They Came By Air

"Trauma alert by air 10 minutes.  Trauma alert by air 10 minutes".  For those of us wearing protective lead, covered head to toe in surgical attire, medical ninja garb, we are prepared to receive whatever comes our way.  We anticipate the badness that has been air lifted to our helicopter pad 24/7.  We first greet you, but you cannot see our face, just our eyes.  You are disoriented from a flight up-up and away from your disaster site, and you are carefully lowered to a small roof top that overseas a metropolis with college parties, gang violence, corporate gatherings and trials and tribulations of everyday life.  

You are here now.  I greet you with a welcome to ____ Medical Center, I'm your nurse.  You're safe now.  We are going to take great care of you.  I do my best to absorb a readers digest version of report with just the highlights from the flight crew, knowing they will repeat it when we cross the red line in the trauma bay.  I explain to my patient that we are going to move fast but we are thorough.  I explain that we will be cutting their clothing off and giving their belongings to security.  I try to prepare them because they are no longer in control.  Their control ended on impact with whatever bad thing landed them on our roof.

In those moments we look at every inch of skin, we check for holes and check existing holes.  We invade your body with needles, airway devices, caterers, tubes, hands and fingers.  We are causing you pain to end your pain and save your life.  We do this out of love for our vocation-- because it is not just a job we show up for-- it is our passion.  We like to fix things.  We are fixers. 

Somedays when they come by air the fix is easier than we thought, but the pain for the body is brutal. The emotional pain can be worse.  One lands on our roof and another- perhaps a soulmate lands on another roof hours away.  Together they became powerless, they were impacted, they became patients, but they are separated and suffering physical pain and a deep hurt not knowing if the other is still breathing or alive.  I can give you drugs to lessen the pain from your trauma, but I can do little to mend your heart.  

I rarely think about the other, because I am so focused on you and fixing you.... but then hours later on the news or in the paper or via a call you learn about the others.  I hope for the best, but know that if you landed on our roof the badness was real and the stark reality of life comes like a speeding bullet.  My patient survives, but there are others who do not.  Maybe one or maybe a couple perish.  It is sad and I selfishly hope that my patients soulmate lives on and makes a recovery, because I have seen the news and it was bad! 

Good Bye ER It's been real

I've always had a love for the ER.  In my opinion there is nothing like the ER.  It is unpredictable and things can change on a dime.  I loved getting train wrecks and working with providers to stabilize them.  Unfortunately I had to walk away from my ER job the other day.  It wasn't because of the patients.  A bad day in the ER is never in my opinion because of the patients.  A bad day in the ER is because of a broken system.  Perhaps my ideals are just not in line with the world of Emergency Nursing.  Perhaps I had too much faith and hope that ENA would advocate for better conditions for ER patients, and really start promoting leadership amongst the ranks of the staff nurses that would force nursing management to grow a spine.

On to new challenges and a new environment.  Its time to step away from the toxicity and into the unknown.

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!

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.

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! 

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.  

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.

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!