Monday, October 26, 2009

What? A touching and beautiful moment in the ER?

Aw. Right after my week of the most annoying ass family members in the entire world, I probably had the sweetest one I have ever seen. I had a little lady in her eighties come in with her grandson, who was probably in his late 20's- they lived together and had been watching the football game together when she had a seizure- he called EMS and followed them to the hospital in the rain. He never left her bedside unless she was asleep. He was genuinely attentive to her every need- he helped her go to the bathroom without thinking twice about it, he helped me steer the bed and lift her on and off the CT table- some people you can tell are doing stuff like this because they're trying to be nice to the nurse or because they don't know what else to do- with him, you could tell it was really because she was his entire world. I took care of her for a good part of the night, and when I finally discharged her and took her out to his truck, I sat and watched him gently lift her up into the passenger's seat and arrange all the blankets around her so she stayed warm, and it was genuinely one of the most touching things I've seen in my entire career. It brought tears to my eyes. I told him what a great job he was doing taking care of her, and how I wished everyone I took care of had a family member like him. I think he thought I was referring to how much he was able to help me with everyday nursing stuff- but it really wasn't that at all. It just felt so wonderful to finally see- after all the abused and neglected nursing home patients, after the full code, advanced Alzheimer's patients with families that never visit, after all the ugly and selfish parts of humanity I see from day to day- a patient with real needs going home to someone who not only would take care of them but who someone genuinely loved them with everything they had. They say in nursing that you see the absolute best and the absolute worst side of mankind. This was one of the few times that I can genuinely say that I saw the best.

Saturday, October 24, 2009

Why don't you try it, then?

Dude. I have a week so far. I'm paying because all of my patients and family members earlier this week were super nice and complementary- telling me how sweet I was, how much I helped them, explained things and that I was an awesome nurse. Naturally, life couldn't stay that way, and the last 2 days I have had the most awful family members EVER. All the patients related to these people have been fine- really sweet, actually. But their family members have seemed to feel the need to tell me how to do my job, even though they medically knew slim to none.
It started with a poor little lady who came in with abdominal pain and turned out to have pneumonia. She also ended up being pretty anemic when we did our blood work, so the doctor went ahead and order a unit of packed red cells to be transfused on the floor. I went in to draw the type and cross before I sent her upstairs, and I explained to the patient in the family what I was drawing and why I was drawing it. Her daughter freaked.
"A blood transfusion? Why are you doing that? She could get AIDs!"
"Well, Ma'am, with the precautions they take with blood donors and the tests they run on blood now, the risk of catching HIV from a blood transfusion is just about none."
"Well that's not what I HEARD! Can't you just give her some iron tablets or something?"
I went on to explain that the doctor wanted to treat her aggressively since she already was not oxygenating well with pneumonia, but that the choice was up to them and that I would go ahead and draw the blood to give them the option, and they could talk with the doctor later. They agreed and were actually very sweet and reasonable. If only I was so lucky with the next patient.

This woman brings in her mom, who was 90. She had fallen the week before on her knee and shoulder. They x rayed the knee, nothing was broken. They apparently didn't x ray the shoulder but referred her to an orthopedist- apparently sometime in that week, the daughter decided since her mom hadn't recovered immediately, that she needed to be admitted to our hospital for rehab. The orthopedist, I'm guessing to shut her up, told her to come to our emergency room and we would admit her, that he called the ER doctor and gave him orders. This is totally not how that works, or what happened, so this old lady had been sitting in a hall bed for an hour and a half waiting to be seen by the time I got to work. I tried explaining that since the ortho didn't admit her directly, that the descision would ultimately be up to the ER doc whether to admit, and that he had to do x-rays first. I probably told her this 4 times, and every time she just stared and said, " But doctor so and so said he was going to admit her!" The whole time, the mom was just sitting in the hall bed chilling, while her daughter demanded blankets for her, because she gets cold, and when is she going to get a bed, Dr. so and so said he would admit her, why doesn't she have a bed yet? I explained the same. things. over. and over. and over. until I thought I was going to strangle this woman. Finally, our ER doc caved and admitted her, because he didn't want to deal with this woman's crap. I had to start an IV on her, so I went ahead and gave all her stuff to the secretary to get her admitted while I knocked the IV out. Miscalculation on my part- the daughter spent about 15 minutes asking my question I'd already answered, so by the time I got to looking for a vein, the patient already had a room. I then spent another 5 explaining that the floor wouldn't take her without and IV, and no, they couldn't start it upstairs.
So I go to start an IV on this woman. It is about as difficult as most IV starts on 90 year olds- not easy- but the whole time the daughter is hovering over me, literally and figuratively. "That needle is so big!" ( I used the baby size) "That tourniquet is so tight!" "She needs more blankets!" And as soon I stuck her mom " OUCH OUCH OUCH you're hurting her!!!" (The patient said nothing). As soon as I draw blood from the IV she screams. I have to explain to her that blood return is the sign of a working IV. You don't know that, but you want to tell me how to insert the IV. Awesome. I then spend another 20 minutes taking the patient to the bathroom, because the daughter insists she can bear no weight at all on either foot, and that I need to pick her up and place her in the wheelchair. Oh hell no. I do this with the assistance of another nurse, but as soon as I get the patient in the bathroom and away from her daughter, I'm able to lift her arms while she stands in front of the toilet. I put her back in the wheelchair and the nurse floating on our side takes her upstairs, with the daughter following her the whole way-" Watch her foot! Watch her foot! Her foot really hurts!" (The patient put her pain at a zero 10 minutes before and refused meds).
And last night, I worked in yellow zone and I had my first note pad lady. Now, I don't necessarily mind that people that want to write stuff down- I tend to overexplain things, so they tend to like me anyway. But there's writing things down because you actually want to know, and writing things down because you are looking for me to screw up. We don't really take patients in this area necessarily- we kind of work in one big team. So the other nurse I'm working with goes to start the IV on this girl there with adominal pain, who's in her 30's- her mom is there with her writing everything down. The first IV blew, so she starts another that won't draw, but that flushes-not unusual for people who are hard sticks- the entire time this woman is hovering over her asking if she can start the IV herself. Uh, no. So, I go in later to give meds, and she's asking me questions about the dosages and indication in a very demanding manner, even though I told them that, as I do with every patient, first thing when I walked into the room. Writing furiously. Then demands to know the name and title of the nurse who started the IV, the PA's name, my name, even though we've already told her, and it's on the board in the room. I explain after giving her daughter morphine that we'll monitor her oxygen sat and may give her a little if it drops. She responds by very haughtily saying, "Well. I don't see any oxygen." I very sweetly explain to her that it's right there, on the wall, and we'll get a cannula, if we need it. We had her drink contrast for a CT, which requires at least 2 hours between the time the contrast as finished and the time the CT is done- she comes out exactly two hours after her daughter finished the contrast, demanding to know where the CT tech is. At some point during this whole exchange, I ask her if she's an RN, too. Her response, " Oh, no, I'm a lab technician. But I have nursing skills. So, yeah, I basically am." Fool, NO. You basically aren't. If you have to ask me what Zofran is for, you totally aren't. That makes me freaking crazy. I understand what labs mean- that doesn't mean I can do your job, so just because you understand nursing doesn't mean you can do my job. Which was obviously what she thought- that she had to watch all of us like hawks so we didn't screw up a job that she could totally do herself.
Out of all of these people, she had the most medical knowledge, and she didn't have much. I have absolutely no problem with questions. I love questions. I have no problems with the patients and family looking at the charts, or giving me tips on where to draw blood. Involvement in care is awesome- it makes for better patient outcomes. But. As soon as people come around with absolutely no medical background whatsover, or just enought medical background to be dangerous, and try to tell me how to do my job- Eff no. I busted my butt in nursing school. I was at the top of my class, and I still have questions everyday. My job is still a challenge. I would just once, love to be able to make the offer to all the people that seem to think my job is easy, for them to try it. Just for about an hour. Try starting an foley on a 450 pound lady. Why don't you start an IV on a screaming three year old whose family is yelling at you? Why don't you run in the room with the demented patient who is throwing his own feces and try adminster a medication? It's a breeze, right? Go for it. If you can knock that out without a problem, come back and tell me how to do my job. But until then, back the hell off.

Tuesday, October 20, 2009

Various insane stories (warning: mature and disgusting situations ahead)

My work schedule has been crazy- lots of days on with nothing to write about but things that would make me sound horribly, horribly bitter, and no time to write about it anyway, and recently 5 days in a row off! Lots of playing/watching hockey, drinking beer, cooking experiments and realizing I'm super out of shape- not much nursing related to mention. So, this seems like a perfect opportunity to pull out some firsthand and secondhand stories that did not merit their own entries- enjoy!

Most recently- a possibly drunk/very hostile man in his mid 40s, who I only saw briefly after leaving fast track to check on red zone friends during shift change. All I knew was that he was there for back pain and was acting a complete fool- screaming at the nurses, swearing, demanding to know when the doctor was going to see him after being there for 15 minutes. He became so threatening to the day nurse that the hospital police had to escort him out without treatment, not before having a big confrontation with the nurse and charge nurse in the hall, during which I was almost sure he was going to get tazed. The awesome part of the story is what I found out the next day- not only did the guy get tazed after leaving the ER, get readmitted, only to have the doctor refuse to treat him because of his behavior, but the initial reason he came to the ER in the first place, the reason he had back pain: he got body slammed by his MOM. His mom. Who, if your math matches mine had to be at the least, 60, but probably more. Yeah.

From the other weekend shift- an elderly man who presented to the ER with a pencil inserted in his urethra. With x-rays to prove it. When asked WHY, the guy apparently kind of shrugged and said he didn't get much action anymore. Okay?

`From one of our ER docs- a psych patient at our sister hospital, who casually walked up to the nurse's station, pulled out his junk, stuck it on one of the charts one of the RNs was working on, and said, "can one of you ladies tube this up to the third floor for me?"

A few weeks ago, patient who ended up on my team after having been on a month long alcohol bender. He was extremely disheveled and mentally jacked- in fact, he was so drunk, he pooped himself, which isn't too unusual. What was unusual was the fact that when we took his pants off to clean him, a lizard ran out! Poor little guy. This my teammate telling me the funniest thing I have ever heard at work: "Girl, he was so drunk he shit a lizard!"

Finally- the confirmed legend. If you are at all squeamish, you should probably skip this one. The best way to tell it is probably the way I first heard about it. About a month after I started my internship, I met up with a friend from nursing school who had also started working in a different ER in the city- the only ER that sees more traffic than mine, as well as TONS of crazy stuff. When I asked her what the weirdest thing she had seen yet was, she thought a minute and replied, "Well. We have this guy who uses his ostomy* as his money maker."
"Wait, what?" I thought I understood this, but I couldn't believe it was true.
"He pimps his colostomy."
"Holy crap."
Apparently, this guy sought treatment on about a weekly basis for STDs in his ostomy at her hospital. As our ERs aren't too far away from each other, and most patients prefer one to the other, I figured she was the only one who would get the joy of treating such classy, and obviously compliant, patient. That was, until I switched to nights, and one of the nurses asked if I had taken care of Mr. Stinky yet. It soon became clear that this Mr. Stinky was the same prostitute (or ostitute?) that my friend's ER saw. I recently found out from one of my friends that this guy took up the time and stunk up the waiting rooms of so many different ERs in the city that the various doctors all got together and told him that if he didn't stop showing up with his nastiness and wasting everyone's time that they were going to call the police and report his source of income (I imagine a citizen like this might have had some warrants as well). Sure enough, he called their bluff and now he's in jail for at least the rest of the year. Looks like I'll have to wait a while before witnessing the horror firsthand.

*in case anyone isn't familiar with the term ostomy, it's when part of the lower bowel has to be removed for one reason or another, and the colon actually has to be re-routed through a hole created surgically in the abdomen, and the patient's stool is collected in a pouch on the outside of the body. Why someone would want to engage in intercourse with this particular hole, however, is a question I cannot answer.

Wednesday, October 14, 2009

Why patient care shoudn't be treated like a business (Or why I hate Press Ganey)

Well, it was bound to happen that there would be a disruption in my perfect work world- other than the swine flu panic that is sending our census through the roof and as a result, making a lot of our patients kind of act like assholes- that I can kind of deal with- but recent management changes- do not want. Our hospital has had not such a great reputation in the past- whether this was deserved or not I can't say, but both our reputation and our patient satisfaction scores- in our case, based on something called a Press Ganey survey, are going up steadily since I've started.
I'll be frank- I think Press-Ganey is pretty much a bunch of bullshit. Scores are calculated based on a card that is mailed out after the patient is discharged, and added together based on the ones that people send back. I learned even in elementary stats that this is a really unreliable indicator of anything- generally the only people that take the time to fill out a survey like this are the people that are pissed off and want to complain. The people that are satisfied are much more likely to tuck it away and deal with it later (never)- I can say this in my own experience- I still haven't filled out my survey for our outpatient radiology department, even though they were super cool and I had a good experience. I put it away to fill it out later, and I lost it. Now, if in my mind I had been disrespected somehow, you know I would have sent that in immediately. We get very few surveys back in relation to how many patients we actually see. And among the few we do get back, some of them are from crazy ass mofos- we actually got a really horrible score from one patient whose only complaint was that the sandwich tray she got in the ER didn't have mustard on it. Seriously.
Some of our administration- at least our awesome night manager- acknowledges that this isn't accurate. He's actually started calling people at home randomly to follow up, or going to visit patients who have been admitted, and find that most of them loved how they were taken care of in our ER and have little or no complaints about their care. So do we change our indicators? NO. What do we do? We hire a consultant to be our interim manager who's whole career is based on improving Press-Ganey scores. To a certain extent by actually making improvements in patient care, but also in a large part coming up with canned lines to feed patients that correspond with Press-Ganey questions. For example, if the survey has a question about whether the staff was respectful of your privacy, we're supposed to say things like "I'm going to pull this curtain for your privacy" every time we leave the room, so they'll remember and check the "excellent!" box.
This makes me ill. I am not selling Avon. I am not promoting a brand. I am taking care of a human being to the best of my ability. The idea that I should be trying to manipulate them into giving me better feedback is disturbing. I may alientate some people with this, but that's fine- this is why I have a big objection to running healthcare like a business as opposed to a social institution. There are many other reasons that I won't get into because it isn't relevant, but patients, especially ER patients, cannot and should not be dealt with in the same manor as hotel patrons. Function and need outweigh satisfaction for me. As much fun as it would be to listen attentively and contact my charge nurse and manager for a patient with a suspected GI bleed who isn't allowed to eat, I can't, because I, frankly, have more important shit to do. I often need to check on the person in the next room to make sure they aren't dying. I may need to help a teammate with a procedure. As nice as it is to build rooms with fancy matresses and new floors, it would probably be a better move in the grand scheme of helping humanity to have plainer rooms and take on more cases for charity care.
Sometimes we have to accept that some people are perpetually unsatisfied. That we could call in the freaking CEO of the hospital to personally thank them for choosing us, and they would still be pissed off about the temperature of their coffee. Sometimes we have to take a kind of paternalistic approach and acknowledge that sometimes, what may satisfy the patient is not in their best interest. Our Press Ganey scores among drug seekers would probably be through the roof if we passed out Dilaudid like candy! Would that actually help anyone? No. I realize that's an extreme example, but treating our hospital like a competitive retail chain is not a comparable model.
The best example I can think of to illustrate this is a patient who came in for tooth pain from a dental abcess who, during my assessment, revealed to me he had taken an entire bottle of Motrin in the last 24 hours because his tooth hurt. He immediately got admitted for observation to make sure he hadn't just made himself a transplant patient, and then promptly spent 20 minutes arguing with me about whether he would allow me to draw blood or start and IV if he wasn't immediately going to get pain meds for his tooth pain. I tried being gentle. I tried being rational. Finally, I had to close the door and tear him a new one- in short- go ahead and leave AMA if you want to, but that would be another pretty damn stupid move- and it got through to him. I then went back to caring nurse mode, and stayed late to adminster his pain medicine while smiling and joking with him. He ended having some damage to his liver, so cussing at the guy was probably the biggest favor I could have done him.
I try to, but don't always live by, the idea that you should treat every patient like it's a member of your family. And I like that approach much better than treating them like a customer. When I worked retail, I would smile through lots of ridiculous bullshit to keep my job. I could have cared less about my customers. By treating my patients like family, I'll put up with a reasonable amount of bullshit, but I refuse to be walked all over. I refuse to kiss ass, I refuse to smile and get my manager when someone acts like a bully. I will give that person the business in the most caring manner possible- just like I would for someone I know and love- and if they still want to talk to my manager, I'll get them. But it usually isn't necessary.
Reasonable people can generally recognize when someone is being real out of genuiene care and concern versus being fake to improve a number on a piece of paper. And I'd like to quit my damn job before I do the latter.

Friday, October 9, 2009

I'm not taking that patient!

Ugh. I think there is always somewhat of a conflict between the ER nurses and the floor nurses. Some of the floors I get on with great, but there is one in particular that seems to freak out if all the patient's vital signs are not within normal limits. I get where they're coming from part of the time- I have had a few patients that I tried to send them that later had to be admitted to ICU- but other times I swear this one particular floor is either a) medically stupid, or b) just plain lazy. I will admit ER nurses tend to be flippant about vitals where I work. a 180/90 blood pressure is perfectly fine for me- our patients are generally hurting and stressed and their vitals are going to be out of whack, whatever.
Before I get into some of these stories, let me first point out that I'm talking about a telemetry floor- meaning they specifically see patients with cardiac issues- so you'd think they would understand basic cardiac pathophysiology. Maybe not.
My hospital is close to a nursing home, so most of our patients have CHF, or congestive heart failure- meaning, in summary, they've had some damage to the heart, so it doesn't work as efficiently and has to pump faster, and the patient is more prone to getting overloaded on fluids, so we're really careful about giving them too much.
The first patient they freaked about was being admitted for fever due to a urinary tract infection- so her heart was already elevated from that- plus she was in late CHF, so her heart rate was 130. It had been that way they whole time- she was completely stable- that was just where she lived. I told the nurse this when I called report. It wasn't sinking in-
"The heart rate's 130!"
"Yes. But there's a medical reason for it."
"But it's 130! Aren't you going to call the doctor?"
"The doctor knows. He was down here lookig at her when he wrote the orders for her to go to your floor. The heart rate isn't going to change."
"You need to call the doctor!"
"You need to call the doctor. I'm not calling him about information he already knows."
That turkey called the house supervisor on me! I explained the situation to her and she immediately sent the patient to the floor. One explainable, out of normal limit vital sign does not an ICU patient make!

I swear they've gotten even worse since. Yesterday we had a similar issue- an elderly man with CHF who had fainted due to dehydration. We gave him a liter of saline fast to get him rehydrated, but we started him on a slower rate of fluids as not to overload him. The blood pressure was 95/52 when we called report- technically normal and completely explainable by his condition. The nurse upstairs did. not. get it.
"That is a low blood pressure!"
"Uh, yeah. But there's a reason why, and it should continue to improve."
"But it's low!"
"Yes. But we don't want to fill him up with fluids too aggressively because of the CHF. "
"But it's really low. What if it drops?"
"Why would it drop? If it drops call the doctor! Do you understand how this works?"
I was literally hitting myself in the head with the phone by the end of the conversation.

Forget completely about the med floors- I swear they aren't allowed to have any sick people up there. Some of it makes sense- they can't give cardiac drugs IV push since their patients aren't on continous monitoring- but the stuff they refuse to accept is freaking ridiculous. I sent them a patient with a 180/90 blood pressure who I had been holding in the ER all night for his blood sugar so they wouldn't have to fill an ICU bed. The admitting doc would have let me send him up a lot earlier but I wanted to get his sugar down the where the meters could actually read it so the floor nurses wouldn't have to send blood to lab. I even started a second IV for them- if EMS starts the first they have to remove it and start a second of their own, unless we do it in the ER.
So the whole night I dealt with time consuming hourly blood sugar crap, I was ready for him to be OUT. His pressure had been high earlier in the night and I knew they wouldn't take him, so I called the doctor and got a ton of orders- including two oral blood pressure meds and and IV meds for the gaps in between. He ordered them all at once, but I wasn't comfortable dumping all three in him at once so I held one and gave it right before he went up- I'd also stopped the insulin drip, started the sliding scale orders, and checked a blood sugar. She did not seem to get that they medicine was going to bring the pressure down soon, so I mentioned that she had order for IV meds, too.
"I can't give that. Can't you call the doctor and get the order changed?"
"You can call the doctor and get the order changed."
"Aren't you going to check another blood sugar?"
"We check an hour after we give insulin. I just gave it."
"But it's been 15 minutes, hasn't it?"
"Do you seriously want me to check it 15 minutes later? That makes absolutely no sense. No."

Ugh. the thing that makes me the craziest about that shit is that they have techs to do that! We have ourselves, and other sick patients! I understand stabalizing people, but please! Not everything is going to be fixed by the time the patient gets admitted. That's why they get admitted.

Tuesday, October 6, 2009


Menstrual cramps?
Not an emergency, in case anyone was wondering.
Also- constipation? And by constipation, I mean, bowel movements were harder today than usual. Did not try Metamucil or drinking more water. Oh, and since we're here- clear vaginal discharge x 1 year. ONE YEAR. No odor, itching, dysuria.
WTF. I mean. Emergency room. Holy shit, emergency room.
I have no words. I am still trying to figure out how it is humanly possible to be nice about this.