Sunday, March 29, 2009

Morale busters

Morale in the ER is definitely down. ts as low as I have ever seen it. There is NO overtime available (where this time last year I could call in and pick up as many as I wanted), people are on edge about getting canned for any little fuck-up and we are elbows to assholes busy all the time, even at night.

What is truly appalling is the LACK of competence that seems to run wild. I actually heard someone say "if they aren't going to pay for my ACLS then I'm just not going to take it." I was nearly shaking I was so pissed off! I actually gave report to the stupidest nurse ever the other day. We had just tubed a Xanax and etoh OD and the doctor (a known jokster) told her we would keep the patient down with rectal tylenol and lidocaine. Her answer was.... "can we give a little versed too?" HOLY SHIT!!! She wasn't kidding.

I just had to start triage AKA Tri-agony. We have the screener who has to put people in the computer and get the general idea of what brought them in (and is responsible for incessantly calling to see if so-and-so can have a visitor) and then there is straight old-fashioned why the hell-are-you-here triage. Everyone has 10/10 pain and some sort of psych disorder that means they just can't wait in the waiting room. What I've noticed is that certain nurses will handle the flow of patients well, where others get the mentality that everyone seriously needs to go straight back. I swear I had a nurse bring me a bleeding hemorrhoid right back....a stable patient. Ugh. But on that note, some nurses are truly nasty when you bring patients back. There is one (one of the unhappy bitches I have mentioned before) who gives a smart comment no matter what you bring. An 88 year old with chest pain and dizziness??? Gets an eye roll and the paper snatched out of my hands so hard I got a paper cut.

Another morale dropper.... here is a situation that one of my friends found herself in...

50-something guy with chest pain. EKG shows not an acute MI, but changes that warrant a trip to the ICU. He has lines x2 and is still having pain. We have a pathway that gets followed in this situation. The first year ED resident wanted the nurse to start a nitro drip.... at 100mcg. Ummm.... we tend to start at 20mcg (3cc/hr) and titrate up based on pain and BP. When the nurse refused the intern gave her a hard time and then changed her order to 3cc/hr (she still didn't know the dosing). The nurse still refused 1)because the intern obviously didn't know what the correct does was and 2) the patient's blood pressure had dropped to 90 systolic. Our policy states that we don't start nitro drips on systolics 90 or below. The attending told her to start it and she still refused. She went to the nursing coordinator in the ED who told her she had to do the order and threatened her with insubordination if she didn't! Ummm.... I thought the Nurse Practice Act allowed us to not give something if we were uncomfortable with it and could articulate why. So she had to meet with her nurse manager (who is a complete C*^T) and then had to schedule a meeting with all of nursing leadership and the physicians in question. She wisely went to our head nurse manager, explained her story and was promptly let off the hook. Still... thats a frightening realization..... in a teaching facility that nursing with years of experience beyond the resident can get in trouble for not following through on an incorrect order.

God I miss flying!

Thursday, March 19, 2009

Why Me?!?!?

I am really starting to get frustrated with the ER. With the budget issues (we are on a hiring freeze AND people are being laid off) and the bulshit that seems to be magnetically attracted to me.....I just want to say FUCK IT and walk out.

I picked up a sick as shitter last week. EMS was called for some sort of respiratory issue in an ESRD patient. When they arrived she was in cardiac arrest. Our ambulances carry the autopulses (aka geezer-squeezer) so they worked her for a while, gave some drugs, got her tubed and got a pulse back. The day shift had her lined (central and arterial) and had coded her at least one more time and on levophed when I got there. The grand plan was 1) titrate to MAP of 60 2) CT of head and chest 3) get the fuck to the ICU before she coded again. When her bed was ready I got report called and was going to go from ER->CT->ICU. That limits the travel time and makes the transfer easier. We went to CT, got her on the table and I got the A-Line (which we were not transducing while traveling) secured, the monitor and went to the control room so I wouldn't get zapped. The tech ran the head and then the other tech hooked up the dye for the chest CT. She had an 18g IV to push dye through. The scan, however, looked a little fucked up and we didn't know why.... until after the scan. I saw blood on the sheets and found that the tech had injected dye INTO THE A-LINE!

I almost shit my pants.

I did the occurrence report, checked with radiology, ICU and ER docs just to make sure there was nothing I needed to do, then went to the ICU with her. Found out she died 3/17. That same day I get a call from the head of the radiology techs. Her interpretation was that I should have stayed in the "Zap room" and supervised. Has anyone ever had to go behind the CT scanner and supervise before? Is here a policy that says so? She also argued that the A-line wasn't labeled...... which it was, in several places. So we will see what the fuck comes of this.

SO with all of the new nurses in the trauma room I haven't been in there much lately. There have been problems (as there usually are with new people). Our Level 1 (rapid infuser) seems to be the bone of contention. Someone fucked it up last week so the solution..... wait for it.... is to set it up daily with the cost (around $2000 a month) coming out of the nursing education budget. Am I the only one saying WHAT THE FUCK?!?! So we are having a hard enough time getting required education and now we have to sacrifice for one person's screw up?

On top of all this the ER is busier than ever. People are waiting hours and hours for primary care stuff. Sore throats, upper resp stuff, viral shit. Nobody has insurance anymore so they all get referred to us. The kicker... they want their primary complaint worked up and then everything else "checked out" while they are here. Then they want prescriptions, and a cab ride home. (do any other ER's out there have to give cab/bus tickets?) They won't call for a ride if they know they can get a free one. GRRRRRrrrrrrrrrr!

I wonder how hard it would be to move south and open a bar? Nursing could be a backup? Hmmm....

Wednesday, March 11, 2009

Pressing Charges

A nurse that I work with was approached by a state delegate not to long ago. The delegate was proposing a change to the state law that would make assault on an emergency healthcare worker (nurse, physician, tech etc) a felony with a mandatory minimum of 6 months in jail. The current law makes it a misdemeanor with no required jail time (it is up to the judge's discretion). Unfortunately, I'm gonna have to throw the bullshit flag on that one. Not sure what makes it different being IN the hospital versus being out on the street.

For example, I had an extremely drunk white chick break out of the heavy duty restraints, run out of the department into the snow (FYI: chasing a patient through snow and ice in Danskos with bootie covers... not fun!), and and then hit me, the police and other staff with fists, bags and everything she had to get away. All the while she was threatening to "give you all hepatitis!" I finally got pissed.... being drunk is not an excuse. I decided to press charges. She was charged with assault and disorderly conduct.

I have never pressed charges on a patient before. To be honest, its a scary thing. The cop will go to court with me, of course. The University police back me 100% and it doesn't hurt that this chick has a laundry list of a criminal history. I hope she gets jail time.

Monday, March 02, 2009

Good Medicine/Bad Medicine

Ironically Bad Medicine' this was the song I listened to on the way to work Friday night. I was walking the Green Mile, but this time I had good help. I am orienting a new nurse to the department. She hasn't been a nurse long (a year and a half) and has a background in burn, so she's a pretty smart cookie and I do like her a lot. She is pretty close to the end of her orientation, so the goal is for her to fly on her own and I am just backup.

Unfortunately, together we have pretty bad juju. We had "the corner" which includes the code room, 2 isolation rooms and another monitored room. We started with an OD on tylenol and 3 sick sick sick cardiac patients. For someone with very little cardiac experience she did very well. I helped with IV's and getting folks started, but she kept up and things went smoothly.

We got a person (I WILL NOT call her a girl) who was "performing" at the lesbian club. I cannot imagine what she could have been doing. She was shorter than me (if that is possible) and as wide as she was tall. She looked like one of the ghetto boys that we see in the trauma room. Boxers, jeans hanging off her butt and a white wifebeater. She had a "seizure" after getting extremely drunk. Funny how she stooped seizing when you told her "Hey, stop it." My orientee got to experience first hand how an ammonia inhalant will fix almost anything! Big girl went to CT and yacked for distance in the hall. It was pretty damn funny!

Years ago I blogged about Dr Rock.... what a jackass. Well, we have an ER counterpart. I'll call her Dr Strychnine. She is a third year ER resident and nobody can stand her. I don't know her well, since her first 2 years I was 1)in neuro 2) flying. So I haven't been present for many of her misadventures. I know the nurses got together and wrote the residency director to ask thatshe not be given Chief Resident. She treats nurses horribly, talks down to them in front of patients and gets very bitchy when she is intimidated by a nurse who knows their shit and doesn't back down. A couple of months ago she tried to get me to put an IV in a diabetic (!) IV drug user's foot (!) so we could run Vancomycin in. When I flat refused she said in front of the patient and family "well, if you aren't comfortable enough to start an IV then I can do it." We also had a disagreement on how to treat symptomatic SVT. I was ready with the adenosine and EKG, she wanted to fluid bolus and wait. Guess who won that one???

So that night we got a transfer with a brain mass. The neurosurgeon and I are good buddies, so he will call and tell the resident just to do whatever I want since I know what to do! (I bet that chaps her ass!) As soon as I started the decadron the guy started seizing! (Neurosurg was at the bedside). A bunch ativan later he settled down. So this guy had a ready ICU bed, report had been called when she finally checked his chest xray. Skinny HIV positive dude man had a spontaneous pneumo that she hadn't picked up on! So everything in green came to a screeching halt so she could do the chest tube. We had Special Forces medics there who would sell their left nut to put the tube in, but she would only let them watch. These guys are trained for this and I have been really impressed with the current group. But no, she had to do it. I refused to watch or help. I wanted nothing to do with this fiasco. She got sterile, made her (humongous) incision and (attempted to) put the tube in. Since her incision was too big she got a motherfucker of an air leak, couldn't get it sealed off and the patient ended up with a chest full of subcutaneous air! Did I mention that she didn't get consent? It wasn't an "emergency" he wasn't unstable and it wasn't a tension. I wouldn't let this bitch touch my enemy's pet rock! It is scary that she will be an attending somewhere (not with us!) soon.

We are currently snowed in with 8inches and still coming. I don't have to work until 2300 Wednesday night. The cop and I are keeping our collective asses here with the puppies, good food and good movies!!!