managers said that I was "mean" for calling them as telling them that it was unacceptable that the ER didn't have insulin.  Well I do find it completely unacceptable to not have insulin stocked in an ER.  I then pointed out to the manager and the charge nurse that this was a chronic issue, which it has been, and that we needed a solution.  She quickly stated that pharmacy wouldn't perform a check and restock twice a day.  I then suggested that the charge nurse at the beginning of the shift check the refrigerator to ensure that insulin was stocked as well as checking our stock levels for vital things like liter bags of normal saline.  I was then told by the charge nurse that I "complain too much".

Maybe I do complain.  But I think that I am right to complain and offer a few suggestions on how to fix this problem we have.

Its interesting how identifying a problem and offering a solution is met with such resistance.

I have decided to turn a new leaf.  I'm not one of my apathetic coworkers, I refuse to give into that mentality.  If there is an issue I will absolutely point it out but I will now offer no less than three solutions.

Compassion and Caring

"Love and compassion are necessities, not luxuries.  Without them humanity cannot survive." ~ Dalai Lama

Compassion is something that one would thing is a given with nursing and the medical system.  Compassion is the one thing that is not delivered in a pill, an IV push in a manufactured way.  Compassion is genuine.  Compassion is ignited from within.  Compassion in the one thing that we can give of ourselves to comfort those who are suffering, as we give it, we also receive great benefits in return.

Why is it in our field there is a lack of compassion.  In order to provide compassionate care we must have received compassion. As we care for our patients and provide compassion it is equally important that we treat the members of our hospital teams with compassion.

http://www.ted.com/talks/view/lang///id/1216

Joan Halifax highlights this concept in a short Ted Talks episode.

2013 ENA President-Elect Deena Brecher speaks at 2013 ENA General Assembly

Incarceritis And New Onset Suicidal Thoughts at Time of Discharge

There is this amazing phenomenon  in the emergency room that results when a patient arrives in the ER while in custody of law enforcement with a new onset of incarceritits.  The symptoms of incarceritis include chest pain, shortness of breath and syncope.  Upon a full medical work up, which often includes lab tests, EKG and x-rays medical findings are usually negative for MI or other life threatening emergencies.  As the patient is discharged they miraculously develop new onset suicidal thoughts.  

Lucky for them they are usually handcuffed to a stretcher and have no personal belongings.  

Thankfully there is a cure for this!  Swift discharge and a bail bonds business card.  

The Waiting Room---- Why do you wait to be seen in the ER?

I have to give PBS props for airing what has to be the most honest look into life in the ER, for the patients that wait to the team that works to care for what is an endless stream of pictures.

If you haven't had a chance to view this gem, I encourage you to click on this link and give it a view!

http://video.pbs.org/video/2365092060/

While MTV shows the party life of nurses on their new show, essentially Jersey Shoring nursing, this is PBS docu is a real look, the real deal!

Who Dat?

I ran into a former manager today and it was an interesting experience.  I hadn't seen her in a while.  When I worked under her she was always well dressed, poised, professional in appearance....  when I saw her today in my former ED I hardly recognized her.  At first I thought she was one of the girls from the hood.  Then I thought she was a visitor.  Maybe it was the bad wig, the overly tight attire, the lab coat the unprofessional lab coat or the fact that she was literally hanging on some guy in the ED.  This was not the same former manager who was well dressed, professional and poised that I once knew.  I stand by my earlier post, leadership is lost!

Leadership Is A Lost Art In The Wake Of Middle Management

Many, many years ago the career field of nursing had leadership as a core value, but over the years reorganization and redefinition of management has suffocated the concept of leadership.  Gone are the days when you looked to your fellow staff nurses for mentorship.  Today's concept of nursing has ultimately killed the bond that drew us all together and it is weakening our very foundation.

When I look around at work there are very few leaders.  By leaders I don't mean managers.  In my opinion the two words have completely different meanings, although in today's hospitals nursing leadership is comprised of managers which is unfortunately an oxymoron most of the time because nursing managers rarely lead, they follow the hire up administration's agendas.  Perhaps that is why there are floors closed to accepting patients because there "isn't enough staff" which causes emergency department patients to sit waiting for hours for beds.  Lean staffing was a concept of management, certainly not nursing leadership.  What good nurse would ever want to subject patients to the hell of the dreaded hallway bed for hours?  Where is leadership advocating for the patient's safety and wellbeing?

I recently had an experience with three nursing managers.  Two of the managers were assistant nurse managers and the other a supervisor in the ED.  I had a critically ill patient who was bottoming out.  The patient's heart rate dropped to 32.  I had five patients to contend with at the time, and my neighbor, a new graduate just off orientation had five patients of her own.  Having informed the three managers who were sitting at the nurses station of the situation with my patient, and seeing how my neighbor looked a bit like a deer in the headlights, I asked my neighbor to ask one of the three manages to come over and assist me.  When my neighbor returned she informed me that they refused to help.  Wow was I blown away, well not really.  This is how our management is.  They are managers not leaders.

About an hour into pacing this patient and starting dobutamine, yes DOBUTAMINE, on this patient, one of the managers shows up.  She is eating popcorn, and coughing.  She tells me, "I'm choking on my popcorn", I shoot her a look which probably included an eye roll and I inform her that I needed her help an hour ago.

Her response to me is cold.  She lashes out that "I'm here now".  My response to her was "I needed you an hour ago".

During this hour that has transpired I had patients who were in pain, physicians trying to call in orders and other patients who had room assignments that needed report called, but I was tied up with a critically ill patient who was in dire need, yet for that hour my patients' needs, my call for assistance was less important than popcorn.

Just because one holds the title of manager does not make one a leader.  Leadership comes from within, regardless of rank, title or pay status.  Unfortunately true leadership has been left to the waste side, abandoned for some alien concept of leadership.

50 Year Old Stripper

Our ER has a special place for the party people in da house.  It's the drunk hall.  Forrest Gump's line of "Life is like a box of chocolates, you never know what you're gunna get" totally describes it perfectly.  Work is nothing less than an adventure when you're working that assignment.

On one particular night I was greeted by some very happy EMTs.  "What are you'll smiling at", I asked.
"You'll see", they replied.
"Can you give me a hint", I ask.
"Drunken stripper", the respond while laughing.

As I walk down the hall to meet Jane Doe Drunken Stripper, she hops off the stretcher naked as the day she came into this world and sacheyed over to another stretcher and began her bump and grind.  Wow, the boys who dropped her off weren't kidding, this chic had moves.

A very nice security guard looked at me while he was putting on his gloves and says, " I guess we won't be fighting this one to get her cloths off."  When folks come back to the drunk hall we change them into gowns, so if they try to wander out the door they can be easily identified.  This practice also helps  us reduces the fragrence in the ER.

We start to approach our naked patient.  She takes a look at the security guard and turns her attention to him.  He's a big guy and hard to miss.  As she begins her floor routine  a crowd of young surgical inters find themselves captive behind her, they look scared, they didn't know where to go, so they just froze.  Stripper lady continued shaking her money maker and then did something that stunned everyone, a gymnast type move, she stretched her leg straight up to the side of her head, the poor residents looked mortified. I was a little jealous I couldn't do that myself after years of yoga, and the security guard just shook his head uttering, "I didn't need to see that".

We managed to get her into gown number 1 out of 8 for the night, and she was moved back to the stretcher.

Throughout the evening she would get her gown off and then slide herself off the stretcher and start her routine.  At one point she started a lap dance on a sleeping orderly, which woke him up real quick with the look of panic on his face.  There were other times when her stretcher was her stage and she was dancing on top of it and asking for money.

A few hours into her stay she was becoming more lucid. When I asked her what her name was she gave me I can only assume was a stage name.

Eventually an older man showed up, saying he had called the ambulance for her. She worked in his strip club.  He had recently demoted her from a dancer to a bar tender because of her age, because she had turned 50.  I asked him if she was depressed about turning 50, he said, " No, she's  pissed at me because I don't want her dancing anymore, I thought I was doing her a favor".

The gentleman was kind enough to leave contact information so she had a ride home after she woke up.

Nurses Gone Wild Convention Style

There's nothing better than going to a convention to recharge your knowledge and your spirits!  Conventions are so informative.  You learn cutting edge techniques, you have a chance to network (job search), you meet nurses from different hospitals so you can get the low down info about where you might or might not want to work, but probably more important than any of that is the pure joy you having watching your co-workers, bosses and friends make total asses of themselves after drinking way too much!  Oh the power of alcohol!  Thank god for libations and lack a inhibition!  There were the intoxicated dancing assistant nurse managers, the puking educators,and the grinding granny (retired nurse).  It was a lovely 3 days!  Now it's back to the grind, but not the kind of grind granny was doing...

Love In the ER

I love a good love story.  One night a woman was rushed to the the ER by her husband because she had chest pain.  The couple were in their later 70's and had just had dinner to celebrate their 50th wedding anniversary. When I asked how the couple met the husband told me a very funny story. 

He told me that he was working in construction at an office building when her heard women screaming.  His boss thinking that the ladies saw a bug, told his worker to go in and check things out.  As the man, the patient's husband, opened the door he was greeted by a cloud of smoke.  The ceiling had collapsed in on the ladies.  When the dust cleared that's when this husband of 50 years met the love of his life.  He told me it was love at first sight. 

Like any good man he pulled pieces of plaster off of his future wife and then asked her out on a date for coffee.  A few months later they married!  

A couple of hours after arriving at the ER, the two lovebirds were on their way home.  She wasn't having an heart attack, just a case of indigestion!  

Hello Gonorrhea Welcome Back- Antibiotic Resistant STDs

A young lady came to the ER complaining of "stankness" from her vajayjay and some abdominal pain. I asked her for a urine sample to do the pregnancy test and send off the standard urine testing.  In the mean time her and her mother settled into the GYN exam room.   When I returned to the room she was already changed.  She asked me the results of her pregnancy test which was negative.  Her mother nodded approvingly.  I asked the patient if she wanted to have her mom wait in the waiting room until after the exam was complete, she declined, and said her mom could stay.  

A resident came and introduced himself.  He asked her about her history which she offered up including dates of treatments and course of treatment. 

After the exam was done and the culture obtained the patient sat up.  The doctor told her she probably had gonorrhea.  Out of the corner of my eye I caught a glimpse of her mom... she didn't look shocked.  I was expecting shocked.  

Her mom looked at the doc and says, "You better giver her something stronger this time. She had this a month ago and the medicine didn't work."

The doctor then asks the patient, "So you had this last month, did you finish the prescription?"

She responded, "Yeh, I did but I don't think it worked, because it came back again."

The doctor went on to explain that she had to abstain from sex and that her partner would need to be tested and treated.  The patient responded that she understood.  When asked about the kind of birth control she was using, she replied that she wasn't using any.  Concerned the doctor explained the risk of other STDs and the increased chances of fertility problems down the road.  The patient then explained that the only person she has unprotected sex with is her boyfriend, and that the other guys have to wear condoms.  

Again out of the corner of my eye I look at the mother's response, still no shock.  

That's when the mother says, "Well I just think that stuff she has mutated."

While my thinking is that it might have had to do with the multiple sex partners and no protection her mother might be on to something.  

Just when you thought that gonorrhea was bad now we do in fact have antibiotic strains.  

http://www.cdc.gov/std/Gonorrhea/arg/basic.htm

Maggots! I have a love hate relationship with them

Some things are not uncommon where I work.  Up to 40% of the patient population I deal with has diabetes and vascular issues. The smell of rotting flesh goes with the territory.  Here is where the poor folks live. They have very limited access to good healthy food, the kind of food diabetics should be eating and with the per capita gun homicide rate of 25.4 per 100,000, people are afraid of going outside for a run or exercise.

Generations of families rely on public assistance and their health care insurance is through Medicaid and Medicare.  The city has 4 hospitals, but there are limited primary care doctors that take Medicaid, and fewer specialists participate with Medicaid.  In other cities and suburbs you see plenty of doctor offices and doctor practices near hospitals, but not in the poor areas with high gun violence, so people go without.  

One evening a woman came in.  She had the triple threat that is common in our patients: obesity, diabetes and vascular disease.  Her legs had loose dressings that looked like an abstract painting.  There were bits of green, brown, yellow,red and tan, there was no evidence of the white gauze that it started out as.  The EMTs brought her in wearing face masks, so everyone knew it was going to be bad.  But how bad could it be?

My co-worker was the lucky nurse to get this patient.  She was a newer nurse, but well skilled and truly a lovely person.  Out of the corner of my eye I see her running out of the ER towards the ambulance entrance.  I walked out after her to see what was up.  

"I'm going to puke", she said. 

She went on to describe that the woman's bandages were concealing a slew of maggots which where eating her flesh.

Now most people would right away freak out.  Maggots in a hospital.  I know it sounds bad.  Okay in this case it wasn't ideal, but the maggots really were helping.  

In other countries around the world maggots are used to treat diabetic ulcers that won't heal with conventional medicine.  Maggots only eat the rotting flesh which allows the new tissue to grow.  Of course the maggots used for treatment are generally grown under sterile conditions, so yes our ER patient's maggots weren't ideal.

How can this happen you might wonder? Well the patient said she had a nurse come take care of her.  Of course "nurse" is a broad term, read the post about the garlic in the vajayjay, she was a "nurse".  This woman was paying someone from her hood to come take care of her, not an agency, not the VNA, just some girl who she knew.  

When we told he patient about the maggots she was stunned.  See that might shock the reader, "How could she not have known?", well if you are 5 foot 1 inch and weigh 360 pounds, you can't walk, the chances are you aren't bathing everyday and you eventually get use to the smell, she also couldn't see her legs.  

Was there an abundance of flies in her house? Yes, the EMTs said that the house was a mess, but she didn't have anyone who cared.  She finally called 9-1-1 when she couldn't take the pain anymore.  

Perhaps we have the reason why no matter what time of year it is, even when it is snowing outside we still have flies buzzing around the ER.  

Nursing Bliss: A Place at the Table

Nursing Bliss: A Place at the Table: I had a chance to see the documentary "A Place at the Table", tonight after my 10 year old went to sleep. The movie opens showin...

Too Painful to Watch

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Brick to Your Head

This is going to sound really insensitive and probably tarnish the halo above my head but it was perhaps one of the funniest and most frustrating nights I ever had in the ER.

The city I work in is called the Brick City. I work in one of the larger hospitals in the town.  On a daily basis our ER is packed.  We might see 300 patients a day in the ER.  There are patients being seen in plastic chairs, there are stretches in the hallways, there are patients waiting for hours in the waiting room just waiting for a chance to get the main ER, when ambulance units arrive with stretchers patients have to be moved just so the medics can get through the hall to find an open bed.

The city has violence, it has gangs, homeless, it has a heartbeat that is uniquely it's own.  It's an energy like something I have never experienced anywhere else in the world.  Newark has that vibe.  It is crude, it is bold, and it is humbling.

One night we had a woman come into the ER with her loved one. They were from an upper middle class suburb about 45 minutes away from the Brick City.  She had come into the ER because she wanted her loved one to get clean and sober, a Friday night epiphany.  Believe me I am all for folks kicking their habits, but there were a couple of issues I had with this particular situation: 1) She was obnoxious, she felt that since she thought that she knew a doctor in the massive hospital, she was privileged.  2) we are not a detox facility and we didn't have what they needed, but we provided a referral, which she didn't think was good enough.  3) she demanded a private room, insinuating that she and her loved one were more important, although there was nothing critical about that person's condition, meanwhile there were seriously ill patients waiting for stretches, even if that was a bed in a hallway a foot away from another patient.

Our ER isn't pretty.  It doesn't smell good.  There are homeless folks in the waiting room, in the ER and waiting outside, but we are damn good at our jobs, even with nursing shortages and cutbacks.

Well on this particular night the person who came for detox was tired of waiting for a room, tired of waiting because we did not have services to offer him. After much ranting and raving from a loved one, the patient went out to smoke a cigarette.  Now leaving the ER to smoke is against our policy, but no matter what we said we, the staff, couldn't be right.  We were always wrong.  Well some might call it karma, but when this person went out to smoke after telling me to "F" myself,  he was hit in the head with a brick.

Welcome to the Brick City!

While I don't condone violence in anyway I also do not condone patients and their loved ones treating nurses like crap.

New Clogs vs Chest Tube

I found the perfect clogs.  They were so comfy.  Did I mention that they were perfect. Beautiful shiny black paten leather, light weight, I was in shoe heaven.  I was gracefully and comfortably gliding to the busy ER, no discomfort.  My feets were happy.

I went into check on a patient who was complaining of coughing for a few days and shortness of breath.  He had taken off his oxygen, and his oxygen saturation was looking crappy.  

Like a good nurse I chat with him for a moment and then listen to his lungs, or should I say lung.  

That's right he only had lung sounds in one lung.

I find an attending physician and alert him to the pneumothorax (collapsed lung),  but the doctor doesn't look phased, no blinking of eyes, no getting up from his chair, he didn't even send a resident over.  So I order a stat chest X-ray and beg the tech to pull it up in the ER for me.  How I love digital technology.  

My hunch was correct-- pneumothorax!  So I grab a resident, ask him to read the xray to confirm the diagnosis (because I'm a silly nurse and I can't diagnose anything).  I quickly walk over to the lazy unimpressed attending to tell him that "the patient has a pneumo."  

"How do you know", he asks.  

"I ordered a chest xray and it shows one, and there's that whole no lung sounds thing", in a slightly smart assed tone. 

He gave me the oh shit look and got up, quickly walked over to the patient and took a listen, then walked over to the computer to check the X-ray.  

So now it was time to fix the problem at hand.  

I gave the patient some pain meds, explained to him that he needed a chest tube and what a chest tube was.  I got the equipment set up.  Now we were just waiting for a doctor to show up, but I had on my comfortable new shoes.

So the resident comes bouncing over and looks thrilled.  How they love to put in chest tubes.  

So Resident A begins putting in the chest tube.  He has a medical student and an intern at the bedside with him.  He in on the bad lung side and I am on the other, holding the patient's hand and talking him through the process.  The patient is doing well, suddenly I hear the splash of fluid hitting the floor.   It's a lot of fluid.  Realizing the residents on the other side are fumbling with the pleurovac and seeing the floor covered in fluid I move over to the other side of the bed, my new clogs are splashing in the lung juice.  I  hook up the chest tube to the pleurovac.

"Thanks I owe you", the resident says.  

"Yes, you do to the tune of about $120 for a new pair of clogs".  

Garlic in the Vajayjay

One afternoon a woman dressed in scrubs came into the ER.  I looked at her triage and her complaint was "UTI".  I asked her for a urine sample which she quickly gave me.  As I ran the usual urine pregnancy test and a urine dip, I noticed the pungent smell of garlic.

I finished the test and returned to the exam room.  I began asking her questions about her history and her current symptoms.  When I asked he why she thought she had a UTI she told me that she "gets them all the time."  I asked her when she last had a UTI and if she was prescribed an antibiotic.

She looked at me and told me, "I'm a nursing assistant and I treat myself".  "Okay", I responded.  "What do you normally take"

"I usually do herbs and stuff", she said, "but I don't think it worked this time."

I asked her why she thought the problem was and what she was taking, she responded, "garlic".

She then went on to tell me that she had inserted a few pieces of garlic into her "vajayjay to cure her UTI, but it disappeared".  "Do you think it went up into my stomach," she asked.

"No mam, it's unlikely that would happen, your vagina is not connected to your stomach".

"Well what the hell do you think happened to the garlic then?", she asked.  "Is it in my uterus?"

Just then a resident walked in to do a pelvic exam.

After the exam, the resident looks at me and says, "I'm never eating garlic ever again".

Vasoline Man and Bath Salts

It's always fun when the medics roll in with a slew of cops.... you never know what that means.  Could it be a stabbing, dude with a GSW or some other type of trauma?  The possibilities are endless.

There is a flurry of activity in the ER bay. There are medics, police, residents, doctors and some fellow nurses.  I see the glistening man in the stretcher, a paramedic says, "he needs a line, I lost it".  I weave my way past the residents, my IV set in hand.  The man's eyes are darting from side to side.  I tell the patient my name, he seems unimpressed.  I see a nice sized vein in my sights.  I lightly grasp his arm to position it, but my hands slides off.  

"Guys", I say to the medics, "why is he so slippery?" I'm not talking about a little slide, I'm talking about a slimy slide.

The medic looks at me and says, "Vasoline, it's Vasoline."

"Why?", I ask.

That's when the medics and police start giving us the play by play.  Apparently the person's neighbors called to police for complaints of loud noises.  When EMS responded to the home they opened the door and found the patient naked, covered in Vasoline and apparently preforming on a webcam with various toys.  

When they checked him out they saw he had a pulse in the 160s, and was probably on bath salts.  

Gotto love the bath salts! 

How Rep. Elton Gallegly voted on health reform: voting records and more.

ENA hired a new Advocate!  He's the former Chief of Staff of Rep. Elton Gallegy (R-Calif.)  Interesting voting record on health care from his prior boss.

How Rep. Elton Gallegly voted on health reform: voting records and more.

http://www.ontheissues.org/CA/Elton_Gallegly_Health_Care.htm

Greedy Hospitals Broken System! Welcome to US Health Scare!

So I just read the Time Magazine article "Bitter Pill" by Steven Brill and I am pissed.  Okay I don't know about the other nurses out there, but hospitals charging "$414 per hour" for my services and I'm being paid less than $40 an hour.  Are you kidding me?  So while I am busting my arse because apparently our budgets don't support additional staff, and I manage 5-9 sick and critical patients in the ER, you almighty administrator are profiting off my 12 hours with no break, fear of making a mistake, fear of losing my license and guilt because I can't care for my patients the way I would want my loved one cared for.  I am sickened by the sham that has become the medical system.

How dare you charge $13,702 for injection of a medication for a dying cancer patient that only cost your hospital $3,500-- and you call yourself a non-profit hospital...  it looks to me that you are making one hell of a profit.  Do you know what's worse than the big bankers that tanked the US economy, that's right the CEOs, administrators, VPs and presidents of hospitals along with the sell out congress who care nothing about the people of this country.  Instead of investing in the health of patients the American Hospital Association spent "$1,859,041 on lobbyists" in Washington in 2012.  Even more disgusting was that "health care" lobbyists were paid $5.36 billion since 1998. And what did nursing get from that.  I know my state doesn't have nurse to patient ratios, because it's too expensive.  God we don't even have enough staff to take breaks.  

How is it that we do not have regionally matched pricing for services?  They should change the "Chargemaster" to the "You're ScrewedMaster"!  Patient's have no idea what they will be charged for services.  

A visit to the ER is like being blindfolded at an unknown car dealership, going for a test-drive, signing a purchase contract all while you are still blindfolded, and when you finally drive off the lot the the blindfold is removed and you find yourself sitting in a Ferrari you can't possibly afford nor return to the dealer.  

There has to be a better way of doing business.  

I highly encourage you read the Time Magazine Article.  

Nursing Bliss: Health or Poverty? Hospital Brass, Congress, and L...

Nursing Bliss: Health or Poverty? Hospital Brass, Congress, and L...: Time Magazine featured a gripping and informative article by Steven Brill called "Bitter Pill, Why Medical Bills are Killing Us", that every...

Epi and Bicarb--- Maybe the TV shows didn't get the ACLS update

Someone really should update some of these medical TV shows that BiCarb just isn't that drug of choice in a code, and while their at it shocking on asystole isn't indicated.  

Breast Hiding Spot

The intermittent sound of the bipap alarm was a little annoying...  all I wanted to say was "leave the damn mask on", but I understand that the mask can be uncomfortable.  Her lungs were crappy, without bipap her pulse ox was in the high 80's.  I called respiratory and they fitted her with a new mask.  She said it felt better and agreed to leave it on.

Her lungs weren't her only problem.  This rotund lady also had a glucose level 750 and it wasn't budging even though she was on an insulin drip and getting hourly boluses of insulin.  She was in DKA. 

About twenty minutes after the bipap mask was changed, I heard the alarm go off, but it stopped by the time I got to the curtain.  I heard the patient rustling in her bed and again the alarm went off and then abruptly it stopped.  As I walked in the room to check her glucose level she quickly moved something.  I thought  it was a cell phone.  I opened the top of the case that held the fingerstick machine and managed to drop a few alcohol wipes on the floor.  As I bent over to pick them  up I saw a bunch of Starburst candy wrappers on the floor.  

I picked them up placed them on her bed so she could see them and then did her fingerstick it was again over 500.

"Okay", I said, "Hand it over." 

She looked at me, with the surprised guilty look that puppies have on their face when they eat their mommy's shoes. 

"I don't got nothing", she said. 

I looked at the cardiac monitor and her pulse jumped up a bit.  I knew she was hiding her stash somewhere and she didn't have many places to hide it.  She didn't have a purse or a table within reach to put it in.  

So I thought to myself where could it be.  

I then decided that I should reassess her lungs and check her monitor leads, as well as the edema in her legs.  

She leaned forward so I could listen to her lungs which still sounded crappy, and there was no sign of starbursts.  I then listened to the front of her chest, and after lifting up her large pendulous breast I found the mother load of candy.  Two packs of Starbursts and a melted chocolate bar still in the wrapper.  

Over the course of the next few hours her glucose level came down and her labs improved.  

Till this day I still can't eat Starbursts!

Don't Choke the Nurse

Hospital ER's have become the dumping grounds for drunks.  Unfortunately ERs also act as the holding place for mentally ill patents waiting for a disposition (either being admitted to a psych facility or discharged home).  Often our intoxicated patients have underlying mental health issues which can make a bad situation worse.

A few months ago a known "drunk" with a psych history got dropped off at our ER by an ambulance squad. He was assigned a stretcher.

A few minutes later he got up and headed over to another patient's bed and started yelling and threatening to kill him because the other patient was the guy who tried to steal his wallet at a bar (the patient wasn't even at a bar earlier).

I managed to calm him down and divert him away from the other patient.

A few minutes later the drunk got up again.  He began walking towards another patient bed, where a patient with a traumatic brain injury started screaming and flaying about. Seeing what was about to happen and the crazed look in the drunks eyes, a male nurse and myself positioned ourselves so that he could not attack the other patient.

I calmly talked to the drunk patient attempting to redirect him, but it wasn't working.  My co-worker, a male nurse also attempted to talk him down with no avail.  In the blink of an eye the drunk man lunged at my co-worker enclosing his hands around his throat.  Two visitors, myself, and a lab tech attempted to free this drunk psychotic man's hands from the nurses throat, my co worker was being choked.  Two other people came to the assistance.  The lab tech pulled the man's elbows back, myself and another nurse tried to pry his fingers off, while visitors secured his legs from kicking.  Our secretary called security, paging them nearly 10 times with no response, she finally had to call the local police.  We finally got the nurse free from the choke hold.  I ordered for someone to get the leather restraints and bring a stretcher closer.

We wrestled the man onto the stretcher.  From the look in his eyes there was no remorse.  He continued to fight as we moved him to a private room.  He attempted to bite, spit, punch and head butt the staff. Security looked stunned.  As I began drawing up Ativan I told security to put the restraints on him, they continued to just stand there looking at me.  "Put on the damn restraints" I ordered again.

Just as they began doing their job a very tall intimidating police officer entered the room.  The patient immediately knew that the game was over.  Security looked at the officer, but they were working at a snails pace. The police office looked at the security guys saying, "any day now".

The patient remained  in the ER overnight until he was sober.  While the charge nurse filled out an incident report the nurse who was choked did not press charges.  The incident was not debriefed, nor did the head of security ever meet with the staff that was involved.

While one nurse was choked, luckily in view of others who could come to his aid, another nurse was punched int her face.

I wish that my friend who was choked had pressed charges.  My profession for some reason just lets this stuff go.  Being assaulted is not part of the job description but we have adopted it as such.

Perhaps we should have let the patient go, let him attack the other patient.  If that should have happened then there would have likely been a lawsuit, and possibly a change.

As if rubbing salt in the wounds, a few weeks later, I was talking to some of the security guards about the incident.  One of them responded, "I don't get paid enough to get hurt", as he was looking at his Facebook page on the hospital's computer.

Safety in the workplace is an issue for everybody.  It doesn't matter how much money you earn.  I work in two ERs one in the inner city, and one in the suburbs.  I can assure you that I am far safer in the one in the inner city.  Our security there is top notch.

Nobody wants to go to work and get hurt, just as nobody wants to go to work and see someone getting attacked.

Police Full Circle

There is nothing more fun than a drunk person being brought to the ER by the police and BLS.  Oh how we love to fill our beds with drunk people (sarcasm). 

One very busy night this lady arrives with a plastic bag full of documents, smelling like alcohol, and in handcuffs.  She had urinated on herself prior to arriving.  She had the trifecta stank:  urine, alcohol, and smokes.  

After sleeping off her buzz, she woke up not knowing where she was.  She was informed where she was and how she got there.  I offered her something to eat, a pair of fresh socks and a toothbrush.  

After she freshened herself up I asked her where she had planned on going, she was to be discharged.  She asked for cab fare to a town 25 miles away.  She said she didn't have any money.  I informed her that she could have a cab voucher to her relative's house, but a 25 mile fare was out of the question.  

In the mean time this person had her own idea how she was going to get some quick cash.  She decided to lift one of the techs purses. Moments after she took the purse she was in a hurry out of the ER.  

Within a minute the tech came looking for her and her purse.  

Well I found the thief.  She had ducked into the bathroom.  She shoved the money from the purse in her sock and ditched the purse in the trash.  

When all was said and done she was re-arrested by the police, and off she went back to the jail she had been released from less than 24 hours earlier. 

Now That's Shooting Yourself In The Foot

Do you know that old saying, shooting yourself in the foot? Well I had a patient who did this both literally and figuratively.

So this poor fool is at "home" "cleaning his gun" and shoots himself in his foot.  He comes to the ER with a friend, not calling 911 of course because he didn't want to have that whole uncomfortable conversation with police.

Now the injury wasn't too bad, it was a grazing, but being an inner city hospital we have armed police in our ER and at the front door.

After the patient is seen and treated, he is discharged home.  Well almost home..

Apparently he had a warrant for unpaid parking tickets, and had just gotten out of jail, and was now going back to jail.

Moral of the story, pay your parking tickets folks before you shoot yourself in the foot.

Roach, Crack Pipe, and Other Party Favors

Working in an inner city that has been labeled one of the worst cities in America, is always challenging and interesting.  It reminds of that  Forrest Gump line, work "...is like a box of chocolates, you never now what you're gunna get", or what you might find, or what might be given to you.  And in the spirit of giving, sometimes our patients give us the things we least expect.

Like the lovely gent who graciously gave up his well used crack pipe to one of our interns... The look on the interns face was priceless as he looked at me shocked, "what do I say?"  My response, "Thank him."

Then there was the time I was restocking one of our OB exam rooms and found a blunt (for those of you not use to the hood terms, it like a joint made with a cheep cigar .  Maybe it was a medical marijuana blunt they had intended for later use? Or maybe they felt bad for the staff. 

There have also been the offers of half eaten food, thank you, but no.  

Nationally our city gets a bad rap.  Sure there is a ton of gang violence, but the spirit of giving is all around.  

The Good, The Bad, and The Lazy

Over the past year we have gained a good dozen or so nurses fresh out of school.  Some of them rock, some of them tread water just bobbing above the surface, and some take laziness to a whole new level.  Like other ERs we have standing orders, and 90% of the staff use them.  Unfortunately when you come in and you are following a person who  is in the other 10% who doesn't, it can make for a really rough chaotic shift-- not to mention the pissed doctors, patients, and loved ones of the patient.
Yesterday I walked into a disaster.  One non English speaking pt was going to the OR, three had beds, of which one had been called for an ultra sound 3 hours ago and was never sent, and one was waiting for a CT that was ordered 4 hours earlier.  Perhaps my favorite surprise was my altered mental status patient from a nursing home that had an assessment done but the nurse said he never actually went in to see the patient who had been in the ER for 2 hours ( how did you assess them if you didn't see them).  And the icing on the cake not one standing order was done, no OR check list either.

When I asked why the standing orders weren't done for a woman who was sent by her provider for an incomplete miscarriage, and why her assessment didn't include a GYN-OB assessment or history the nurse said "I just didn't do it" not a great answer since she was on her way to the OR.  Just when you think things can't get worse that same non English speaking patient was consented on an English consent form, without a translator or a witness-- stupid new resident!
This of course lead to a call to the residents' attending and a very good lesson for that new resident.

For the first 3 hours of my shift one of my fantastic co-workers helped sort out the mess that had been left.  When our charge came over to get the scoop on why earlier CT, ultra sound, and the OR called all sorts of pissed,  5 nurses in our little section of the ER enlightened her to the track record of a particular nurse I had followed.

Through the course of the evening when things settled down we had some time to discuss the trends each of us were seeing amongst some of the newer nurses.  One had said that a new grad nurse had a patient with a cardiac history come in for chest pain and the nurse did none of the standing orders.  She had not even started an IV.  I had a very similar experience with the same nurse who told me that a resident told her not to do anything.  When I asked her which resident it was she "couldn't remember".  Which was funny because the residents didn't recall that conversation with her.

As we chatted about the possible ways of opening our new co-workers up to the concept of completing standing orders we thought about the ways that would impact them the most.  If you stressed the urgency of the matter to them would that shift them into gear?  One suggested writing up the nurses, while another suggested having them walk in the shoes of the patient.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Great Lengths

Sometimes nurses have to get creative.  Let me rephrase that very creative.  One morning an unconscious man arrived in the ER, a present from the EMTs.  From the looks and smells of him he was likely homeless.

In our ER we have standing orders so that the nurses can get the ball rolling.

A couple of nurses and a tech immediately undress this gentleman, triage info is gathered, a finger stick completed, IV lines in, labs drawn.  The final thing needed was a urine.

This of course would require a straight cath due to his unconscious state.

One of my co-workers attempted to insert a foley, it was unsuccessful.  She attempted another sized foley, but was unsuccessful again.  She came over to the nurses station shaking her head and asked for some assistance, her face was flushed.

While the foley fringe was not the issue the length apparently was.  This gentleman was not of average size.

After a few attempts and a run to the supply room, we enlisted input from  one of our attending physicians, and that's when the brainstorming came to a solution.

Our solution was a NG tube!  A successful cath complete UDS and UA sent to the lab.

Nurses, we're a creative lot aren't we!

Nursing Bliss: Insurance and Addiction- Not What the Doctor Order...

Nursing Bliss: Insurance and Addiction- Not What the Doctor Order...: Having worked in the Emergency Room in a few facilities over the years I have seen the heartbreak in the eyes of the family or loved ones...