Follow-Up

A little follow-up on my folks from a couple of weeks ago. I did all of the occurrence paperwork, emailed our nurse manager and clinician and met with the nurse manager as well. Obviously, I am in the clear as I was the one busting ass to get things the way they needed to be. The nurse I got signout from is going to be "educated" in the way things are supposed to run. I think he might have to do additional time in one of the ICU's so he understands what critical care is supposed to be (and maybe what a sick patient looks like?!?!) Risk management is also getting involved and I have to be interviewed by one of the big shots about what happened from my perspective.

The Know-It-All

More proof that just because you have the title Dr before your name or MD after, you don't know EVERYTHING (much to the resident's dismay!)

I had an ER resident argue with me about a little old lady with a head bleed. I did a neuro exam on her.... prior to consenting and doing the checklist for an MRI. I told the resd that she was expressively aphagic and that I was going to contact her husband to help with the MRI checklist. The resident said "oh, she's just a little confused" and wanted me to go ahead with the checklist.

To quote one of my favorite TV characters..... "HOMIE DON'T PLAY DAT!"

I may have spent a year in neuro hell.... but I KNOW my neuro patients and my exam findings. I don't want to take crap from a 3rd year resident who would probably kill the patient if left to her own devices.

Washington

I have said many times, I'm in VA. We have Williamsburg and Jamestown to the southeast, and Washington DC to the north. Its a very historic state. I am (thankfully) off today. I have lots of friends who live in DC and I must say.... I don't envy them. They are talking about the Metro having over an hour and a half wait. The bridges into DC were closed at 3am this morning. I'm glad that I don't have to fly up there today either!!!

Being as close as I am, I wonder, should I be there? Should I be witnessing history in person? Ummm.... I'm there in spirit, but I have no desire to be around THAT many people. I don't even like the malls at Christmas, so THE Mall today??? I don't think so. The cop and I walked from the Washington Monument all the way across the mall to the Capitol building. Thats HUGE. I have sat on the steps of the Capitol, Lincoln Memorial and walked the halls of ALL of the Smithsonian Museums. I still get goosebumps at the Vietnam War Memorial, and the National Law Enforcement Memorial brought me to tears. I stayed in a riverfront suite in The Watergate Hotel and stood in front of the White House and watched foreign tourists get sprayed with the sprinklers!!! We have been so fortunate to live close enough to visit very frequently. As a child, I don't think I appreciated it. To my friends all over the country and the world.... if you get a chance to go to DC... GO! It is an amazing place. (Just don't plan on getting in today!)

I think I'll just watch on TV!

Scared

In this economy it seems like we should all be scared. There doesn't seem to be a whole lot you can depend on. The cop and I have joked that no matter what the economy does, we will always have jobs. While we have been a bit more careful with our spending, it has been a comforting thought.

Since I returned to the hospital the economic status has been very visible. Overtime is very limited and very hard to come by. People actually rush to sign up when it becomes available. A lot of our supplemental staff (float pool) have been cancelled or sent home. We had a meeting with ER management this week and it appears that while the hospital had millions upon millions to build a new addition (and already can't staff it!) they have found a need to start layoffs. The letter we all got in the mail is a bunch of managerial bullshit with the number 300 on it. 300 people could get laid off! The majority will probably be nursing, "since they make up the majority of the staff." It seems that the supplemental department will be closed, hourly personnel will be let go and everyone close to retirement will be offered a package to retire early. I know that I am vested, experienced, and hard working.... but I am still scared that it will be me.

FUCK FUCK FUCK FUCK

In any job there is an element of inconsistency. There are many ways to do things that result in the same (or similar) outcomes. As nurses, we all work under the same "don't let the doctors/residents/interns kill the patients" thought, but in the background we all have the "don't let one of my colleagues fuck up and kill my patient either." This is the real world and I'm not going to bullshit this.... we all know that some nurses are just better at their jobs than others. I know that I'm nowhere near the best, but I try to give 110% to all of them (except maybe the drunken assholes.... they get about 85% :) ) .

What do we as nurses consider our rules when dealing with peers?

• Don't kill anyone (duh)
• Don't leave pee, poop, vomit or other goodies for the next shift to clean up (unless they say its ok and MEAN it!)
• Don't leave the rooms trashed
• If you say you did something.... you better have done it
• If someone is screaming for help, or if their patient is tanking, you help them
• Don't do anything unsafe, or leave a patient in an unsafe condition for the next nurse

I picked up 4 patients in the green mile last night from a traditionally shitty nurse to follow behind. His rooms are ALWAYS a mess and I don't think he understands how to prioritize. One patient had the flu and was getting IV fluids, another was a psych guy with random belly pain. The other 2 patients were sick... really really sick.

The first was a 39 year old with a fever (103) low bp (70-80 systolic) and a heart rate in the 140-150 range. Yeah... sick girl (hello is the word SEPSIS going off in anyone's mind?) She had been there for hours, was not on the monitor, not even changed from her clothes... potassium was being run straight in. Grrrr.....labs sent (no blood cultures) and vitals had not been documented in hours. It took a long time to get her straightened out...

The other patient had something similar to Steven's-Johnsons Syndrome. They were calling it something else. She was in her 70's and her skin had been sloughing off like a burn for a day. She had popped blisters all over and was soaked from them. Her temp on arrival was 94.4 and very little had been done to warm her. She had no IV, and the IV fluids, labs and antibiotics had not been given. This poor soul was in really bad shape.... especially after waiting 9 hours before I even showed up. The attending, Dr B, had no idea she didn't have a line until my relief had gone. She quickly got an IJ, labs, fluids, IV pain meds (!) and cleaned, warmed, wound care and big warming blanket. I gave her fluids a little on the gentle side since she was old AND had a recent MI. Despite all of this, she was awake and alert, smiling through everything and thankful for her care. When I called burn (she went there for the wound care) I explained the whole situation, apologized profusely and took her to the unit myself.

I had already contacted my supervisor and made copies of the charts this morning when Burn called me back. My patient tanked her pressure after getting to burn, was placed on Levophed and then coded and died this morning. I was soooo angry that I could hardly think straight. Yes, she had lots of medical issues and may have been on her way out the door, but as my very good friend said later, "she may have been going out the door, but we didn't have to throw rocks at her while she left!"

I anticipate some phone calls over this one. To what extent would you hold the previous nurse accountable?

GRRR... I am SO very sorry. I'm sorry for my patient and her family. I hope that she is somewhere warm and dry and that the events of her last day aren't even a memory. I'm just so sorry (and mad) that this happened.

Bad Moon Rising

You can tell the moon is full... seriously crazy shit.

Lady who walks backwards everywhere she goes and has the hat pulled down over her eyes like the guy on 'Fat Albert'

Lady who gets nervous and eats the foam from her egg crate mattress. (she wonders why her stomach hurts!)

Woman with a live roach in her ear that swears GOD is whispering to her (the roach came out alive and in one piece! Ewwwww!)

Man with a hemicorpectomy (amputated just below belly-button) who was "walking along when al of a sudden two dudes stole his legs and left him in a chair"

This was just Thursday night.... Friday night the barometic pressure must have dropped as well, 'cuz there were cerebral aneuryms blowing like fireworks. We sent 5 up tubed and sick as shit. Out of 5, 1, maybe 2 might survive. I am truly exhausted and am going to bed. Will fill in the blanks later.

BItchy Nurses

Nurses in my ED have a reputation for being notoriously bitchy. I remember being scared of them when I ran EMS. I wonder if it's because we get hit, chased, bitten and generally abused by out patients on a regular basis. Yes, we take it... most of the time, but we can dish it out and then some. I can play the charming southern girl, but can flip into Linda Blair from 'The Exorcist' at the drop of a hat. Now that I'm back in the ER full-time I have noticed that some people don't need an excuse to be bitchy. I am happy when I go into work...I blast the radio (sometimes the songs predict my night... 'Highway to Hell' does not bode well!), drink my Starbucks and generally smile about my cool job.

I work with nurses that come in hating life. They are bitchy, treat the patients poorly and generally bring gloom and doom. I work with one in particular... she yells a lot. If someone is sick as shit I get pretty quiet, I hum Buffett songs under my breath. There is enough going on without my little soprano drawl over the noise. This chick yells over whoever is talking, it doesn't matter who. I caught her screaming over the trauma attending the other morning. Some poor guy wrecked his car, was crumping for ems and came in the trauma room. I was the trauma back-up and essentially the critical care resource. She was screaming for drugs and pressors (not the rights ones!) and when we started the Levophed she didn't know the dose. Grrr.... she pisses me off.

When she and her buddies get together they are almost intolerable. To say that they are "badge Bunnies" would be an understatement. I get dirty looks when the police officers come in.... I think the cop's buddies know them well enough to ignore them. With the current economic situation I know that I need to stay in the ER and ride this out. Even if a flight job comes up I still need to watch out for myself. Flight programs are expensive to maintain and can be considered "expendable," especially when the hospital is overbudget already. Ugh.... sorry this is a boring post.... am back for 3 days on Thursday. We will see what happens.

Drunk 101

Also known as "Why I Hate Drunk People"

I have been fortunate in the last 7+ years to NOT have to work New Year's Eve. There have been plenty of people with children that want Christmas off so I have always traded. I have never been a big partier, so New Year's has usually consisted of staying home with the cop, the dog(s) and a bottle of wine. This year all of the detectives had to work drunk hours (7p-3a) so I traded a friend so he could have the night off with his wife.

The roads were almost empty and the only fast moving cars were the two state troopers that zoomed past me, switched lanes and waved out the windows. (being a cop's wife AND an ER nurse has its benefits!) The ER was almost empty too... which was was a little eerie. I was walking the green mile in my least fav zone. All was calm, Dr B was there for the overnight so at least I didn't have to deal with some low life turd that treats the nurses like shit (believe me, there are some up and coming assholes). At ten minutes til midnight we placed our bets on the first GSW of the new year, I called the cop to make sure he was wither under a bridge or underpass for the "fireworks." Instead of real pyrotechnics, the inhabitants of our city shoot guns up in the air to celebrate. The shitheads forget that what goes up must come down, so its best to be under shelter at the stroke of midnight. The girls and I went outside to hear the gunfire and then back in 'cuz it was too damn cold.

About 30 minutes later the fucker broke loose. Squads from all over the city bringing in the first drunks of the year in droves. I scored #1.... 5'10 120lbs, dressed like a high class hooker in CFM boots. She barely made it to midnight, tripped and cracked her chin on the pavement. She arrived backboarded, screaming like hell that she had to pee. Dr B was gettin her off the board when she kicked him square in the nuts.... poor guy. Not how you want to ring in the new year. She proceeded to bleed everywhere, swear, swing and stumble all over the room. Once she was sutured she told us all to fuck off, pulled her IV and staggered out into the night. Her replacement was almost identical, except the next one puked for distance all over the room, herself and her very sweet (and sober) boyfriend in his suit.

A recommendation to all med students and nursing students out there... never NEVER get drunk and show up in the ED. Even better, don't show up on one of our busiest nights of the year, march into the nurse's station with your drunk boyfriend and demand that we take care of you RIGHT NOW. This little bitch announced that she was a fourth year student and she wanted her GOD-DAMN-PAIN-MEDICINE! (she was there with a migraine) I have had 1 or 2 migraines in my life... I couldn't lift my head off the pillow, much less walk, scream etc. Her boy-toy actually grabbed one of my buddies by the arm and told her to "get in here and start her IV." He came close to having it broke off in his ass.

The next contestant was a drunk Guatemalan who kept trying to grab my boobs. K screamed him to shut up and talk american while I "helped" him back into his bed. He puked in the sink and on the phone before tracking it through the department while trying to find a phone. We had a couple of people hit in the head with beer bottles and one who got popped with a frying pan (chronically battered woman who was so drunk she peed on herself). Thank God Dr B was there.... he ripped those dumb fuckers out of their collars and off the backboards and didn't waste time with CT scans unless they really needed them. It was a long long night. I was happy to make it out in one piece.


I actually fired a patient Thursday night. He was a bad asthmatic who was working like a dog, tripoding, satting 80% on his nebs, spitting on the floor (instead of his bag he was given), pulling IV's and giving me a shit-on of attitude. After 4 nebs, 4gms of Mag, terbutaline, epi, steroids he was still refusing to be tubed and was getting aggressive towards me. I took him off the monitor, turned the neb off and told him good luck, he was on his own. (let me also say that the Dr was there, was aware of the situation and supported me 100%).

I hope that the drunken craziness and the assholes don't continue to follow me through 2009.