Spoke my mind

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Be careful when taking walks

One of our ER docs told me this story:

Many years ago, when I was doing my residency near The Other Big City, police brought this elderly gentleman in to the ER. They said that they'd found him wandering around and when they stopped to question him, he responded with incoherent words and neither one of the officers could figure out what the man was saying.

And neither could we. His vitals weren't normal but they weren't off the wall either. One of the nurses thought she detected some AoB (Alcohol on Breath) but for the most part this guy appeared benign. Lungs clear, good heart sounds, no apparent signs of trauma.

Then, one of the cardiology residents who happened to be down on a consult happened to pass by the ER room while we were trying to figure out what the hell to do. He stopped, poked his head in and asked one of the nurses what was going on. Upon being told the gist of the story; the resident shook his head and said: "He's not mentally confused or unstable. He's speaking a different language. I don't know what it is but I know it's not gibberish." Apparently this cardiology resident was of Indian extraction and had heard it before.

This set of a flurry of activity... and before long, they managed to find an Indian-American nurse who was called down to help translate.

Apparently, this gentleman had recently arrived in country; visiting his son's family for the holidays. He'd had a glass or two of wine in the afternoon and had decided to stretch his legs with a walk and take in some fresh air. That was when the police found him and the poor man spoke not a syllable of English. Fearing that he'd been injured/lost and wanting to make sure he was ok health-wise, the police brought him in and that's where all the fun started.

What's in your RSI box?

Nurse K posted a random bleg a while ago about RSI boxes. I must admit that when she mentioned that her ED didn't have a RSI (Rapid Sequence Induction) box, I was slightly surprised. I thought all EDs had something similar - I mean, having one makes a lot of sense.

But then again, my old hospital's ED didn't have one either.

So Nurse K, here's what we have in our ED:
- Meds in the box:
* Atropine Sulfate (1 mg/10 ml) prefilled syringe X 1
* Etomidate (2 mg/ml) 10 ml vial X 1
* Ketamine Hydrochloride (50 mg/ml) 10 ml vial X 1
* Lidocaine Hydrochloride 2% (100 mg/5 ml) prefilled syringe X 1
* Midazolam (2 mg/2 ml) vial X 2
* Succinylcholine (20 mg/ml) 10 ml vial X 1
* Vecuronium (10 mg) vial X 1

- Dilutants:
* Sterile Water for injection (10 ml) vial X 2

- Tools:
* 60 ml syringe X 1
* 20 ml syringe X 2
* 10 ml syringe X 2
* 3 ml syringe X 3
* BD 18G 1.5 inch IV needle X 2
* Easy Cap II Carbon Dioxide detector X 2 (no longer used. Now part of intubation bag)

- Misc:
* Alcohol swabs x 15
* Controlled substance documentation form

Some piccys:


RSI Box against a standard computer keyboard (to provide scale for sizing).


Closer view of RSI (notice the red pharmacy lock indicating a stocked, ready to use box).


Naturally, no nursing job can be complete without "documentation". A typical pharmacy use/waste form. Two RNs (or an RN and Pharmacist) to initial waste/use before restocking and locking the box.

We have 3 such boxes in our ED. Our airway/intubation kits are separate (they usually hang out in the trauma/code rooms near our crash carts). A while ago we decided to switch out CO2 detectors from the RSI boxes to the airway boxes. There are separate kits for peds intubation (in separate boxes as well). We also have our own anti-platelet/thrombolytic boxes (tPA, tnkASE, Integrilin).

Once a box has been used, a nurse (or tech) walks the box down to pharmacy and it gets re-stocked.

So, what's in your RSI box?

The Vent

Quoting another ED nurse:

Ok,..was gonna try to stay out of this,.but I just can't help myself! I agree that this is a great place to vent. This is supposed to be a safe place to vent. A place to let out all my frustrations away from patients and co workers. A place to verbalize all those thoughts that I would NEVER, EVER say to someones face while at work! A place to voice my opinions to other health professionals who understand where I'm coming from.

I don't expect solutions to my frustrations. I don't expect someone to tell me how to fix everything and make my job a day at the park. It just makes me feel better to write it all down and get it out! It makes me feel better for someone who understands to say "yeah, I'm with you there!". If occasionally I learn something in the process of venting then good for me! If commenting to someone else's vent makes them chuckle or breathe a little easier that's great.

I've been a nurse for a long time and I do understand that those who aren't in the medical field don't always understand what I'm venting about. I've often whined about something to my husband (a non medical person) that seemed like an obvious situation to whine about and he looks at me like I'm crazy! I then have to go into more detail about my complaint and sometimes he will understand.

That's why I come here! I shouldn't have to explain to any of my fellow nurses how it makes me feel when a 22yr old tells me he has abd pain 14/10, can't keep anything down, while eating Cheeto's and coke, talking on his cell phone! There is no need to explain my initial thoughts when he then tells me he has no medical hx, takes no reg meds and is allergic to Tylenol, toradol, haldol, vistaril, naprosyn, ultram, and phenergan!

I come to this site because we are all in the same boat. We are all caring, compassionate, well educated, professionals who are trying to do the best we can for our pts. We get frustrated when, because of situations beyond our control, we can't do our jobs!

I would never, ever, tell a new Mom, who is worried about her 8mo olds 2hr temp of 102 that she is wasting my time and resources by coming to the ER instead of running to walmart to buy some tylenol! I would never, ever tell the man with back pain for "about 2yrs now, no one can figure out what's causing it" that he needs to loose 100lbs and find a family doc to take care of these "flair ups".

BUT,.when that same Mom comes up to the triage desk and complains that they have been waiting "almost an hour" and "people who came in after us have already gone back" and then gets nasty with me when I explain that the sickest pts go first, I'm gonna come to allnurses and VENT! I would so love to take that Mom by the hand, take her back to Rm 3 the 6yr old who was found in the bottom of the pool, then to Rm 5 the 18yr old unrestrained driver of a roll over MVI who was ejected, then to Rm 8 the 60yr old who suddenly couldn't speak and has a L sided facial droop, Rm 24 the 22yr old ruptured ectopic with a BP of 54/20 who is bleeding out faster than we can put it in and of course OR is full! I would so love to put everything in perspective for that Mom,..but alas,..I can't,..I won't.

I come to this site to vent to other nurses! To those that know exactly what I'm feeling. I don't vent to my neighbor or my hairdresser. I'm not directing my vent to any patient or family member. I'm here to talk to other like minded professionals!

If you have stumbled in to this site as a non medical person, just looking for an interesting read, or free medical advice you should be prepared for what you might see. Nursing can be a very unpleasant job at times. We see people at their worst. We see things on a regular bases that most people will never witness in their lives. We are expected to leave the room of a dead 3yr old and smile and ask Mrs Jones if "there's anything we can do for her, I have the time".

We are expected to understand that when the doc orders 100 of Morphine, he really meant Fentanyl. We understand why our pt with SOB really does need an 18g in the AC. We understand why a pt with abd pain must stay NPO. We know how to do our jobs and we do understand that non medical people don't understand!!

I find it insulting for a non medical person to make judgments on how I do a job that they couldn't do. I don't argue with my mechanic about the best way to fix my car. I don't argue with the electrician about how to fix my furnace. WHY WHY do people think it's ok to not only argue with us, but accuse us of being cold, and uncaring when we are doing a job that many people say they could never do?

I must stop,..if you are a non medical person and are offended by what is said on this nursing site,...it's simple,...see that little red box with the white X in the top right corner of the screen? Click it!

You ROCK lady!

Apparently I'm a libertarian...

Saw this little "test" over at Respiratory Therapy 101 and decided to give it a shot.

You are a Social Liberal (88% permissive) and an... Economic Conservative (80% permissive) You are best described as a: Libertarian Link: The Politics Test on Ok Cupid Also : The OkCupid Dating Persona Test

Friedrich Hayek's Road to Serfdom and lewrockwell.com - it's where it all started folks!

- Spook (proud Paul-ite)

Paul Newman has passed on

Ya know, I'm not usually one to get all weepy and mopey about celebrities.

But I've always enjoyed Newman's work - be it something silly like "Slapshot" or iconic such as "Hustler" or "Cool Hand Luke". He was a humanitarian to boot with charities benefiting children.

So long Mr. Newman and thanks for the fond memories.

Healthy ER abusers are a "myth"

A recent article in Slate claims that the uninsured without a PMD and the insured folks who have PMDs both visit the ERs (or ED if you are Dr. WhiteCoat ;-)) in roughly the same proportion:

If you believe the conventional wisdom, the E.R. abusers of our nation are especially responsible for many problems in health care. They fill up E.R. waiting rooms and because they can't (or won't) pay their medical bills, the insured patients who prudently wait for weekday appointments to see their doctors end up bearing the costs of the abusers' in the form of higher insurance premiums. The oft-repeated claim is that if we can just find a way to get the abusers out of the E.R. waiting rooms, we'd eliminate many of the high costs associated with health care in the United States.

The problem is that this story of the healthy, cavalier, uninsured E.R. abuser is largely a myth. E.R. use by the uninsured is not wrecking health care. In fact, the uninsured don't even use the E.R. any more often than those with insurance do. And now, a new study shows that the increased use of the E.R. over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor's office. So, the real question is: Why is everybody, insured and uninsured, coming to the E.R. in droves? The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care.

Click here for the full article

Hmmm...

The "Nursing School" Car

I worked two jobs during nursing school. I bought a beat up 1995 Plymouth Neon - stick shift and a pretty decent radio. It had 2/40 air conditioning (2 windows rolled down driving at 40 mph). The only thing I cared about was the heater, since I lived in Buffalo.

The gauges worked when they felt like it. I once drove an entire stretch from Ohio through Illinois with a non-working instrument panel - I had no idea how much gas I had left or if the engine was overheating etc. The only thing that worked faithfully was the tachometer - so I used to guesstimate my speed based on engine revs and which gear I was in (e.g.: 1800-2000 rpm in 5th gear was roughly 35 mph).

Since the instrument panel worked erratically, the odometer didn't always run either. I had no idea about the true mileage of the car. These things sorta start to matter because you start to imagine scenarios like where your pistons ram through the camshaft because of a timing belt that wasn't replaced at the 'appropriate mileage' or busting a strut because of not having a safety inspection done at the 'appropriate mileage' so on and so forth...

It took me on several 1000 mile trips (and helped me move between two apartments. How I managed to cram my clothes, utensils, computer, stereo system and books and transport them thousands of miles, I alone know). It lasted through some of the worst winters Buffalo threw at us. It saved my ass during a real bad 75 mph spin out on the I-55.

That piece of junk lasted till 2007. I was driving home after my 4th 12 hour night shift in a row. I entered a school zone and with kids around, hit the brakes to slow down. Pedal went all the way to the floor but the car kept going. I used the gearbox to slow down to the point where I could yank the emergency brake. Thankfully, it worked and I was able to stop the car. By then I was wide awake and terrified.

I upgraded to a Honda within 2 weeks after that incident.

So, that was my "school car". What was yours?

Secret Santa

Yeah, I know it's a little "early" to be making posts about Santa Claus and Christmas, but I just ran across a post from Terry over at Counting Sheep (check her out y'all) that reminded me about something.

You see, I do not observe the holiday, but it sure is important to most of my coworkers.

I have the exact same opinion about this holiday. I'm not a religious person and don't observe any religious holidays - the only holidays I actually care about, for sentimental reasons are Independence Day and New Years...

...And my birthday - well, it's not recognized as a holiday just yet but I'm working on it :-p

But I know how important this holiday (and Thanksgiving) is for many of my co-workers. My experiences with my first job at a Mennonite hospital in a smallish town in the middle-of-nowhere-midwest-America just solidified the whole thing.

So I always volunteer to cover someone else's shift for Christmas and Thanksgiving - even if it's not my turn.

The way I see it: I get paid time and a half and someone gets to stay home and spend that time with their family/loved ones.

It's a win-win solution as far as I'm concerned. :-)

The more I think about it...

... the more I realize what an awesome thing it was for me to push off from "The Toxic Environment" (aka Old Job). The people I worked with were awesome but the job in itself sucked the life outta me.

I sit here nursing a beer, thinking about all the amazing things I've done since I left that job - all the while knowing that I've barely scratched the surface! I sit here thinking about how I'm working a much busier and more intense environment (my feet hurt like they've never hurt before) and yet don't feel as desolate and run down as I used to.

There exists a greater scope for teaching - be it patients, new grads or EMS students - something that I greatly enjoy.

I'm challenged here - both physically as well as mentally/professionally and I'm surprised to find that I like that. More is expected of me and I find that a little exciting.

So yeah, I guess I ought to thank my sister-in-law (was her idea for me to come down here).