Tuesday, September 29, 2009

excitement, a little too much!

Yikes. This whole weekend has been pretty uneventful- lots of flu, actually, dare I say it, slow? Until... Sunday night. We got our payback, cause shit hit the fan.
I had a lot going on the whole night- a septic nursing home patient, full abdominal pain workup, and a chest pain who I was trying to get upstairs at the same time, but stuff I knew how to do- just a lot of it until later that night. I'm finally hitting a lull and getting rid of some people when they wheel back a lady with her foot up in the air and her sister walking next to her, carrying a bag.
She's been bit by a snake, they don't know what kind. Her vitals are stable, so I hook her up to the monitor and start and IV. My manager and I open the bag and pick up this snake trying to figure out what it is. The doctor comes in and looks with us- we don't recognize the markings, but it has a diamond shaped head. Uh oh, this is bad news. Poisonous. Our charge nurse wanders by and takes one look at it- Copperhead. Balls.
I call poison control and the doctor orders Crofab- an antivenom, apparently- they send it up in powdered vials with mixing instructions. My manager and I try to mix it and it's seriously insane- mix each vial with sterile water and then mix that in 250 ml of saline? Each vial? All of them? We don't know. I call the pharmacist, who tells me to send it back, so they can mix it. Thank you.
I end up waiting about an hour for the Crofab- while I'm waiting, they try to bring an wheelchair back to another room, that isn't clean- mine is, so I end up with a patient with chest pain and ST elevation on his EKG, which means acute heart attack, fly them the hell out to a cath lab emergency. Yikes. We repeat EKGs, start IVs- I explain to the family it may not be what it looks like and the doctor needs to interpret the EKG himself. We get meds at about the same time I get the Crofab- I give both and we repeat the EKG after I give the nitroglycerin, we show it to the doctor, and he confirms it- yup, ST elevation MI. We rush around working on transfers, starting a second IV- meanwhile I'm watching the snakebite lady like a hawk to make sure she doesn't have an anaphylactic reaction to the Crobfab. we get the transfer in order and fly the patient out, and with the Crofab going and my patient's vitals stable, I'm finally feeling at ease. I ended up having her the whole night, since we had no ICU beds, and she did great- we had cold compresses on her foot, so the swelling actually went down remarkably and she was looking great.
Luckily we had lots of EMS students there- not only were they able to help out with vitals and EKGs, but they also got to see some real stuff. It's always stressful at the time, but I love it now- I'm now the resident ER expert on snakebites, as I'm the first person to have dealt with one and given Crofab! Plus, I had lots of fun chasing the other girls on my team around with that dead snake.

Wednesday, September 23, 2009

Appropriate transfers, you're doing it so wrong.

Ugh. The state of nursing in other facilities that we get patients from is nothing short of frightening, frankly. I won't even go into the stupid crap like the PEG tube replacements that the geriatrics docs should do at the nursing homes but are too lazy to, or the DNRs with low 02 sats (what are we going to do, intubate them?) but stuff that can only fall under the category of why-the-f would-you-ever-call-an-ambulance-for-this?
My favorites lately, from the nursing homes- a lady who banged her knee on a cabinet, denying pain, with a little bruise, who they sent via EMS to rule out a fracture; a hypoglycemic patient with a blood sugar of 95 when EMS arrived- supposedly, the patient had a sugar of 20 that they gave glucagon for. BS. When they arrived, they asked if they still wanted to send the patient-oh, absolutely. He was acting "altered". Oh, by the way, he had Alzheimer's. A 35 year old down's syndrome patient with a twitching knee. Really? One of our sassier ER docs has actually called and gotten in yelling matches with the nursing home doc on multiple occassions over the inappropriate crap they send over.
Probably even better is the psych facility down the street. I'm really starting to wonder if any RNs are actually employed at this place. Transfers we've gotten include: a ten year old with a fever. No tylenol or motrin given for 8 hours. A patient who was detoxing from cocaine that they woke up at 4:30 AM. He was confused, so they decided he was having a stroke. He was probably about 38, and had no facial droop, no weakness, no suggestive symptoms other than confusion that could easily be explained by the fact that it was four in the freaking morning! I always love the countless "altered mental status" patients they send us that need to the "medically cleared" who are either on drugs or withdrawing from drugs. Uh, yeah. They're sluggish and feel like crap and are mentally a little slow because they are withdrawing from an addictive substance. HOLY CRAP.
The absolute best, however, is the crap we've been getting this last week- I can't believe I'm saying this- but CPRs in progress from other hospitals. Seriously. Well, one hospital, specifically- a long term care facility that basically see ICU style patients day in an day out. Their patients code. They are sick. Do they run the CPR as they are trained to do? Nope. They call the ambulance and send it across the street so that when the patient dies, someone else has to do all the paperwork. We've gotten two of these in the last couple of days. Usually, by the time the EMS has been dispatched, arrives, does their work, and gets them to our ER, the patient has been down at least half an hour, but usually longer. They are always older patients with tons of comorbidities, so the docs usually call it after 1-5 minutes, as they should.
Man. I know I enjoy work more than most people- I work in the ER because I have to bust my butt there and it makes the time fly- but how lazy can you possibly be? I can't tell if these people are really so medically stupid that they're actually concerned about the conditions these patients are dealing with, or if they are so lazy that they are looking for any excuse to call EMS so that they don't have to do their work and take care of their own patients. Either way, it makes me want to drive across the street and smack them in their faces.

Saturday, September 12, 2009

My Hallmark nursing moment, with help from the hospital police.

Sometimes, with the drug seekers, the drama queens, and the legal requirement of pulling elderly people trying to mercifully go in peace from the sweet arms of death, I get in a completely shitty mood and forget why I do this job. I had actually just dealt with the latter in my trauma room- a 78 year old Alzheimer's patient in respiratory distress that the family (over the phone, of course) insisted be intubated- when I got orders back for a little boy who was being seen for knee pain.
I should probably mention that pediatric patients scare the hell out of me- especially when they need IVs. In this case, our tech had already stuck him- but whoops, didn't draw all of the labs the doctor ordered, nor did she start a line. Balls. So, we have to go back in there and put an IV in this little three year old who's already hurting. As we're prepping him, I chat with him about his spider man shirt and ask him if he wants to be a superhero when he grows up. He says no, that he wants to be a policeman. He gets really excited and tells me that he saw one at the store earlier that day. We stick him, and I bring him a popsickle, and he's pretty happy, but I get the idea that I can do more.
It was pretty slow, so I ran up to triage and grabbed the cops posted up there. I explain to them that I have a little boy who idolizes the police and ask if they would go talk to him for a little while. Both of them gathered some stuff up and came back to talk to the little boy- they brought him a little police badge and a bear, and told him that they had heard he was a brave kid, and that they needed his help to be a deputy. They gave him two stuffed animals as a reward for being their helper. He was so excited. I have never seen a kid's eyes light up like that before- I know that they completely made his day. I had tears in my eyes watching how great they were with him, and how happy he was- and I had this moment like, oh, yeah. This is the reason that I do this job. I remember now.
We actually ended up transferring him to the children's hospital- the doctor started to suspect he had septic arthritis- but I felt so good that he would actually have one happy memory from a pretty traumatic day.

Thursday, September 10, 2009

baby update

So, I just got the news recently about the details of everything with my little newborn a few weeks ago. One of the ER nurses here is friends with one of the girls in the nursery, who told her that apparently, the cause of death was sepsis. Pretty soon after he got admitted, the little guy spiked a fever, and since he wasn't really old enough to have developed an immune response, his organs eventually shut down.
The sad part is that he might have lived if he was cared for by the mother- if the mom had cleaned her feces off of him at birth, if he had gotten care earlier, or if he could have gotten some maternal antibodies from breast milk.
The good thing was it was nothing intentional, and the nurses caring for him loved him a lot. Apparently they all adored the little baby and had even given him a name. So in the short time that he was alive, there were lots of people who cared for him- which is really all any of us can hope for.

Wednesday, September 9, 2009

oh, drug seekers.

Arrggh. So I get a patient the night before last, 18 year old, comes in on the ambulance, in his words, in a sickle cell crisis. Chest and joint pain, 10/10. Huge kid. Like, 350, 6'3. Immediately starts asking me for pain medicine, but in a very desperate, sweet sort of way- "Oh please, miss, I'm hurting so bad." I tell the doctor the story and get him some Tylenol, since we can give some per protocol. I tell him very sweetly and sympathetically that I can't do anything until the doctor sees him but that his chart is second in line and he should be in soon. I go to take care of my other patients. I'm in a room for 15 minutes- when I come out, he's called me three times asking for pain meds. Same story- sorry dude, I don't have MD behind my name, I can't give you Dilaudid yet.
I reach a lull and tell him that I can at least start an IV so that when I do get orders, he'll be ready to go. Kid has absolute garbage for veins, naturally- I call one of our medics but he's tied up doing other things, so he can't help for a little while. In the meantime, the patient falls asleep- the doc gives me orders- as soon as the kid wakes up, he is all over me again asking for pain meds, water, blankets, crackers, juice. My medic finally gets a line and I go to medicate him- first red flag- he asks me how many milligrams he's getting. I can see this in some cases, but it always makes me a little suspicious. Two. He's already pissed about that. Twenty minutes later, he calls me in asking for more pain meds. I tell the doctor, who rightfully says no- he demands to talk to the doctor. He calls me about 8 times about it, starting to yell at this point. The doctor tells him no in person- he calls me every hour on the hour after that, arguing with me about the number of minutes that have passed.
At this point, I talk to the lab, who helpfully point out that no sickled cells were present on his CBC. Hmm. I very delicately inform the doctor, who orders two more of Dilaudid anyway(!)
Naturally, he immediately wants more, along with more juice, and lets us know by yelling at us out the door all night long. Finally, it becomes time for his third dose- I'm stuck in a room dealing with a demented patient who is trying to fight the breathing treatment she needs. He is calling the secretary constantly at this point, since apparently the doctor had told him he would get another dose, probably since the patient starting pulling shit saying that he couldn't go home and needed to be admitted, but he hadn't written an order yet. I try to explain this to him- that I can't give narcotics based on his word alone- and he starts screaming at me about how I'm not listening to him, that he wants the doctor and the charge nurse, that I don't care, etc. I finally get the order his last dose- he tells the charge nurse that he has a ride home.
We wait a while and I discharge him- he's clearly drugged out of his mind at this point, so we keep him in the room for a while to let him sleep it off while he waits for his ride. It's right about shift change at this point, and his hulking ass keeps trying to get out of bed and run out of the room. We tell him repeatedly that he has to have a ride at the bedside before he can leave- he responds to this by pointing at random nurses while everyone is taking report and screaming that his ride is here. When that doesn't work, he screams at me that he wants food, that we've kept him her all night without feeding him. I tell him no repeatedly, that he's discharged and his ride can pull through McDonalds. We finally have to call the police- I decide this is probably a good time to go home.
When I got back to work last night, the nurse who took report tells me he was here until noon that day- apparently he lied about having a ride and spent the whole morning yelling at the nurses for breakfast tray. During that time, one of the family practice doctors walked by and recognized him (he's been here 20 times this year for the same thing) and let us know that apparently, he's not even sickle cell- he just has the sickle call trait. Awesome. I can't wait for the night that he comes in next. Someone's going to have some explaining to do.

Sunday, September 6, 2009

surprises, not the good kind.

Yipes. I think God may be trying to teach me a lesson when I get into my "you're not actually sick" mode- see my disaster a couple of months ago, when my prescription refill turned out to be a heart attack. I get it the worst when I work yellow zone- you would think people with STDs and flu like symptoms wouldn't wait for 8 hours to be seen in the ER, but you would be wrong. They wait, but are super pissed off at everyone by the time they get back there. I respond by being incredibly annoyed, since when I see gunshot wounds and heart attacks every other day of the week, your 10/10 finger pain and tonsilitis are not as urgent in my mind. That doesn't stop those patients, of course, from being on the call light every ten minutes and making me want to run in and slap them senseless.
I had one of these, or so I thought, the other night. The patient spoke little to no English- he had a family member in there translating for him who was incredibly demanding. His cheif complaint was fever- when they took it in triage, it was 97.9. She started telling me all of this totally off the wall stuff- there must have been some kind of language barrier- He has "fever from the inside". He drinks 5-6 gallons of water a day, and he says it all tastes like salt. He got an over the counter Penicillin shot(?) because some healer told him he had an infection? What the hell? I told them I would wait for the Nurse Practitioner to come in, and the family member got pissed off because a Doctor wasn't going to see him. Five minutes later, he hits the call light to let us know he's feeling bad. Uh, yeah. I start a line at this point just so they feel like I'm doing something. The NP sees them, and they finally calm down for a while.
Right as I'm telling people how they're driving me insane, the lab calls to ask about the patient's history. None, why? They're getting "weird" results. So far the blood sugar is reading 1,000. And then it hits me- drinking tons of water? Nausea? Ugh. New onset Diabetes. I look at his urine results- high ketones. Great. Now I have a DKA patient. I do a recollect on the blood just to make sure and call my charge to get this dude the hell out of yellow zone. After the transfer, the lab calls me back- the final blood sugar reading was 1208. The guy ended up going to ICU. Turns out, I can't always tell who's "not sick".