New Outlook. Same Great Nurse!

It's been a while since I updated my blog.

Mea Culpa. I got busy. I had great things happen in my personal life and then not so great things and some downright ugly things. Stuff you wish had never happened to you and yet wish had continued to last... It is complicated.

Nevertheless, I'm still in the same State I moved to from my previous job working med-surg. I'm still an ED Nurse working within the same hospital system - just at a different hospital campus as of June 2014.

I left the former hospital in the system for more reasons than one. Suffice to say that I'm quite happy at my new job - warts and all.

One of the biggest adjustments I've had to make is with my current ED: the implementation of a new method of patient flow, in order to expedite patient throughput and try and reduce 'wait time in the waiting room'. This is achieved by revitalising and reusing what is called "Fast Track" in most EDs. While this does place an extraordinary burden on the Nurses and the Doc/PA/NP assigned to the section - it does seem to have an impact by lowering waiting times in the ED. I've had numerous patients tell me that 'I've never been brought back to be seen this fast before".
There's still lots to be tweaked in the system, IMO. But it's early stages yet. I'm sure improvements will be incorporated (I've already passed on suggestions to management.)

The other BIG adjustment I've had to make with my current ED over the old one is:
Cameraderie (i.e. Recognising your team). That includes the big, giant role our secretaries play in our day-to-day.

To give an example, while I was in the midst of transferring a critical patient to a specialty hospital. I went about it based on my prior experience at my old ED - I was calling x-ray, CT scan to bring copies of the studies, I was trying to set up transport for the patient while trying to get the EMTALA done and. ... that's when the secretary called me out and admonished me! To quote "What are you doing??!! That's my job. You worry about EMTALA and giving report and your nurse duties! I'll worry about the chart, transport and everything else!"

STUNNED ..... doesn't even begin to describe my reaction. Never mind the fact that the secretaries also take calls - from labs to family members to weirdos - and KNOW ENOUGH to either address it with the level of appropriateness to the right party (nurse, doc, tech, family, lab etc.) but also handle "family calls" appropriately - instead of the standard at my old ED; pretty much no matter what the call, the response was "talk to the nurse."

Yeah, there are changes. I'm sure I'll revisit this post soon. Till then....

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....

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 ...

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'?

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??!!

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]

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! :-)

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!

Confession...

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

The live version of "Duress" absolutely kicks ass.

That is all.

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!

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.

"Old Lady With The Low Heart Rate"

I think this one is one for "the books". Y'know? The 'stash' of interesting patients/encounters that you file away some place?

Last week I was assigned to one of our two "Acute side" pods [2 nurses to deal with a theoretical 8 beds.] Naturally, given the state of Emergency Departments these days, those "8 beds" can 'stretch' to 12, 14 or 16 (this is the "acute side", mind you) depending on how many patients you can cram in before you're 'forced' to go on Divert... and of course, you don't get any additional "help" when you're over loaded. Management seems to think that it's ok to staff 2 nurses to 8 beds even when 6 of those patients are on vents...

... but I digress.

Anyway, my partner and I are already dealing with 13 patients (6 in rooms, 7 in hallway stretchers - some "sharing" hallway assignments) when we're curtly informed by the charge nurse that one of our room patients needs to come out because there's a lady out in triage with a "low heart rate and no discernible BP".

My partner and I look at each other and practically play 'Rock, Paper, Scissors' to decide which one of our "critical patients" in our rooms has instantly become 'less critical' so that they can sit out in the hallway while we treat this new patient emergency....

Ok, Ok. Just kidding. We pulled one of our semi-stable chest pain patients (the one we deemed to be at the lowest risk of all our patients) out of his room to open up a spot for our new patient (but we DID play rock-paper-scissors to decide who would pick up the new patient and I DID lose...)

So I walk into the room as the triage nurse and a tech assist the patient to the stretcher. I introduce myself to the patient and her husband (they're both about 90+ years old) and I note that the patient can still walk, albeit with assistance... and that she's still talking.

Triage had told me that the patient's HR was about 30 bpm and she couldn't get a BP.

Not the kind of behavior I'd expect from someone with such a low HR and no BP!, I thought to myself.

As she was settling in, getting undressed and hooked onto the bedside monitor; I asked my questions while surreptitiously assessing the pt. Radial pulse indicated a HR of 28. To confirm, I checked a carotid... also about 28-30 (with super-long pauses between beats). I used my stethoscope to check out her lungs and heart sounds - nothing exceptional other than her irregular bradycardia, with long pauses.

I did a manual BP - she was 55/20!

But she's sitting up and talking to me! Her only complaint is "feeling a little dizzy, like I've been feeling off and on this week except tonight it got worse".

Well, I'll say!

Of course, while this was going on; other things were stepping into high gear. Someone showed up with the EKG machine, someone else started hooking her up to the bedside transcutaneous pacer and a paramedic student started looking for a vein for an IV in her arm. I requested that he get an 18 gauge in her Right A/C and to come grab me if he had any trouble.

The patient shoo'ed all us 'men' outside (especially her husband) as we were trying to get her undressed for the EKG/monitor. She managed a wry smile and said "even after all these years, I'm still modest about myself around him". That elicited a chuckle from the two female techs and a grin from me.

"Well, you got nothing to worry about from us M'am. We'll make sure he doesn't catch a sneak peak", I said with a grin; which elicited a good belly laugh from her.

I figured it was time for me to step outside and talk to the husband.

"Hi Mr. Smith. While we're getting your wife settled in, I'd like to tell you what we're planning to do. First we'll hook her up the the bedside monitor so that I can keep an eye on her heart and other important signs even if I'm not in the room. Some of my colleagues are going to do an EKG, a simple electrical "picture" of her heart to see if there is any abnormality. Other colleagues are going to start an IV on her and draw some blood at the same time to test and see if she is or has suffered heart damage in the near past.

Do you have any questions so far?"

"No, I don't", said Mr. Smith.

"What I'd like to ask you though is your perception on things", I continued; "What made you bring her to the ER tonight. Has anything changed over the past week or was it something that happened tonight? Were you engaged in any activity which is not the norm for the two of you? Any strange/different food or drink? Medications?"

When I mentioned medications, Mr. Smith calmly tells me, "I think she took one too many of her BP meds. That explains her symptoms and her bradycardia. I don't think it's anything serious but given her bradycardia, I thought it best to get it checked out".

Now, normally, I don't have 90+ year old gentlemen use the words "symptoms, bradycardia and BP meds" in the same sentence... much less articulate them in a manner as to suggest a medical diagnosis!

Before I could ask the husband where he learned them neat words, out comes the paramedic student with a grin on his face as he hands me a bunch of vaccutainers containing blood samples. "Here you go Spook! 18G in the Right A/C, just like you requested".

As I was thanking him, the student turned around to face the husband and exclaimed, "Mr. Smith! Say, you wouldn't be the same Mr. Smith who was head of cardio-thoracic surgery at Sprawling Metropolis Trauma Center, would you?! I've heard so much about you! My Dad was a paramedic and he used to talk about you all the time!"

I swear I saw the old gentleman in front of me *blush* and mumble, "Yes. I was. But that was a long time ago".

Well, that probably explains him knowing all them words, eh?

Right when I was about to say something, the tech walked out with the 12-lead EKG report. I quietly stopped her and took the paper copy of the EKG to show it to Mr. Smith. I let him take a quick look at it, before I hurried over to the ER doc to show it to him.

Both the ER doc and I now approached the patient and her husband, to explain things as to where we stood. The ER doc was convinced that while her condition was serious, it didn't warrant an immediate pacemaker implant or surgery. Her lab work seemed to indicate no emergent abnormalities and he was inclined to agree with the husband that the pt. had probably taken one too many pills by accident.


The plan was to admit her to remote telemetry overnight - just in case.
While the ER doc was talking with the admitting consultant over the phone, I saw Mr. Smith quietly sneak into his wife's room.

They held hands for a while. Looking into each others eyes. Saying nothing... and yet 'speaking' all that need to be 'said'.

A little while later, I saw him get up, gently lean over and give his wife a heartfelt kiss. He brushed her hair off her face, while they were still holding hands. Then they said something that I couldn't hear and her bent over to kiss her again.

The look they had on their faces was just... well, indescribable.

[I did feel guilty that I witnessed what was obviously meant to be a tender, intimate, private moment between the two of 'em].

Mr. Smith slowly shuffled out of the room, taking care to close the curtains and shut the sliding door. He ambled over to me and said "Thank you for all your help today son. I'm loathe to leave but she insists I do. She says that I need my rest and that the dogs would get antsy without us."

He paused.... and looked down...

"Trust her to be more worried about me and the dogs even as she's lined up in a hospital!"


I walked over to Mr. Smith and bent down on my knees so that his eyes could see mine. I took his hands in mine.

"Mr. Smith, you're wife is as concerned about you as you are about her. But at this point in time, there's not a whole lot else you can do for her. I won't dare to presume to tell you how how things ought to be, but Sir; this hospital has strict visiting hours. As much as I'd love to bend the rules, you and I both know I can't."

He looked up slightly. A striking face; worn by the ravages of time, worry and care. A mist occluded his bright grey eyes.

"I've never been away from her. Ever. She'll be terrified. I know she will!"
That last response sounded less like a statement and more like a plea...

It nearly broke my heart.
"Hold on Mr. Smith. Let me see what I can do to..."

Just like that, I saw him shake his head. Take a few deep breaths in. Then he looked down to meet my eyes - his steel grey fiercely boring into my liquid brown.

"You take good care of her. She's all I have left!" I felt his hands clench mine, as if reinforcing his desperate plea.

"We will, Mr. Smith", I mumbled; "I promise".

He nodded assent, and then slowly shuffled off.


Leaving me all alone, to contemplate the loving bond that is shared between a man and his beloved wife....

Spoke my mind

Sent to me via email:



[Click image to zoom]

If you created this image, lemme know so I can credit you.

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?