Wednesday, January 2, 2013

Attitude

ER Nursey recently posted about a migraine pt. that she had. Apparently this lady defied existing 'expectations' of Migraneurs who frequent the EDs and refused narcs - instead preferring alternatives.

You know what really hits me about that post (and other patients like her)?

They're polite. They apologize. They're generally civil and nice.

Don't get me wrong - I'm a pretty generous guy. I give ample leeway to the fact that being sick/in pain/miserable tends to alter pts. behavior somewhat (makes 'em irritable, cranky, fussy etc.) and to a point; I'm willing to let that slide and chalk it up to the pt. being "sick". I get it - you're sick. You're hurting. You're in pain. You're feeling miserable.

By and large, a good majority of my "sick and irritable" patients respond to my care and ministrations in a positive manner.

But right from the days of my working on the floor to my current job in the ED, there's certain kinds of pts. who just win me over with their verbal and non-verbal cues.

Be it the 96 year old great, great grand mother who had the misfortune of fracturing her hip who only wants "A couple Tylenol and an ice pack dear. I'll be all right".... to the 60-odd year old man who has not urinated in 12+ hours, in severe distress and pain with a grossly distended bladder (and abdomen) from the pressure; grit his teeth, smile thinly and say "do what needs to be done Doc" [more on this later]... to the 45 year old single mom retching and vomiting air, in incredible pain from the cancer that's eating away at her trying to smile and put on a brave face for her kids while her only concern is to "get better because Tommy has a school play coming up and he needs me".

The examples are numerous. But their effect is the same.

Someone once said: "Attitude - it's all the difference between and adventure or an ordeal".

I'm by no means stating that people who are sick or who are in pain are having an "adventure". BUT, their attitude of how they deal with their illness or pain speaks volumes about their character.
Especially when you contrast that behaviour against patients/family who don't give a damn.
"Don't give a damn?! How can you say such a cruel thing?!"

- when you have someone come up to the front desk and say "I need help getting XYZ outta the car".... well, how did XYZ get IN THE CAR in the first place??!!
- when you have patients, who the minute they cross the ER entrance; seemingly become invalids - they drove themselves here, walked from the parking lot to the sign-in desk... and from then on were completely incapable of helping themselves - including walking, toileting themselves etc.
- when you're accused of being a racist/chauvanist/motherfucker/'you're lucky I didn't punch you in your motherfucking face'/etc. --- all for requesting co-operation from folks so that I could figure out what was wrong with 'em....

Monday, April 4, 2011

Must be new ...

"Spook, lab's holding on 5-oh".

I immediately rush over from the emergent-foot-pain-for-four-months-at-3-in-the-am patient to take what could be an important call with life altering critical lab values.

"ER, this is Spook how can I help you?"

Excited hyper-voiced lab dude: "Good Day Spook! I have a critical lab value for you!"

Who the hell has critic... oh wait!
Only person I'm expecting anything to show up on is drunk-hooker-chick who comes in about once every other week, for the past 8+ years, for the same reason - acute alcohol intoxication (sometimes with SI thrown in for variety).

So without any preamble, I ask "so what's her BAL (Blood Alcohol Level)?"
Excited not-so-hyper voiced lab dude: "Oh! How did you... anyway, it's 299!" [roughly 3 times the legal limit].
Me: "That's it? *snort* Business must be hard... Thanks lab dude."

Poor kid! Getting all excited about a BAL of 299 ... on drunken-hooker-chick no less! Obviously he hasn't met our other heavyweights.

I give the kid 2 weeks...

I set the phone down and walked into the med room to procure some STAT Motrin to administer to the emergent-foot-pain-for-four-months ...

Friday, March 18, 2011

Informed Consent

"Sir, your mother is very sick. Her Troponins came back elevated. The question is do we need to admit her to the ICU where she may need pressors or ..."

The son turned and looked at me. I could already tell that he was lost.
The admitting doctor had just walked into the room and after her assessment, had let loose...

He didn't understand a word beyond "your mother is very sick".
He managed to nod at the 'appropriate' times; while looking politely dumb otherwise.

The admitting doctor carried on and I was called away to another patient who was having trouble with their heart rate.

When I managed to figure out what was going on with my other patient and had intervened to stabilize the problem, Ms. "elevated troponins" was still 'stable' and was being admitted to the ICU with orders for "pressors" among a myriad others.

As I walked into the room, with bags of meds, tubing and IV pumps; the son was sitting at the bedside, caressing his mother's hand while talking in a whisper to her ear.

While I was setting up the IV pumps and meds, I made small talk with Mr. Smith, the son. Are you the oldest son? How many siblings do you have? etc.
"Mr. Smith, I know you just had a serious discussion with the Doctor about your mother's condition. Do you have any questions?"

Scarcely had the words left my mouth when out poured a torrent of questions!!! It was like the Johnstown flood!

Why is she going to the ICU?
Is my mother dying?
What the **** is pressors?
Why are her lab results abnormal? What the hell does that mean?
Why is she so 'sleepy'?

So on and so forth...

I did my best to answer his questions, in layman terms as much as I could. "Pressor is just a fancy word for medicine that helps raise blood pressure. As you can see on the monitor, your mother's blood pressure is too low. If it stays low, her brain and heart and kidneys won't get enough food and oxygen and that'll cause damage." etc.

I ended up spending a good bit of time explaining things to Mr. Smith - and in the end, I had the admitting doc paged back into the room [while I was present] to make sure he had his questions answered.

Mr. Smith wasn't an idiot - he was an engineer who managed a successful business.
He was just clueless about "medical issues". Just like John Q Public with no medical background.

All he knew and cared about was the fact that his mother was sick, literally comatose ... and that's it.

Walking into this room and talking about "ICU" and "pressors" - how the hell is he supposed to understand any of this? Even with a 'medical background' such issues are difficult to comprehend.
Now put yourself in this man's shoes - we're talking about your loved one here. If someone wearing hospital scrubs or a white-coat walks in starts mouthing of "ICU", "pressors", "heroic measures if her heart stops" - what would you think? How would you feel?


Yes, there are mitigating circumstances. "Look, at her condition now, she will definitely die. The procedure we're looking to perform has a chance of success but it also carries the risk that she'll die from the procedure. What are you're wishes?"

Ms. Smith's case certainly wasn't that dire. Critical, yes. Unstable, no.

But even if she was - doesn't the family/kin/PoA deserve that little bit of knowledge? In PLAIN TERMS that they can understand?
Instead of saying "we need to put her on pressors and admit her to the ICU" can we not say "We need to put her on medication to help maintain a good blood pressure that will help her heart and we need to admit her to the ICU so that she'll be more closely monitored" ??

What does that take - an extra 30 seconds of speech?


It just really makes me wonder - how "informed", is 'informed consent'?

Saturday, June 13, 2009

Holy Crappy Week Batman!

Walked into work and as I was swiping in, an unfamiliar face dressed in scrubs with an unfamiliar ID badge approached me and asked, "excuse me but are you a nurse in the ED?"
"Yes I am" I cautiously replied, "how can I help ya?"
"Do you know the code for the tube system?"
"Are you new here?" I asked. I thought we weren't hiring anymore??
"Oh yes. I'm an agency nurse and I haven't worked here before. And they haven't assigned me a code"

OH SHIT!
That's what my mind said the instant she said "agency nurse".
When management is desperate enough to call in agency nurses, you can bet your last dollar that the fecal matter has well and truly hit the air recirculation device!!

I wasn't mistaken either.
Last three shifts have been pure chaos and unadulterated mayhem. You know all the amount of drama they manage to squeeze into one episode of ER? Well, try compressing each episode to 15 minutes and repeat for the entire shift and the next shift and the next shift and the next... that's how it's been down here in The Pit.

A combination of "work everyone up no matter what" doctors, combined with semi-indifferent/downright-lazy support personnel, staff callouts, a downed CT scanner, temperamental tube system, malfunctioning lab software and an erratically performing computer charting system... all conspired to transform an ordeal into the perfect and most horrific nightmare.

If that wasn't bad enough, the patients seeking our services were all the "borderline" kind: Sick enough to die at any moment... but they just ain't dead yet. Which means long, drawn out (and sometimes repeated) codes. Add to this mix, the more than usual amount of violent drunks, actively psychotic and abusive psych patients and more than the usual amount of attempted suicides.

You name it, we ran out of it:
* Pre-filled saline flushes? Check
* Primary IV tubing? Check
* Wrist/ankle restraints? Check
* Hospital beds for admitted patients? Check
* Pre-filled Dilaudid and Morphine Carpujects? Check
* 16 and 14 french foleys? Check
* Blankets (warm or otherwise)? Check
* Food trays (even simple sandwiches)? Check
* 20g IV catheters? Check
* Batteries for portable monitors? Check

On and endlessly on.
Everything from Dynamaps to portable EKG machines kept switching off because there was just not enough time to plug them in to recharge! At one point, our supply of Percocets, Zofran, Ativan and Propofol got so low that Pharmacy had to raid ICU stock for our supply!

I'm just thankful that our water supply didn't run out!

Nobody is yelling at anyone else... yet. But morale is strained. There is definitely a sense of "Us (staff)" Vs "Them (patients)" amongst some of the staff. Management is trying - and failing gloriously! - in trying to perk up flagging team spirit. Instead of support in the form of more staff/better equipment, meaningless platitudes are being offered (again!).

I mean, in what kind of "First Class ED" do I need to hunt high and low for a frigging thermometer??!!

We've been on continuous "Bypass/Divert" status since Monday but it seems to make not one iota of difference. Wave upon wave of the sick, the wounded and the dying keep crashing against the thin white line of ED staff... and we're just barely holding on.

We have not slowed down at all from the winter.

Just yesterday I walked into work at 1100 hrs and there were 19 "holds" (pts. who have been admitted to the hospital but are hanging out in the ED because there are no beds available). NINETEEN!!! Psych, Tele, ICU, Med-Surg, Stroke... you name it, we were holding 'em down here. Close to 40% of our ED bed capacity was being occupied by admitted patients - which meant that triage and bed flow was a complete disaster all day long.

We've been getting slammed like crazy. Last month, we shattered all previous volume records.

I've been consistently working over 44+ hours/week! I was supposed to work 1100 - 1900 yesterday but ended up staying till 2230 to help out because we were so busy (crashing patients left right and center).
And it was on my day off!!!

I mean, it's freaking JUNE; not FEBRUARY! What the hell people??!!

Monday, June 1, 2009

Untitled

I try all I can, what more is there to do?
Why, lets intubate! And get a ventilator too!
One Pressor, Two Pressor, Three Pressor, Four
There's nothing left to pump into you any more
Five fluids, six fluids, seven bags and eight
yet your foley output shows naught all night.

You lie there listless in bed
and here I am at my wits end.
Surrounded by all of modern medicine's marvels
and with nothing to show for all our travails

The only saving grace, if any
Was that you passed from this world surrounded by family
As cruel and abrupt as was your passing
I can only hope the final battle was worth the living.

I'm tired. My feet hurt. My back aches. My mind is fatigued.
And yet, the thought remains - "what if I'd done this or that or something more?!"
A wise colleague imparts sage advice
"Hindsight never resurrected the dead"...

... and then after a pause, added:
"Go home! Get some sleep. I'll see you back tonight..."

And so I go home to toss and turn
and snatch fits of sleep
For return I must in the morrow
back to earn my keep.

To dance that dance once again
Against that ancient and final foe
We may win or we may loose
But the dance is one we cannot choose

- © Spook, RN [June 2009]

Thursday, May 14, 2009

Die erste Pistole

About 10 days ago, I walked into my local shooting range and put down 500 smackers for this little beauty:



The Smith & Wesson M&P 9 9mm semi-automatic pistol. Truth be told, I wanted the Beretta 92fs but apparently there's a serious shortage of Beretta pistols. I also liked the CZ but going by the advice I was given (stick with "tried and true" brand names for your first pistol) - I decided on the M&P. And I gotta say, them interchangeable back-straps was a big selling point to me. The ergonomics of the pistol is superb (which is another reason I really liked the Beretta and the CZ - the "feel").

So yesterday, I went over to the range and sent 200 bullets at this target:



Yes, yes. I know. My aim sucks (12 yards). But that's the whole point of buying the pistol - gotta work on that aim!

All in all, I'm one happy little boy.

Next up:
M1 Garand
Beretta 92 fs

Gotta start puttin' in some overtime at work! :-)

Wednesday, May 6, 2009

I curse the fact that ...

... my iPhone can't record video and I didn't have my camera around.

I was walking out of the locker room headed toward the ER (ED if you are... well, you ought to know by now) to start my shift when I heard the unmistakable sound of a piano! Our hospital foyer has a grand piano but to date I always thought it was just for show.

My curiosity piqued, I mosied over. And what a sight to behold!

One of our Urology docs was belting out a kick ass rendition of "Bloody Well Right" by Supertramp! Right there in our hospital foyer. He had this big, silly grin on his face as his fingers danced over the keys.

I just had to walk over and ask... I mean, I couldn't believe my ears!

"Hey Doc! 'Bloody Well Right' by Supertramp, right?!"
He just looked at me and nodded, that grin still plastered on his face. He was obviously enjoying himself :-)


So that's that. Along with Uro Doc, that makes 6 other people (other than myself) that I know of, who have heard of Supertramp and who obviously like their music.



Holla at all you Supertramp fans out there!

Saturday, April 25, 2009

Confession...

I just rediscovered "Swervedriver"... and fell in love all over again.

The live version of "Duress" absolutely kicks ass.

That is all.

Thursday, April 23, 2009

Notice to all current owners of handguns...

EDIT TO ADD:: All future readers of this post, disregard the "(note: concealed/open carry is not an option in my State)" part of the following post.

In other words - I'm looking towards your opinion regarding your recommended "carry" weapons (be the concealed or open); or otherwise.

Thanks!



In any case, here's the original post ------
... that means YOU AD! And LawDog! and... all others :-)

My permit has finally arrived.

Here's the deal -- I'm having a SUPER hard time picking out what I'd like to own (note: concealed/open carry is not an option in my State).

I'm looking for something self-defense-ish (but not limited to). I've shot/tried the following -

* S&W 14 6" barrel 38 special
* S & W M&P (both the 9mm and 0.45 - I prefer the 9... didn't like 45 wasn't too comfortable)
* Colt M1911
* Springfield XD
* Sig Sauer P220 (have to re-evaluate this one)
* Glock 19

That's about it... I have a 90 day window period.


Please recommend your favorites and why.
Oh and anyone who can recommend a place I can get my hands on a good M1 Garand, please let me know!

Thanks!

Tuesday, April 21, 2009

The Med Error

My first med error (and as things go in ones career, the one I VIVIDLY recall the most) happened when I was orienting on days, my first job as a brand spanking new RN on an extremely busy ortho-neuro-gyne-med-surg floor (years later, my co-workers and I took to calling our unit 'The Dump'. Anyway...)

I had an absolute KICK-ASS preceptor who'd been working there for decades. She was smart, talented, hard-working, dedicated and blessed with a dry sense of humor She rode my ass mercilessly all shift long, every single day at work. Her simple rationale: "I'm not trying to be a 'nag' but I'm trying to give you an idea of how really hard this job is. Make use of me, my time and expertise the best you can NOW... because in 6 weeks or less; you'll be ON YOUR OWN".

She scared me poop-less.... but she also made me sit up and take notes.

Now, all "background story" aside:
I was on my last shift of week 3 of orientation. I had a 79 year old post-op ORIF of the Left ankle. I'd gotten through the initial 4-hour period window of post-op patients with their constant monitoring... heck, I'd even gotten 70% of my documentation done. I grinned to my cocky self and thought 'this is going good'.

As are many patients who are post surgery, pt. developed nausea and vomiting. There was a standing order for Droperidol (Inapsine). I drew up the right amount, checked it against the MAR, and showed it all to my preceptor before walking into the pts. room to administer it.

I administered the dose with no hassle, flushed the port and after reassuring the family that the medication should help, left the room to chart.

15 minutes later, as I'm walking by the pts. room, I notice that she seemed drowsy. "Maybe pt. is just tired." I told myself; "After all, pt. has had a long day." I congratulated myself on the quick intervention to resolve pts. nausea/vomiting and my head ballooned with grandiose ideas of what a 'kick ass nurse' I was going to be.

Well, as they say - pride commeth before a fall.

Half an hour later, as I was walking by rounding on my patients, I noticed that the pt. I'd administered Droperidol to seemed to be in a REALLY DEEP SLEEP.

My "still-cocky brain" somehow managed to tarry a tad bit longer to ogle its fine work. Ahhh, she's resting so comfortably....
That was when the "other" brain's screams became more audible.... "she's not breathing! She's not breathing! She's not bre...." (and so on)

!! PANIC !!

Klaxons went off in my "cocky brain" and my bladder did it's best to burst past my sphincter and empty itself in a glorious waterfall onto my shiny new white scrub pants...

I somehow managed to "rush into the room" while also not outwardly appearing to "rush into the room". My mind was racing the speed of light and winning, while all my lungs could do was echo the "Oh my god! Oh my God! Oh my God" chorus... as my heart proceeded to jump out of my mouth and take off for parts unknown.

Outwardly, while I did my best to not appear to be the nervous debris that I was, I attempted a feeble smile at the family as I managed to croak "I'm just here to make sure XYZ is all right"... while my stomach was doing somersaults worthy of an Olympic gymnast medal.

The pt. was a 'little hard' to arouse. But to a noobie nurse like me, anything less that "full arousal" was = "comatose". Even though my heart was incognito, I could feel its rate climb into the Ionosphere. A cold, icy ball materialized in what was left of my stomach....

"Cocky-brain" had been replaced by "Panic-brain". "I killed the patient" seemed to be the medley of the moment - interspersed with "you are an idiot" and "how stupid of you" and various other choice epithets [I'm omitting a few phrases (ok, LOTS of phrases)]....

Miraculously, from somewhere in the depths of my foggy (non panic-ky) brain, I latched onto an idea. I walked outside and brought back a portable pulse-ox machine. This way I'd have an idea of the pts. heart rate and oxygenation while I manually counted the respiratory rate and the blood pressure.

My initial readings were fairly "normal" (i.e. not too deviant from pts. known baseline and previous vitals)... save for the respiratory rate. For the rest of the shift, it hovered around the 12-14 mark (while the other signs stayed stable).

For the remainder of my shift (6 hours), I was in that room as often as I could (sometimes as often as every 5-10 minutes).

Throughout all this drama, my preceptor kept mum - except to encourage me to check in on that patient as often as I could while also hounding me about my other patients.

By the end of that shift, I was a wreck. I was convinced I'd nearly killed the patient. I had worse than a "lowlife no good slacker" opinion of myself. My report off to the night shift was very somber and gloomy.

As I plopped my weary butt down to chart after the shift, my preceptor mosied over and nonchalantly said "you want to talk about it?"
Dejected, head downcast, I mumbled "I'm so sorry. I don't know what happened. One minute pt. was fine but the next minute.... well; I don't know what to say!"
She simply asked "Well, what do you think happened? What do you think caused the pt. to become that way?"
"I really don't know", I stammered. "I wish I did!"; I said, somewhat emotionally.

"Walk me through it. Walk me through your interactions with that patient during the shift".
And so I proceeded to describe it all, in painstaking detail.

"Do you think any of the medications you gave the patient over the shift might have caused that?"

*Blink* *Blink* "Why, now that you mention it, the whole damned business started after I medicated the pt. for nausea!"
"Well, what did you give?"
"Inaps.... wait a minute!"
"How fast did you give the Inapsine? Did you give it slowly over a good 1-2 minutes?"

I thought real hard. And then it hit me - in my eagerness to relieve my pt. of nausea/vomiting; I might have slammed the medication in too fast. 0.625 mg didn't seem like "a lot" to my dumb-brain... but I'd forgotten to take other criteria into consideration. Not to mention the cardinal sin of administering a medication I wasn't too familiar with - especially with regards to effects AND side-effects.

My face turned a beet red: "I... uh... might have... ummm ... given it a little too fast".

My preceptor smiled and winked at me and said: "Lesson learned".
I was thunder struck!! "WAIT!", I sputtered; "you KNEW all along??!! WHY didn't you tell me???!!!"

"Because I'm here to teach you and you're here to learn. Knowing you, I'm rather confident that after today - you will never give any medication without knowing what it can and cannot do... and how to give it appropriately. Being a nurse is more than charting meds and giving them as ordered - as you've no doubt learned today."

She then reached over and patted my back and said: "Don't beat yourself too much over it. I was observing the patient all along too. Your subsequent reaction to the patient's status is commendable - if a little inefficient. But, you're learning and you attempted to do the right thing; which is what counts any way. Someday, I'll share my own 'learning lessons' with you. But for now, finish your charting and I'll see you tomorrow".


It has a mark left in the only place that counts. No matter how old or how experienced you get...
You never forget it.