Don't they know it's Christmas aatt alll.....

In my inbox this morning:

Hood Hospital weekly huddle up gather round circle jerk!

Hey nurses! Great job on being totally awesome and getting us stroke certified! So, you know how you guys did that education and only got payed for half of it because you're our bitches and we threatened and intimidated you? Well, not only did you do that, but you also voluntarily remembered some information and were able to recite it to some people with money, so great job! Way to go! Pat yourselves on the back!

Oh. B-T- Dubs, even though we'll be getting like, lots more money because of that stroke certification you worked so hard to get, we're eliminating all bonus and cutting down strictly on overtime during the busiest time of year. Yeah, we figured since you aren't getting a Christmas bonus we might as well get you something, and that something is a figurative ass raping with no lube. We'll be thinking of you and your atrociously understaffed coworkers in this most special of seasons, while we watch our eight year olds open the Ipads we bought with the money we saved on your overtime pay. Yes, we truly hold you dear in our hearts when we attempt to fill the void where our souls once were with 20 dollar mimosas. We think about the verbal and physical assault you will most surely endure when the inevitable 6 hour average wait times return to your ED because you don't have enough nurses available to take care of the patients. We sincerely mean it when we say we couldn't stick it to you so hard if you didn't take it. Thanks for all that you do.

Happy Holidays!

Sincerely, Hood Hospital upper management

Holy crap guys. 2 glasses of wine hasn't killed the rage yet. Should I go for 3?

Hood Nurse, shaping the future of nursing

OMG, guys. Someone was smoking the wrong stuff and decided to send a shiny new nurse extern along with me so I could show him the ropes yesterday. Poor guy. I think it was my by default since I came in a few hours early and was the only night nurse there when he showed up. It totally solidified in my mind the fact that I am in no way, shape or form prepared to teach anyone anything- I was trying to show him how stuff in the ER works and just let him get some experience whilst trying to deal with my regular shit magnet assignment, and I kept losing the poor kid because I was practically running back and forth from the doctor's station to the omnicell to patients rooms and back for about 3 hours straight. On the bright side, my terrible luck probably made for an exciting introduction the the ED for him- we got a spontaneous pneumohemothorax, fake catonic state vs. possible dystonic reaction, pneumonia, hypertensive crisis, and a rollover MVC with a giant head laceration who kept passing out in just the first couple of hours.

I tried take advantage of teachable moments, but most of my education went something like, "Okay, new extern. Go into room 15 and listen to that lady's lung sounds so you can know the difference between regular wheezing and 'oh shit' wheezing. She sounds like total hell, so we're gonna give her some steroids and breathing treatments." Hot mess. He got to work on some assessment opportunities and some IV starts, and we figured out the order system, but I just felt so bad that he was stuck with someone as disorganized as scatterbrained as myself.

He couldn't have been nicer, either- he actually gave me a hug at the end of my shift and seemed genuinely disappointed that I wasn't going to be there with him the next shift- I hope they can pair him with someone that can actually get their thoughts together long enough to explain what they're doing, because I sure wasn't that person last night.

Sometimes when I'm having my on days I think to myself, "Wow, I'm like an experienced, grown up nurse now." Yeah, not so much. Trying to teach someone else really solidified the fact that I still have some growing up to do. Good luck you, new extern.

"I have worms in my brain"

You have no idea how many times in my career I have seen complaints like this. And usually the culprit is the same- the crazy. So imagine my surprise last night when my friend hands me the chart for my new patient and just says "brain worms". Shut up. I have had enough psych patients to last me a lifetime, thanks a lot. No. For real real. This lady had MFin' worms in her brain, y'all. Neurocysticercosis, which until I met this woman, I had no idea existed. This is just a little bit worse than her CT.

I DID NOT learn about this is nursing school, because I would have remembered and had nightmares about brain worms. Apparently, it's not uncommon in less developed nations- most people get it through undercooked infected pork or food that's been exposed to infected meat or people. This poor lady had just come in for headaches from hell and- surprise!- at one time or currently, was hosting these delightful creatures in her brain tissue. Eeee. Another addition to my list of phobias.

You are so dumb, for real

The bedroom intruder app has taken the hood hospital's night shift by storm. For anyone not familiar, it's a collection of sound clips from a rather popular viral video that you can see here.

Let me just tell you that this weekend, we got extra use out of one particular part with all the foolish, foolish things we saw.

As usual, there is the always reliable material from triage. I think my favorite complaint had to have been the guy who checked in because he's been walking a lot and he had two blisters on his foot. You came to the ER for that? Seriously? You are really, really dumb.

And how about one of my fellow employees from a department that is not mine and will not be named, who during a stroke forum, asked if we were going to give TPA for hemmorhagic strokes. Wha wah. I won't even say it.

The winner this week by far has been the surrounding nursing homes, though. Long term critical care hospital sent over a guy being treated long term for sepsis with low O2 sats- amazingly enough, they called and gave us report, telling us he had been febrile and couldn't maintain his sats even on 100% oxygen on a non-rebreather mask. Since we start oxygen at 2 liters through a cannula and work up to a non-rebreather, which requires around 15 liters to work properly, we figured this guy was gonna be in pretty bad shape. To our surprise, he came to us okay looking with normal vitals. The medics that brought him in told us that they apparently walked in to pick him up and found him lying flat, wearing a non rebreather mask with O2 going at 5 liters a minute. Well. I think you found your problem, which is, you're dumb.
This wasn't even close to the worst- we also got an EMS transfer at 11PM on a weekend for- I can't believe I'm saying this- mold in the PEG tube. Yup. Apparently mold grows very quickly, like over a matter of hours, and is very dangerous once it appears in the PEG tube that you no longer use and clearly, no longer flush. Definitely a situation where an ambulance needs to be called.
The best still, I believe, was the poor little lady they sent over for, as they put it on the transfer sheet "excessive bleeding to the Virginia". And while I would be concerned if my patient's virginia was bleeding also, the situation apparently resulted when for whatever reason, they were trying to catheterize this little lady (and I'm willing to bet, were doing it wrong) and noticed some blood after several attempts. They called the medics, who brought her to us- the doctor did an exam to find everything in order and perfectly normal, other than a tiny spot of blood in the diaper. Yup, I had to call them back on that one. Nursing home, you are really dumb, for real. Stop sending us stupid transfers. We gonna find you.

Let me tell you how to do it right

I mean, seriously. If you're gonna fake a syncopal episode in the waiting room and commit to lying on the nasty ass hospital floor, you probably shouldn't reach into your pocket with your eyes still closed and pull out your wallet when the nurse asks for your ID so she can check you in. Nurses are trained in these things and we know you cannot respond to verbal commands while passed out, so you are not going to trick us. Instead, we will just tell you very quietly that you better stand up right now before we get the ammonia poppers. Please practice at home and try again the next time you come, which I'm sure you will, thanks.

Shit magnet

Yes, I will officially take my title now. Unfortunately, my friend who charged the extra shift I picked up last night also shares the same honor, so we were screwed from the start. My patient load when I walk in- little old granny with blood glucose of 700 and a thousand family members with the collective IQ of a brick who want everything just so, lady with mentation from crazy town withdrawing from benzos trying to climb out of bed, sweating profusely and making Frankenstein noises, and teenage "suicide attempt" with 5 Aspirin who absolutely refused to drink her activated charcoal. Well, of course we had to have about 7 staff members climb on top of her while her stupid ass tried to bite us and we crammed and NG tube and a bunch of charcoal down her nose hole. And of course we had no rooms so these people were admitted and I was stuck with them all night, and naturally granny had to be turned and have boo boo cleaned and have an apple juice and have blood sugars checked every 20 minutes but you can't do it on that finger, or that finger, and if she wasn't perfectly symmetrical lying in the bed I knew about it.

I had her long enough that I had to try and start her admission assessment, and with every new question found out about a new medical problem that we didn't know about before, but no one knew when or how it was treated and what it was called, and the daughter was trying to give me her very limited knowledge of her mothers medical information while at the same time screaming at some poor police officer on the phone about how her car was stolen. My relatively simple constipation via EMS most definitely turned out to not only have a massive bowel obstruction requiring surgery, but she also was in renal failure. FML.

So this morning over beers, we had this conversation.

Me: Yeah, you need to find some safe place to put me where the train wreck crazy patients won't find me.

Charge nurse buddy: Yeah, like your house.

Well, yeah, it's probably the only way. Could you go ahead and pay me though?

That's a new one

During a discharge for a simple laceration repair-

Me: Okay, so here's your prescriptions, just keep that clean and dry and elevated until you can follow up with the doctor.

Patient:Where is that doctor's number again?

Me: Oh, right on this second page of your discharge papers.

Patient: And where can I get your phone number?

Me: Buddy, I'm gonna need you to stop.

Well, there you go guys. New ER pick up line.

Haunted

It's been a month and a half and I still can't shake the guilt and sadness of a patient dying under my care. Surprisingly, the process of dying is not something we see very often in the ER. We see lots of CPRs in progress, but to put it quite frankly, these people are already dead. They don't talk to us. They don't move or blink their eyes. We never saw them smile or interact with their families or heard them say thank you. They lie there while we try to revive them, and it almost never works.

When we do see death like this, it's not in people who are ready for it. This man was no different. He had not been given a terminal diagnosis or an amount of time he was supposed to live. He was older but healthy- he looked much younger than his 70 years. He came to the ER because he was feeling weak. He walked up to the desk and checked in without a fuss. When the triage nurse took his blood pressure, it was 68/40.

I could tell immediately by looking at him that he was very sick. We were able to establish a couple of IVs on him and we gave him some fluids. He said he felt better, but he was very tired. His blood pressure was rising, but not a lot. He really seemed to be doing better. His sweet wife gave him a kiss and ran down the street to get him some clothing and his meds from home when we told her we would be admitting him. When she left, I stayed with him, and something frightening started to happen. He would fall asleep, but his breathing would slow and his oxygen saturation would start to drop. I stayed with him for about a half hour straight. He would fall asleep and I would call his name and shake him awake. "Mister, mister", I said to him, "Are you okay? Are you still with me? Please stay with me." He would open his eyes and say, "I'm with you. I'm feeling better." I was so frightened for him. At this point I just had to step out of the room for 5 minutes to go to the bathroom- I grabbed one of our nurses who was floating to stay with him. I just told her to watch him very close, that I was very worried about him. When I came back a few minutes later, he was breathing with snoring respirations, and his wife had showed up at the same time as me to see the other staff panicking and pushing his bed into a trauma room.

She burst into tears and I got her a chair to sit in and gave her a hug. I told her very hastily that we were going to help the doctor with a sterile procedure and that afterwards she could come in a be with him. It all happened so fast after that. We put in a central line and an arterial line, I learned how to use the arterial line, we started more fluids and vasopressors. We get his blood pressure half way decent, but he's becoming less responsive so we have to intubate him. We get his tests results back and his troponin is through the roof- chances are, he's had or having a massive heart attack and is going into cardiogenic shock. He's not stable enough for any type of intervention, but I start a heparin drip in addition to the blood pressure meds to try and bust up any kind of blockage that may be happening in the heart. I get a second and I'm able to talk to his wife and niece and her husband. They never had children, but they are very close with their niece. They all filter in and out, trying to be there for him but give us space to work.

Despite everything, his blood pressure starts to drop again. I start two more vasopressors and quickly bump them all to their maximum dose. We get the doctor in and she talks to the wife about the fact that not many options are left. She agrees to stick to the vasopressors but decides she doesn't want us to do CPR when the time comes. It comes slowly. The blood pressure stops reading. The heart rate drops. I go to get his wife but she can't bear to watch. She came in a little while after his heart finally stopped. She took his hand and wept and whispered his name. "What am I going to do without you?", she asked him. I wondered, too.

My grandfather died a few months before this happened. He suffered from Alzheimer's for years. We got a chance to say goodbye, but it doesn't make it much easier. Suddenly I'll be surprised by something that makes me think of him and I'm reminded of just how much I miss him.

When I think of him, I often think of this family, too. How much his wife must have hurt on her first Thanksgiving without her husband. About how the reminders must sneak up and hurt her, too.

After she left his room and I was running amok trying get things in order, I walked by her crying outside his room. I walked up and hugged her, unsuccessfully fighting tears. "I'm so sorry," I told her, " If only I could have done something more." I will always remember what she said to me. Even in her moment of grief, she hugged me and said, "No baby. You did a great job. It was just his time. God was ready, but we weren't."

I can't completely explain why, but this particular thing has just shaken me to my core. I don't know whether it's own experiences at the time or just how unfair the whole thing felt. I always look up the other ER visits when I go to call the medical examiner, and it was obvious just by looking at his visits that this man took care of himself. He went to the doctor and did what he was supposed to do. It was clear from the short time that I had to interact with the patient and his wife that they were very sweet- the kind of people you feel blessed to take care of. The kind that remind you why you do what you do. And I guess even with the outcome, I do feel blessed to have taken care of them. I just wish they could have gotten something different.

Warped

Every day I find new and different ways that this job his warped my mind.

Recently, I've taken up running after developing an intense case of muffin top in literally every pair of jeans I own, which with asthma and general laziness has been a bit of a challenge for me.

I had a particularly challenging morning the other day, when I decided to get beer and tacos after work but then decided to fun afterwards because I felt guilty (dear readers, never do this).

Well, after about a mile I stopped to get a drink of water and threw up a little. Then I got really dizzy and kind of felt like passing out.

Instead of thinking what any normal person might have, the only thing going through my head was, "Dude, I am not having a syncopal episode out here. I've been running and working a 12 and I smell like hell. These underwear are gross. If EMS shows up here and I wake up I am refusing the hell out of transport."

I think something is wrong with me.

I mean, really

Sometimes I just wonder about the fate of humanity and whether at some point we aren't just going to devolve to the point that we're so stupid that we just run off a cliff in mass like effin lemmings.

Nights when people do things like come in on an ambulance drunk for knee pain they've had 5 years. When this man was automatically discharged by the ER doctor for being foolish, he then refused to leave the room because he claimed he couldn't walk on his knee, despite the fact that EMS made him walk in from the ambulance bay, where he was walked to triage and back from triage to the room in which he was currently sitting. Yeah, stuff like that.

Or when people call the hospital operator threatening suicide from the telephone in their family member's rooms on the med floor who then proceed to assault the staff responding to the call attempting to help them. This fool acted so crazy that medics responding to the call couldn't even get him on a stretcher to get him down to the ER, so the police had to cuff him to the recliner in the room and push him into the elevator. When he finally got downstairs, about 5 people had to sit on him in addition to the cuffs and ankle restraints to keep him from punching, headbutting, and biting those of us trying to get vital signs.

Don't let me forget the people with absolutely no clue as to their family members med history. I'm not asking for everyone's family member to be a doctor or nurse, but basic comprehension of how any human body might work would be nice. EMS brought an unresponsive lady last night- apparently when they asked family if they knew anything about medical history, this is seriously what they came up with and put in writing:

"She had some fluid on her leg due to depression.

One time B4, she fainted once about 6 yr ago."

Um, no. I don't think that's it at all.

Or how about taking out your own IV, running from the ER, and attempting to stop the bleeding with the surface wipes that say "NOT FOR HUMAN SKIN" on them in giant red letters. No, that can't be good on open flesh.

Oh, and I nearly forgot possibly the winner for dumbest person of them night. This is a real conversation that someone had on the phone with one of our clinical secretaries:

Secretary: Hello, this is hood hospital, how can I help you?

Patient:Yes, is Mary (another secretary) there?

Secretary: Um, no sir.

Patient: Well, is big bulgarian doctor there?

Secretary: Sir, we can't disclose that information for security reasons.

Patient:But I'm a regular patient there.

Secretary: Sir, this is an ER, not a doctor's office, there are no regular patients here.

Patient: Well, see, I'm in (city on the other side of the US) and I'm pretty sure I'm passing a kidney stone.

Secretary: Well, sir, we can't really do anything for you when you're on the other side of the country. You'll have to go to another ER in the city you're currently in.

Patient: Oh. Well, I'm low on gas. But I'm in a lot of pain. Do you think I should go in?

Secretary: Sir, I can't make that decision for you.

Patient: Well, I'm just really low on gas.

Secretary: I'm sorry to hear that. Good luck. Go somewhere in the city you're in.

Yeah, wow. Lord help us.

The Reverse Midas Touch

So I ended up with what I call the Gomer rooms last night- the rooms where all the super sick thousand year old nursing home patients and the super sick non compliant frequent flyers always end up- add to that a full moon and the fact that I am a compete and utter shit magnet and wowzer. Literally everyone I took care of today seemed to be on the express train to FUBAR.

My first patient as the clock struck midnight was the sickest DKA I've ever seen- and I've seen a lot of DKA. She was breathing about 40 times a minute when she came to my room, and her eyes kept rolling to the back of her head like she was about to stop breathing... yeah. As soon as I hooked her up to cardiac monitoring I could actually see on her strip her potassium was going to be stupid high- the final count was 7. Yikes. It took eternity to get an IV on her- I was finally able to stick a neonate needle in vein right above her wrist joint. About half a bag of saline and some IV insulin she started looking like one of the living again, but damn.

A little before I shipped her up to ICU with her insulin drip and a myriad of other shit, another lady, this one in her early 70s rolled in with difficulty breathing and chest pain- not an uncommon sight where I work- didn't think a whole lot one way or the other. Her vitals were probably better than mine but she appeared pretty distressed. I gave her oxygen, which helped her, and did an EKG, which looked fine as well. We sent her for a CT of the lungs to rule out a blood clot- and ohhh wow. She had a GIANT saddle pulmonary embolus. Enormous, like, miraculous you're still alive embolus. We had to give her blood thinners, but she was already anemic from chemotherapy so I also had to give her a blood transfusion. Yeah. She made it to the next shift alright but I'm curious how she'll do later on.

So the last guy I get has poor circulation from diabetes and a yeast infection to his junk. Yeah. He sure did get his foreskin stuck over his glans so tight that he couldn't even go pee. We had to give him moderate sedation to even attempt to put a catheter in the poor guy, and even that didn't work. He was super nice, and a very good sport about the whole thing- they left the whole mess in the hands of urology as I was leaving.

Well, I'm pretty sure I'm just cursed.

Quoth the patient part 2

"Are you gonna start that Tramadol drip on me now?"

Ma'am, that's not a thing.

Thank You, FDA

Just saw on the news today that the FDA is banning Four Loko. I would just like to say to them on behalf of all emergency medical personnel, police, anyone who has ever driven after 11PM, and people with annoying-ass friends who can't handle their booze, thank you. Thank you for saving me countless hours of chasing some idiot asshole around the ER because he is drunk and strung out on caffeine and thinks he needs to fight everyone. I mean, really, a tall boy sized can with the alcohol content of wine and more caffeine than a Red Bull in fruity flavors sold for 2.50? Whose idea was this, the creator of bum fights? I'd like a personal apology from this person issued to all night staff at hood hospital, stat double stat. Thanks.

Quoth the patient

"I want some more of that pain juice in my IV."

Yeah, I bet you do.

New Most Favorite Blog EVER

I know this relates to customers in a comic book store, but I'm kind of jealous I didn't think to illustrate my ridiculous patients and the things they say first. Nonetheless, the parallels are amazing. Funniest thing you'll read all year- Our Valued Customers.

Post-apolcalpyse

Well, I must admit I've been super lazy as of late. I haven't been to work since my last post- been doing some traveling and then just chilling at home this past week, as I seem to have taken a ton of time off in the summer while I was sort of hating what I do. As always, I've been utilizing my time very wisely by watching lots of TV shows with my husband, one of which is The Walking Dead. If you haven't seen it, I very much suggest you watch it- it comes on AMC and I believe the pilot is up for viewing on their website. That being said, I don't know if I can keep watching it.

My husband loves zombies- he's actually been reading the comics the show is based on for years. Me, yeah, not so much. The whole idea of a post-apocalyptic world really, really upsets me. Not just zombies- natural disasters, terrorism, disease...yeah. I want to throw up thinking about it. I can't even really verbalize what it is. I think a big part of it is the inhumanity that comes with living in a lawless world and how much it challenges the things I want to believe about the human race- I think it's mostly the idea that I would have to become that in order to stay alive.

We did this stupid computer module when I took community health to help us learn about bio-terror and nuclear warfare. It's probably the most vivid memory I have of nursing school, because it bothered me greatly. It upsets me to think about it even more now that I work in ER. In the scenario they gave us, you have to triage patients that are victims of a nuclear blast using the disaster triage system. In the everyday world, we use a system where the sickest patients are seen first, and the healthier patients have to wait. Where I work, we assign them a number based on acuity- those who are actively dying or who are very at risk get a level 1- it goes down in acuity to level 5. Disaster triage works by color- red, yellow, and green from worst acuity down. But in disaster triage, the patients who would be a 1 or sometimes even a 2 at hood hospital would get a black tag. You even physically place a tag or write on the patients in these scenarios. In most situations, this would pretty much mean you just won't do CPR, but in this particular module you had patients with obvious radiation poisoning who you could do nothing for, but they were still talking to you. Cute little old people, in fact, who were crying and asking what was wrong, but as the module points out, you don't have time to explain or hold their hand or give them a hug, because you have a waiting room full of hundreds of other people you might be able to save- you just put a black tag on them and walk away. I was in tears. Like, lots of tears.

All these situations also face you with the inherent question- would you stick around your job or come in to help, or would you get the hell out of there? Most of these scenarios put you at a great risk as a nurse, be it exposure to radiation or disease or violence from the inevitable chaos. It would almost certainly mean not knowing what has happened to your loved ones. This is a question I pose a lot to people over beers, and almost everyone I've asked say they'd try and get out alive. I can't say what I'd do for sure, but I would like to think I'd stay. Partially because I feel it's the right thing to do, but I'd be lying if a big part of it wasn't the fact that I would probably rather die than try to fight to stay alive in a world like that. I think I might be at peace with the possibility of risking or giving my life to do the right thing. Even in doing the right thing and getting out alive, I know I would have to go against every principle that's natural for me as a nurse. The experience would probably scar me for life, but I hope I would have the courage to stay.

Unless it's zombies. Then I'm getting the hell out of there, cause I'm not trying to get eaten by undead. But I'm curious, internets- what do you think you'd do?

Bullies

Well, I'm pretty sure my feelings on Press Ganey are pretty well documented already. But for real. This shit is getting ridiculous. Not only can just about anyone talk their way into some Dilaudid- they know why.

This crazy lady checked in the other day with chest pain related to her "asthma"- apparently this disease cause you to make squealing whiny noises at the end of every expiration, despite the fact that the lungs are totally clear. Yeah. She told the nurse in triage that she had been there the last 3 days (she failed to mention that she had been escorted out the last two times for acting foolish), but she did tell us that her sister was a nurse on the floor, and that she knew we had all kinds of empty beds upstairs and that we had Press-Ganey so we had to do what she said. Yeeahh. She sure didn't get admitted, but she did get a full cardiac and PE workup. Whatever do you think the results were?

I always make sure to ask the doctors for pain medicine when people request it, but I always word it just like they did and I chart accordingly.. "Yeah, last time they gave me some D medicine and it made me feel so much better"... This no longer gets the "Hell no, they get 325 of Tylenol" and I might hope for, but instead an eye roll and an order for the D medicine they seek. Big bulgarian doc was going off on one of his little rants the other day when a patient of his from the night before came back with the same complaint. "What does she think we will do for her?" he said, "What does she expect to accomplish from this visit?" Uh, I don't know dude. Maybe it's the fact that we give her IV Dilaudid and a prescription for Norco? Why wouldn't she come back?

It's even gone past pain medicines and into treatments. Somehow good medical care has become synonymous with drawing blood. Oh, a hypochondriac, eh? Yeah, lets get a CBC and an FBP for that ear pain so that we'll feel that the complaint was taken seriously. Besides, the nurse has nothing else to do. One of the same doctors who once lectured me about mentioning gastric lavage in a patient who had actually taken the pills in timeframe in which it might have been useful later ordered the same treatment because some lady's hoodrat boyfriend insisted she have it. We never do this anymore, but we sure were ready to did do it for him.

Our former director of medicine, who I absolutely loved, developed this fake form for us to stick up in triage. He said we might as well just start putting them up there since we're apparently supposed to be Starbucks now anyway. He was not cool with us making copies, but from my memory, it read something like this.

Hood Hospital Triage Questionare

check all that apply:

1.Are you interested in the doctor's opinion or knowledge as it applies to your care today?

__ yes __no

(if the answer is yes, please disregard the rest of this form. If no, please continue)

2.What labs do you feel are needed for us to have provided you with good care today?

__ CBC __CMP __PTT/APTT __Complete screen for STDS

__Cardiac enzymes __BNP __Serum Spider Venom Titer

3.What kind of pain medicine would you like? Please circle dosage or indicate of not listed.

__Dilaudid- 2 mg, 4 mg, 8mg, all you've got.

__Morphine-2 mg, 4mg, 8 mg, 10 mg, a bag to go.

__Demerol-25mg, 50mg, 100mg

4.How fast would you like that pushed? Please indicate in seconds or minutes:_____

5. Please check any medications you feel may supplement your medication experience:

__Zofran __Benadryl __Phenergan __ Valium __Ativan __Reglan

6.Would you like to be admitted today?

__No __Yes

If so, for how long?

__Just for observation __Until my pain is gone completely __ Until my next check comes in __Indefinitely

7.Please check any medicines you would like to be discharged with:

__Norco __Percocet __Ultram __Phenergan __Dilaudid chewables

__Also, refill everything I normally take __Other (please indicate.)

Toward the end I know I'm making my own stuff up, but it's what we're coming to. I'm serious.

Is this a national phenomenon?

So, I was talking to one of the NPs that I really like a couple weeks ago, and she was telling me a story about how she had to remove a makeup sponge from some lady's vagina that night. Of course, I always need to know the how and why, so she got back to me and it turned out the lady was on her period and had run out of pads and tampons. Next logical conclusion- shove a makeup sponge up there! It's absorbent, right? Right.
Fast forward to two weeks after that. Same NP. Same complaint. Yeah, I ran out of tampons so I stuck this makeup sponge up there because someone told me that would work. Why not? This time, though, there was a twist. Not only did she successfully recover the makeup sponge, but as an added bonus there was also a condom floating around in there. So she pulls it out and says to the girl, "Is there anything else up there you need me to get out for you?" Priceless. Apparently she was not as amused as I was.
I have never heard about this until this month. Anyone else heard any tales of makeup sponges being suitable feminine hygiene product replacements? I will do some research on Google and get back to you guys.


UPDATE- I've found one source that mentions makeup sponges being used for tampon substitutes in an article written by an escort addressing the problem of how to work on your period, because apparently all escorts know thats always the week when you fill up on appointments. OMGz, hate it when that happens. Anyway, even there it was only mentioned in passing about how it sort of works the same way as a real sponge designed for that sort of thing. Now, before you say, "Hood nurse, you lazy crackhoe, you probably just stopped after one google search", you would be wrong. Because I scoured Yahoo! answers for a good 20 minutes for various tampon replacements, and came up empty on the makeup sponge front. And anyone who has ever read Yahoo! answers knows that is the population most likely to stick use a makeup sponge or equally ridiculous item as a tampon. Seriously. Just read Yahoo! answers topics about STDS and pregnancy. You'll give up on humanity in 10 minutes.

I can't do this forever.

I've been entertaining the thought of going back to NP school next fall. I was talking to my husband about all this the other day after a rather exciting ER night with running around the unit giving emergent meds and saving lives and other such adrenaline charged activities. My goal ever since I started nursing school was to ultimately become an FNP- although I also thought I wanted to run a pedi clinic and now I'm pretty sure that's actually the worst job ever. After that particular shift, I told him I still wanted to go back to school but I was a little bit ambivalent because I thought I would miss critical care. And I will. But when I was saying that, I wasn't thinking about days like today.

The man I took care of today walked into triage and was wheeled out to a funeral home. I talked to him. We started IVs, central lines, arterial lines, every vasopressor under the sun, a Heparin drip, we intubated, I titrated, inserted tubes wherever I had to and it was all for naught. He still died. I had to watch his wife stand next to him and hold his hand and sob. And I still came home with the feeling that if I had just done something a little different or a little earlier that he would have lived, despite what anyone says to me. I'm still sitting here in my apartment crying in my beer. It's days like this that I think maybe I'm not the kind of person who's supposed to be a career ER nurse. Time to get my transcripts in order.

And I thought I had a bad day.

I took care of my terrible horrible whiny-ass non-compliant patient from hell the other day. This time she was came to ER for a nosebleed that we were actually able to stop until she picked at it incessantly with a nubby towel and blew it every time the bleeding stopped. Why? Why not? She needs something to do, I guess. We packed one side and then she actually made the other side start bleeding by scratching it with paper towels. I swear she's doing this foolishness on purpose. I overall had a crap night, and it would have bothered me more were it not for the patient I took care of earlier in the evening.

No matter how bad it gets, at least I didn't wake up from my sleep to find my lips and tongue so swollen that I couldn't put my tongue back in my mouth, go downstairs to call an ambulance, fall down said stairs and get a compound ankle fracture on top of the worst angioedema I've ever seen in my life. Not only that, but this poor woman couldn't get conscious sedation or really even enough pain medicine for the doctor to reset the bone in her ankle because we didn't want her to lose her airway and end up getting a cricotomy. So she had to just sit there and feel all of it, after her husband totally bailed on her because he didn't want to see it happen.

Yup. All that makes a 12 hour shift 15 minute lunch, two bathroom breaks and histronic crazy patients sound pretty awesome in comparison.

Nursing daydreams

Sometimes, when I'm sitting at the nurses' station in my TURP blood/urine soaked scrubs, catching up on hours of charting drinking a warm coke, I space out a little bit and have these fantasies about the shit I would do if someone talked to me the wrong way on the last day of work. These things that run through my head that I would get fired for immediately if I ever actually did them.

I think about the family members with zero medical background who want to nitpick the ER staffs choices on IV placement. I mean, seriously? I don't try to tell the A/C repairman how to do his job. I don't break into the kitchen at McDonalds and tell you how to flip my burger. Why do you think you can tell me how to start my IV? I was telling my super awesome charge nurse about this today, after some douche lady kicked him out of her husbands room because he didn't attempt an IV start on her husband where she thought he should. By the way, he's the best IV starter of anyone in our entire ED. If someone did this to me on my last day, I would hand them the IV start kit and a saline flush and tell them to go to town. "Oh. You know how to do this then? Cool. Here you go. Yeah. We need a purple, two greens, and one blue tube for the labs the doctor has ordered on your husband. Yeah, I'm sure you do this all the time so you already know how much to put in each one. Awesome. Call us when you're done and we'll bring his meds. What, you're a bank teller and you don't start IVs at your job? Well, you seem to think you know everything so I'm sure you can figure it out. Make sure you use a 22 gauge or larger so it's easy for the CT tech to inject the contrast. Later!"

I have this other fantasy when I'm at triage and I type up this document in very classy script like they would use at a fancy restaurant to place next to the check in forms that reads as follows:

Dear Patrons,

Due to a high demand and a disappointing crop, we will not be offering Dilaudid or Phenergan on our menu this evening or for coming evenings until further notice. We apologize for any inconvenience this may cause and hope that you will still thoroughly enjoy your experience at Hood Hospital.

Sincerely, HH staff.

I swear. My night at triage would be so much better.

Or probably my most frequent, where I transport a patient to ICU, they give me attitude as always, and instead of responding in a passive aggressive manner like I usually do, I just throw off my jacket and take out my earrings and respond the way most of our patients would. "Bitch, why you looking at me like that? I drew your AM labs, ho, so you best step off before I tear out your weave. Yeah. That's what I thought." And then I would throw my Spectralink to the ground all gangsta like before the police show up in record time to escort me off the premises.

Ah. It feels so real after the 3 glasses of box wine I just drank. If only I didn't really, really, need the money.

Compassion Deficit

I think everyone has their type of patient that they just can't get over the feeling of wanting to kick. I've been a little surprised at myself lately at who it's been. I've always known that I can't deal with the entitled patients. I know why, and I've learned how to deal with them. But lately another sort of pet peeve- I hate to even call it that, because it's a little stronger than that- has crept over me for our addicts.

This may seem like a given to a lot of nurses, especially those that work in ER. But it sort of bothers me. I've always sort of felt deep inside that the reason I always end up with so many high drama psych patients is that God knows I know how to deal with them. I always thought that I would feel sort of a kinship or at least a deep empathy for addicts because of my own past. I was never a substance abuser, but I've dealt my whole life with a lot of unhealthy tendencies. When I was about 13 or 14, I started cutting myself. A couple years later, I also started dieting to a ridiculous degree even though I was already underweight. When I slipped up, I would make myself throw up. I didn't tell anyone. For a long time. When my family found out, and I realized how much it hurt them to see me this way, I worked very hard to stop. I had my setbacks, and I still have the tendency to do these things. I always will. The thoughts still run through my head, but I have it in me to stop myself because I think about how it hurts the people around me.

I think this is where I struggle. I hurt for our depressed patients. I hurt for the type of people who rely on some self destructive behavior to escape all the bad things they feel. But I hurt even more for their families.

I took care of a lady with liver failure and esophogeal varicies their other day. I remembered her face. I knew why she was here. Drank herself sick again. This time, though, her son was with her. I knew I would have remembered him. He was a big cherubic looking kid. Really quiet. Really young, about 21. He never asked us for a thing. He sat there and stroked his mom's hair and held her hand while we tried to start an IV on her scarred-up shit veins. I don't think she even really acknowledged his presence. She did demand Dilaudid from us while he sat outside the room and cried. He asked one of the nurses how much it would cost to get his mother a liver transplant. That was enough to make me cry, too.

And my patient last night. Came in via EMS for approximately the 50th time this year. Took 9 Vicodin at once for whatever bullshit pain complaint she made up at that particular moment. Her tooth...nope. Maybe her back. And/or neuropathy. Wherever the pain was, she wasn't trying to kill herself or get high. She was just trying to make the pain better. In fact, the pain was still there, could she get some more pain medicine? Yeah. No. So her husband came back. Apparently this was a pretty regular little routine for them. By the way, she'd also been popping Xanax all day like they were sweet tarts. She does the and passes out, he says, so he just calls the ambulance as soon as she does it. Take her meds away, we tell him. Nope. Can't do it. Supposedly if he takes her meds she throws boiling water on him. Why he stayed with her I have no clue. But he did. The whole night he hugged and kissed her while she drooled. He cleaned and changed her when she peed on herself. This is my wife, he said. I married her because I love her. The EMTs who ran on her knew her by name. They said he would run down the block and use the pay phone to call 911 because she got so irate and abusive when he did it, so he would call from outside the house and pretend it wasn't him. I felt so awful for him. He clearly loved his wife so much, and there was absolutely nothing he could do for her.

I looked into both of these people's faces trying to find what it was that made these people love them. I could not figure it out for the life of me. Who had they been? And what happened? I can understand trying and failing. But I cannot understand looking into the eyes of your loved one and seeing the desperation I saw in both of these men and not wanting to change at all. The selfishness in them made me sick. It didn't change the way I cared for them but it just felt... bad. Like there was an anger in me for them that I really felt uncomfortable with. Chances are that these women will both kill themselves with their behavior one of these days. An awful part of me felt like it would be better for their loved ones if they went ahead and did it.

Is this normal? Am I putting too much on them? And is it even fair for me to compare my problems with theirs? This job sneaks up on me so bad some days.

Reach for the Stars!

Ugh. Sorry guys. I have sucked at updating this lately. I really have trouble motivating myself to write about work when it seems like I have nothing to do but complain, but hot damn. The douchebag stretch has continued with very few exceptions.
I have some things to be thankful for- we're actually adequately staffed, which is amazing.
And I took care of the most wonderful old lady the night before last. I mean, she was the cutest ever. And so sweet. She actually said to me at one point, "I'm so thankful you came into my life. I could just be around you forever. It's so wonderful to be around happy people." Had she not had to stay and repair her broken leg, I probably would have picked her up and taken her home with me.
Now for last night. Not so much luck. For every sweet normal patient, there were 3 psycho douches on the loose in all my other rooms. It wasn't all bad, however, because I've kind of figured something out. I'm almost okay with douchebaggery if you make it an art form. I'm talking, really, truly, dedicating your whole visit to being absolutely crazy and unreasonable. It's the in betweens that kill me.
Whining and requesting Dilaudid for your UTI is just annoying. Coming in and being "allergic" to everything except Dilaudid and Phenergan and then trying to convince me that it's fine for me to discharge you with the Huber needle still in your Mediport because they do it at your cancer center all the time just makes me want to hit you.
No. If you want to act like a jackass, you need to just aim high and go for the gold so at least you're entertaining. For example, try coming the ER on an ambulance a day after you've signed out AMA from another hospital for a uterine prolapse you've had for 10 years but refuse to have fixed, and sign out AMA repeatedly from said ER as soon as you get your narcotic pain meds. Do it frequently enough that the staff is on a first name basis with you. But make sure to walk the halls with your prolapse hanging out and dripping God-knows-what secretions all over the floor for all the patients and their family members to see. Take your prolapse along with you into the trauma room where your nurse is trying to start an IV so that your can tell her to call the EMS service to tell them to hurry up because it's been 20 minutes and they're taking too long. Make sure you insist on being discharged with Hydrocodone because "it's the only thing that works." If you really want to shine at hood hospital, you need to aim for the stars.
How about refusing to be triaged because it's too cold in the waiting room, and sleeping in the play area whilst scaring the shit out of everyone's children? Make sure when you finally do get back to be triaged, your only complaint is the HIV you've had for 15 years that you've stopped taking meds for for 8 years, despite the fact that you get government assistance. Make sure to refuse to be weighed, especially if one of your complaints was weight loss. When you do get back to a room and the nurse tries to draw your blood, don't give it away for free. You should try to charge the nurse at least twenty dollars a tube and insist on being admitted without having any tests run first. When you do inevitably get discharged, don't leave unless escorted out by the police. Make sure you use every racial slur possible when interacting with the staff about your discharge instructions. Continue to demand money for your blood, and refuse to walk out of the room that you walked back to because your feet hurt. When the police do haul you away, it's a good idea to exit the ER screaming that your nurse is a bitch hoe who stole your 5 ccs of HIV positive blood and sold it for money, and that she is the reason you don't fuck with white bitches. Bonus if you ask the officer who is escorting you off the premises,"Why do you defend these whores?" Yeah. It's lots of fun for everyone. At least when you do this, we can stand outside your room and laugh hysterically while you're taken away in cuffs insisting on another popsickle because your other one melted, and we have stories to tell our friends over beers. Anything worth doing is worth doing right, damn it.

Come one, come all

One of my work friends is the most hilarious angry person ever- I'll always remember the night that her whole side was full of combative and hateful patients and she went on a huge rant after work in the morning about it. "It was a special for douchebags" she said. "Somebody put a sign up. 2 for 1. Bring all your douchebags. Come one, come all."

That's all I could think of tonight. Holy shit. All night long from the second we got there. Douchebags on parade. The day nurse talking crazy to me in report over me mentioning a page was missing out of a chart. The crazy lady who kept demanding pain medicine with a negative CT who insisted we give her a soft c-collar to wear home. Oh, yeah. And the police had to escort her out to get her to leave. Sweet.

Record AWOLs. Oh, you're not going to give me the prescriptions/treatments/tests I think I need NOW? No, that's okay. I'll just take out my own IV and leave. Great. Awesome.

It's also hot right now to lie about having a ride home. No, it's okay. Go ahead and give me that Morphine.

The lady with the "migraine headaches" who was allergic to everything that you usually prescribe for migraine headaches? Shocker. The one who of course gets no relief from non narcotics, but the last time she was here we gave her that D medicine and that seemed to help her a lot. Well, she got some Demerol. Apparently that wasn't the right D medicine but the person who gave it to her forgot to ask if she had a ride home so we were stuck with that foolishness for a minute. By the time she did produce a ride home for herself (also, for her 9 year old son who she had brought along for the party, because why not?) her blood pressure was too low for that other D medicine so she opted to stay for another liter of saline so she could experience the healing touch of Dilaudid. Her ride didn't get it and actually asked me how long it would take for her blood pressure to be high enough. Really!? Also, she tried to tell us she was homeless but she had a blackberry and had just gotten a new tattoo that day. Bitch, please. I can't afford a new tattoo. Amazingly, once we delivered the correct D medicine, her migraine was cured and kittens and rainbows actually flew out of the IV site when she "accidentally" took it out herself. Fabulous!

Once we finally got rid of her, she passed the douche torch to the husband of another patient who presented to the hospital because she didn't follow her diet orders after being discharged for gastroenteritis the day before. After walking up to the desk 4 times in an hour to insist his wife be seen above the patients waiting in front of her, he finally demanded that we call an ambulance for his wife because "we clearly weren't going to do anything for her". Yeah, no. Not how ERs work. I told him such and he nearly ran the practitioner over with the wheelchair he grabbed to try to roll her out in as she was walking in to see the patient. The patient was fine. She was discharged within the hour with exactly what we thought she had.

Luckily, the educator didn't let the ball drop by walking in and talking crazy to me about some foolish paperwork he never sent me about getting "checked off" to work in triage (never mind the fact that had already been working up there for several months before they decided I needed to be trained and checked off) and then being an ultra mega douche when I had no idea what he was talking about.

Oh! And I almost forgot! The guy whose mom died four times last year- I guess she died for the 5th time last night! Yup! I may have remembered his name and made a couple of phone calls to EVERYONE about that as soon as I saw his name on the tracker.

In my head, I imagine it was probably him that led the march of douchebags to the ER last night, and that there might have been a bullhorn involved. "Come one, come all, to hood hospital! Follow me to all your work excuses for STDs, your favorite D medicines, sandwich trays, and free yellow fall risk footies! 2 for 1! Huzzah!"

Isolation? What?

Dude. Seriously. ER nurses are a special breed. I took care of an MRSA patient today and I was thinking back about how we had to deal with that on the floor when I was in nursing school. Gown and gloves if you're going to step over the red line. Don't you dare cross that red line to hand that MRSA patient the phone or give them a glass of water if you 're not decked out in that sexy plastic gown.

ER is the polar opposite. Pretty much projectile blood and shit are the only reasons I will put on an isolation gown these days. Oh. Flesh eating bacteria. That's about it. So many of our patients come in without any kind of information that when we realize we should be wearing PPE, it's already way the hell too late anyway. We took this little MRSA lady up to the ICU today and they were teasing us about our lack of gowns. "ER nurses have special immunity", they said. I agreed with her. "Yup. It's called we've probably been exposed to everything ever."

I just feel sorry for the nurses that will have to take care of me when I'm old. Those poor bastards are going to need hazmat suits.

Floor nurses, I salute you.

I'll be the first to admit that at times, I've been hard on floor nurses. I get mad when despite my extra efforts to get a patient settled before going to the floor, they still talk crazy to me in report. I want to pull my hair out when I have to repeat everything 4 times in report because they just aren't listening. I get irritated when they yell at me because they're getting slammed, or when they sit at the nurses station talking and stare at me while I transport a 300 pound patient on my own and then act like I'm a lazy bitch when I ask for help.

But when I think about it, I respect them a whole lot and I could never do the job they do. I was thinking about it today, when it 0530 this girl rolled in. Again. Whiny, screaming, ungrateful, non-compliant to the point that it almost seems out of spite and disdain- a giant middle finger to the entire medical profession. I walked out of another patient's room to find her flailing of the stretcher screaming. I swore out loud without even thinking about it. The foolishness of her last visit was naturally multiplied for this visit. She turned up the drama to a whole new level. Even though I had ended up with pretty wonderful patients for most of the night, 15 minutes in I was like," I am totally done with this shit and I need a drink. I kind of hate this job sometimes." As I was pushing her second dose of Dilaudid in an hour while she asked me for ice chips for the 20 thousandth time between screams of pain, I started thinking about the nurses on the floor.

This douchebag always gets admitted. Always. Those poor nurses show up at the beginning of their shift and have to take care of this idiot asshole through the whole thing. All of it. There's no end in sight. No one to call report to. No nice long breaks for ultrasounds or CTs. No. They have to put up with this crap for 12 hours straight. And then a lot of the times they have to come back to the same bullshit the next day. I really, really don't think I could ever do that. I would take the bed down the elevator and push it out into the parking lot if I had to deal with that crap for my whole shift. I'm serious. At the best, I would call in every time I knew I was coming back to that crap the next day. And I can't even imagine the dreaded moment when you get report and recognize a name and realize, oh shit. This night is going to be the worst. If I was a floor nurse, I would probably not have a license and/or be in jail for punching someone's face.

So floor nurses, I salute you. For all you do, but especially for not punching people like I would. Sincerely, Hood Nurse

Totally badass

So, I think one of my weaknesses at this job is going along with the fuss a lot of people make about their medical conditions. A good deal of the people I see are being treated for problems I've had before- sprains, breaks, gastroenteritis and nasty upper respiratory infections- mostly at home with zero drama. When I have to deliver morphine for something that turns out to be a stomach bug or send someone home with Hydrocodone, but apparently not enough, for a sprained ankle, I kind of want to punch something. Bitch, please. Suck it up.
But lately. Wow. I've taken care of a couple of people so tough and badass that all I could do is sit back in admiration.
We had the adorable young stabbing victim. He was on the way to the bar when a guy flagged him down in the road. He said he normally wouldn't have stopped but that the guy had his kids with him and he wanted to help. He picked the man up to bring him somewhere for help, and the man stabbed him in the stomach and ran off. This guy drove himself home about 10 or 15 miles, where his sister then brought him up to the hospital. He probably had a good 4 inches of intestine sticking out of his abdominal wall. He didn't scream or cry. He strolled in casually where we brought him back to a trauma room- the only fuss he made at all was when I had to start his two 16 gauge IVs- and by made a fuss, I let him squeeze one hand while I started the IV with the other and he looked away. He never once asked for narcotics, but he did want to know what kind of antibiotics he was getting. He was a little nervous about getting transferred for surgery. He looked at me and said "Can't you just push it back in there?". I laughed and told him that he probably wouldn't want it done that way. He smiled and said,"No, it's cool. Just dump some of that hand sanitizer you guys use on there. It'll be fine." Hilarious. I was sad to see him go.
I took care of an older man recently who had fallen off his roof at about 6 that night. Not doing anything stupid like lots of our patients, just trying to clean the gutters. He fell about 10 feet but he stuck it out at home and tried to take some Aleve. He came it at 1 AM cause the pain got worse. I was pretty freaked out that he had broken something important or had a traumatic injury to an organ, yet he was incredibly patient about waiting to see a doctor and very sweet and funny. I got him some Fentanyl and we x-ray and CT'd just about everything- nothing life threatening going on, but homeboy had broken off a chunk of his scapula. Yeah. It was just floating around in there while he was chilling at the house with his OTC pain meds.
Then last week. I took care of a lady with a Hemoglobin at about half of what it should be. I asked her if she'd be feeling dizzy or weak. Yeah. For a while now. But she was trying to get in a clinic. She didn't want to come to the ER and bother anyone. Was a little freaked out about getting transfused. No, it's fine. I'm really okay as long as I'm lying down. It's been like this three weeks and the only time I wanted to pass out was going up some stairs. I talked her into the transfusion and finally got her upstairs to a bed. She'd been a hold in the ER most of the night with zero complaints.

I realize it's a little extreme. But I love patients like this. There's something very refreshing about taking care of people that actually belong in the ER, but it's even more refreshing when you can tell that they don't even think of treating the ER like a Starbucks. I wish there was some kind of medal of honor I could give them so that they could go out in the community and be like, "Yeah guys, look at this. I had a legit painful illness but I handled it like it was nothing. I'm a badass, fear me." At least I get to give them IV pain meds. I guess that's the next best thing.

Oh, summer.

If I ever get crazy enough to go back and get my masters, I think I may do some kind of study on the kinds of patients the ER sees in the summer time versus the winter.
We're hardly seeing any respiratory distress right now compared to the winter time- in February, we actually ran out of ventilators. Someone had to hop in their car to drive to our sister hospital and pick one up. The ICU was full non stop- no doubt the result of winter illnesses gone horribly wrong.
Summer is a whole other set of fuckery. I would say slightly less challenging and slightly more entertaining, although sometimes I'm just done with this shit. I mean, really. What is it about high temperatures that make people stab one another ALL THE TIME. And if you have to stab one another, okay, but please don't come to the hospital to see your boyfriend when you were the one who put him here in the first place by stabbing him, and then try to talk crazy to the ER staff when they ask you to leave because you were the stabber, then try to sneak back in after you are asked to leave only to get more crazy with the ER physician, who then has no other choice than to put you in a headlock because you can't act right.
Also- I like to drink and I know plenty of people who enjoy drugs. Please enjoy these activities safely in your own house and refrain from coming to the hospital like a normal person so I don't have to try and start an IV on your stupid ass. I have more important things to do, like taking care of all of these stabbing victims.
Another note about alcohol- drinking is fine, but if you're going to do so, please refrain from doing it on or around your roof. Just stay away from the roof altogether. Roofs and booze are mortal enemies and you should keep them apart at all times. If you really need to go on the roof, when you inevitably fall off, this is a time when it is appropriate to call an ambulance. Because when you come to the hospital in the back of your friend's SUV, and we have to go get a stretcher and climb in the car and try to cram one of the backboards EMS left here under you while we hold C spine and you scream at us, that's a whole thing and it would be a lot easier if you let the medics do that in the first place when you're on the ground and not in the back of a car.
At least I'll get away from it all today. Yes, dear blog readers, I am finally taking a vacation. I am going to rent a house with friends, drink for a week and float down a river. I think I'll manage to stay off the roof, refrain from stabbing anyone, and stay out of the hospital. If not, I may be gone for a little over a week.

Yeah, I know we're not supposed to judge.

But I'm just gonna come out and say it. If you're my age (24), on kid number 5, and you can't refrain from coming to my ER with sobbing with a blood alcohol three times the legal limit- yeah. You've pretty much failed at life so far. Especially when you do this often enough that your mother in law has to take care of your 5 kids full time, yet you can't hold your booze enough to not try and jump out of the bed non stop to try to hit me in my face.
I will humbly clean up your piss and gently tell you stop whenever you try to crush my fingers because I'm trying to make sure your circulation still looks good after the soft wrist restraints I had to put on you. But in my mind, I am totally thinking you're an asshat. Yeah. Sorry about that.

Follow up: WTF/ face punching day

So yeah. I promised a follow up to the last post and I'm approaching some nice time off, so I figure I should stop being lazy. As I'm describing probably my second worst post intership shift ever, second only to ICU hold hell fest 2009, I'll at least make this fun by breaking it down hour by hour and pretending this is an episode of 24.
1900- Get stuck in the break room before shift listening to the same shit on repeat from management about how much we collectively suck and how our blood cultures are contaminated. And how there would be lunchmeat and bread sitting out for hours the next night to celebrate the fact that we've enacted an inefficient and expensive system in order to improve an arbitrary statistic that our VP is concerned with for some reason- Hooray!
1910- Walk out to get report from dayshift to death glares, even though we are late due to management's tomfoolery. Figure out that I am now responsible for transporting a patient upstairs who has had a bed for an hour and a half. Cool, whatever. Finish report and get my affairs in order.
0730-Transport said patient upstairs. While pushing patient into room, I drop the chart at the closest nurse's station where, from what I can tell, two able bodied women are sitting working on computers. Neither of them comes into the room to help me, but one does ask me to transport the chart to a different nurses station after I get done transporting a patient. I reply that I'll get on that in a second and continue helping the patient to the room. I get her fixed up and come out to find that one of the ladies has managed to stand up and pick up the chart themselves-amazing- I take the cue and book it down to the ER. One of these turkeys follows me and starts to chide me about how she doesn't appreciate me rolling my eyes at her. Really? If you have time to be worrying about something like that, you clearly have too little to do up here. I shake my head and continue walking, to which she responds, "I'm not done talking to you". I reply, "Really, because you need to stop." She asks me my name. My head turns around like the exorcist at this point, and respond with my name and offer my charge nurse's number. She then tears into me about how unprofessional my behavior was, how rude it was to walk away from her, how she has a witness to my eye-rolling, how she is my customer, and how I should stop using closed body language. What a freak. I managed to hold back the urge to curb check her crazy ass, and asked what she wanted from me. An apology. Okay. I'm sorry that my face upsets you and that I have patients down in the ER and I don't have time to stand up here and chat with you about body language. That's all I have to say to you. This is the closest I can get to a semi amicable resolution and I get the hell out of there before this drama queen can suck me into any more of her bullshit.
1950-Standard work stuff- I help my sweet hyperkalemic patient on and off the bedpan approximately 1,000 times while dodging the 13 family members in the room- I don't mind because they're cool and I fundamentally disagree with catheters for convenience, but it took up quite a bit of time. I run in and out of there to help my teammates, and my charge nurse brings me a schitzophrenic patient with chest pain. I deal with the standard business with him, but it all takes about 3 times longer as he can't follow simple commands because he refuses to take off his headphones. Awesome.
2030-I come out of chest pain room to find two hall beds- a little boy with a painful rash and a lady with pink eye, which she apparently obtained when someone threw urine in her face.
2035-Medicate cute little hall bed boy with Tyelenol with codeine. He proceeds to dance about in the hallway.
2045-Take a million telephone orders on my hyperkalemic lady, then proceed to do all of said million orders while chest pain man drifts in and out of conciousness asking me for pain meds.
2120- Get out of room after drawing labs and administering tons of meds to find my hall people's discharge instructions ready and urine lady standing at the nurses station yelling at us to hurry our asses up because her ride was here.
2125-Take vital signs and give the most thorough discharge instructions I have ever given for scabies for the little boy in the bed next to hers. No, I don't reward bad behavior.
2135-Discharge rude ass hall bed lady with pink eye, who then swears at me and tells me it's impossible for her to have pink eye. Explain to her about 4 times in a row what Norco consists of. Mmkay. I don't even need to see your ride sweetheart, just get out of here, now. Seriously.
2145-Admitting doc comes down to see hyperkalemic lady, several more bathrooms trips ensue, a couple more hallbeds filter in and out.
2230-Admitting doc finally gets me my chart back and I work on getting my lady upstairs. I call report and go in to do her now labs before I ship her up. All the lady has is a field IV- I've actually attempted to start another IV to help out the floor nurses with zero sucess. No problem, I tell the floor nurse, it draws great and maybe she can get a PICC line in the morning or something. I'll draw everything she needs now so you don't have to fool with it. I go to draw the labs and get nothing. I fanangle a little. Nothing. I go to flush it. Infiltrated. Fuck. I get super awesome charge nurse on the case along with one of our medics, but she has nothing. I mean, not even tiny hand veins. It's a complete nightmare, because the woman is an absolute saint about it, and her poor husband is hovering over us watching and commenting on our every move, talking non stop. She is actually in tears by the time we can start another line- a neonate size in her thumb. I'm about to be in tears with her.
2320- Poor sweet hyperkalemic lady finally goes upstairs. I call and update the floor nurse.
2330- I discharge headphones and prepare for the A -raping I know I'm about to endure. No patients in the waiting room to fill up with, a couple more hallbeds cooking, I help my teammates, I wait for my ambulance....
0010...and it comes. With my super sick but still awful frequent flyer with a blood pressure that would have made me faint earlier in my career. She screams and flails about on the bed while I attempt to collect her medical information. She doesn't have a primary doctor. Excellent.
0030-One of our awesome medics manages to get a tiny IV in her hand after much screaming. Being super sick apparently did not make her accustomed to this sort of thing. I feel bad for her, until...
0040- I go in to give her medications and she is now in no apparent distress and unwilling to get off her cellphone to verify her name. I shouldn't even say that I don't feel bad for her at this point, because I do. I'm just annoyed. Reconnect her to the monitor she has taken herself off of.
0110- Realize I'm getting cranky and try to drag myself back to eat some food.
0115- Get a call for critical labs for my patient. Run to report them, run back to finish my "break".
0130-Finish my break, run up to draw blood for a type and screen for my patient who now needs a blood transfusion, with her 24 gauge IV. Good luck with that shit. She refuses to let me draw it until she finishes braiding her hair. Fabulous. Attempt to adress her blood pressure with minimal success. Reconnect her to the monitor she has taken herself off of AGAIN.
0150- Get another ambulance carrying a man with approximately 15 complaints, missed dialysis twice in a row now, with high blood pressure, diabetes, no meds, no doctor. Starts by complaining about what a douchebag the dialysis doctor is for not prescribing him medicine. Screams at everyone for pain medicine whenever we ask for any sort of information/cooperation. Falls asleep with an open mouth snore during the doctors evaluation. Gets Asprin and Nitro paste for his chest pain.
0215-Get about one thousand calls from my other patient about how much she's itching. Explain to her that she's already maxed out on Benadryl and there's absolutely nothing else I can do for her. Offer her non pharmacological relief for her itching. Get stared at like I just said the dumbest thing in the history of humanity and watch patient scratch herself violently. Reconnect her to the monitor for the hundreth time. Explain the importance of keeping the oximeter on her finger for the hundredth time. Attempt again, unsucessfully, to try and fix her blood pressure. Argue with ER doc about how yeah, dude, she really really does need to get admitted. Yeah, I know she's here alot. She's sick.
0230-Run into the room of my screaming chest pain patient, who has now woken up from the loud snoring to-duh- excruciating pain unrelieved by Nitroglycerin. Tell the doctor. Reconnect my other patient to the monitor.
0240-Go in to medicate my excruciating chest pain patient to find him snoring and unarousable except to violent shaking-again. Leave room to write down the multiple critical labs I've recieved on him (apparently it isn't a good thing to miss your dialysis twice).
0250-Go back into the room to deliver pain medicine now that patient is awake and screaming.
0300-Reconnect patient to the monitor. Find her in room with admitting doctor, who talks to me like I'm an idiot because she's doing the violent itching act for her as well. Explain that she got the max dose of Benadryl to her approximately two hours ago and that I already notified the ER doctor. Am met with a blank stare.
0320- Leave the room to get more critical labs on my other patient. Get order for about 15 meds to correct said critical labs. Am running to get them when admitting doc runs into me to ask for some labs and meds on my other patient. I go to do that first because I want her out of here, STAT.
0330- Reconnect patient to monitor. Go in to draw labs out of this lady's IV with zero sucess. Attempt to flush IV. No dice. Contemplate suicide. I mean, this chick has nada for veins, and she's scratched out her tiny IV. I get a grown up nurse just to make sure. Yup. Grown up nurse attempts IV start is lady's foot and nearly gets kicked in the face. Much screaming ensues.
0345-IV badasses are assembled and attempt to fix this freaking nightmare. More screaming ensues. Patients blood pressure gets even worse.
0400-IV search continues and I walk out of room to keep from screaming. Take a few minutes of me time to avoid screaming and yanking out all of my hair.
0405-Go to give million meds to my other patient to correct his ridiculous labs. He refuses to wake up. I give his IV meds and his kayexalate, which he drinks okay with encouragement- then promptly spits it in my face.
0430-Finally finish with giving meds and wipe most of the kayexalate out of my hair. Walk in to more screaming and no IV. Hug and thank my teammates and go to have a pow wow with the admitting doctor about what the hell we are going to do with this woman. Baby ER doctor jumps to my rescue and offers to try and start an IV in her neck.
0445-Set doctor up for neck IV, stand at the bedside and hold the patients hand while saying a little prayer that this works so I don't have to run screaming from the ER. By the grace of God, he gets a wonderful line and all is dandy.
0500-Read through admitting doctors orders for something I can give to fix this lady's blood pressure. Attempt to chart all the fuckery that has ensued.
0515-Go in with blood pressure meds and Benadryl in hand to find patient disconnected from monitor, tugging at the monitoring cables and yanking the tubing connected to the precious, golden IV. Wait for patient to finish braiding her hair. Change the linens at her request. Reconnect her to the monitor. Tell her the good news- the admitting is giving you another dose of Benadryl- Hooray! Am met with more blank stares. Give boatload of meds.
0545-Get out of room to find my other patient has a bed. I didn't know he had orders yet. I whip through all the now orders and call report.
0610-Go in to recheck my lady's blood pressure with zero results. Give pain meds. Reconnect patient to monitor.
0620-Give more blood pressure meds. Reconnect patient to monitor.
0630-Chart, weep silently, attempt to wash kayexalate off my scrubs.
0645-Recheck blood pressure and reconnect patient to monitor. She has a bed now, too, but there isn't much I can do about it as her blood pressure is atrocious and they won't take her like that anyway, nor should they have to. Make sure her stuff is charted beautifully.
0700-Get paperwork in order and give report to dayshift. Get attitude for not fixing blood pressure with my magical nurse wand. Too tired to care.
0715-0900-Sit through mind numbing meeting adressing same topics discussed before this horrid shift. Eat an unadvisable amount of donuts.

Man. Even though I was taking mostly two patients with hall beds through all this crap, sometimes just two real rooms are enough to kill me. In retrospect I feel a little better- I'm thankful that I didn't get stuck with 4 people like this at once. But everyone has their limit. Apparently sick folks and tons of attitude was enought to push me to the line.

Strong post to follow.

Listen, I need to drink and go to bed, so I can't really go into detail, but lets just say due the perfect storm of some personal fuckery, some super sick and borderline abusive patients, and PMS, I want to punch faces.

When you start your shift with getting into a verbal altercation with some douchebag floor charge nurse who is on some customer service board because she didn't like the way you looked at her when she asks you to bring a chart to another nurses station while you transport a patient and she sits on her ass, the night is not going to go well. Especially if what follows involves not one, but two patients with NO veins pulling out their 24 gauge thumb IVs literally right before you're about to send them upstairs due to foolishness. Especially if what follows that is some idiot spitting Kayexalate all over your face, hair and clothing right before you have to sit through a "meeting" where you're supposed to bring up your "issues", which actually means management is going to jerk off for an hour and a half while you make fun of them to yourself and snicker. And when you do try to bring up sincere questions, some day shift charge nurse turd tries to use it as an opportunity to be as condescending as possible towards you and to climb just a little bit further up management's ass.

Seriously. Sometimes I hate everyone and I just pitch my spectralink across the ER, scream back at the patients who scream at me, kick the piece of crap printers that never work with all my might, cuss out specific nurses on the floor and the ICU, and wield blunt fill needles in a threatening fashion.

It's a good thing I have self control. And champagne and orange juice in my fridge.

well.

It's been a rough couple of days and I may or may not be on the internets in the coming weeks depending on how I'm doing.  

However, my nifty visitor log did offer my one nugget of joy- this little device tracks where blog visitors are from and how they got there- apparently, somebody got to my blog the other day by googling "big busted nurses".  Nice.  

Move along, nothing to see here.  

Psych patient mojo.

Oh goodness. Where I work, everyone seems to have their niche. We all must send out some sort of pheromones that attract certain types of patients. One of my coworkers always ends up with the nursing home patients with hypotension, while another always gets the a-holes who want to get all Jerry Springer and fight with the staff. As I may have mentioned before, I draw the psych patients. Even if I go to the clinic area, they find me.

Tonight I was totally on my game. I had about 2 psych patients with chest pain cutting up (one of which threatened to kick my ass), then a third who developed chest pain when she figured out that she wasn't going to get admitted for the side effects of her bipolar meds that had been going on for 3 weeks. Pretty standard stuff for me but lots of it. So the doctor had already established a pattern when at 5 AM, I brought him the chart of the patient who saw the US mint commercial on TV and decided that it was a sign that the government was trying to assassinate him. Yeah. He didn't even really seem all that shocked when I told him the dude had listen Jesus Christ as his person to contact in an emergency, or that he had brought a turd to the hospital with him in a plastic bag so that we could check it for the poison that the government had injected into his body.

He just kind of sighed, looked at me and said, "Damn it, hood nurse. Take your psych patient mojo elsewhere." Oh, if only.

Please advise

Real quick. I am not familiar with meth so much, as crack cocaine is by far the popular favorite at hood hospital. Does meth normally make your breath and urine smell like a GI bleed turd rotting in the sun? Or does driving around the city trying to get back to your home state, only to end up in a small town in the opposite direction because you are totally meth-ed out, then getting picked up by the police and subsequently EMS when they cops are like "WTF is wrong with the dude" and then ending up at the hospital without a glass of water or a breath mint cause this?

I did a google search on "meth breath" which yielded lots on enlightening results, but the descriptions were always somewhere along the lines of breath having a "foul, chemical smell", which unless said "chemical" happens to be shit, is not quite what this smells like. Please help. For research purposes, of course.

Apparently people are reading this for some reason- Whee!!!

It's been a pretty happy week on the internet tubes for me here lately- which is pretty nice as my real life week has been a little rough lately. I can't complain too much, life overall is still good, but my husband is on tour with his band and I'm missing him something awful. I've had the blog to cheer me up- it's been taking off, by my standards anyway, in that I've gotten a few new readers and some shout-outs from some pretty fabulous and funny fellow med-bloggers and I'm feeling all fuzzy like inside. Wow. Enough to unknowingly inspire me to use alliteration, apparently.

Anyway. Point is, I've received some internets awards/recognition from both Living Dead Nurse and Rachedy, both who are always awesome. You should probably be reading their stuff at this moment.

Rules are as follows:

1.Thank the blogger that gave you the award.

2.Sum up your blogging philosophy, motivation, experience using 10 words.

3. Pass the award on to 10 other blogs you feel have substance.

Listen, I don't know if I deserve this all the time- I don't know if entries solely about how it's a bad idea to piss your pants to be hateful really count as substance, but thanks! I'm glad people are reading it.

I don't know if I have blogging philosophy, per se, I try to make the experience and thoughts I have make sense and I try to avoid abusing the English language. Occasionally I am aware of what a jaded douchebag I sound like and I try to interject a story or two about nice people.

My reading list makes about as much sense as my blog, which is to say, not much at all, but the above blogs included, I also enjoy these:

1.Madness: Tales of an Emergency Room Nurse- This lady is pretty much a badass. Not only are her posts hilarious, but she is full of righteous indignation over all the fuckery the hospitals pull on their nurses every day, and she expresses it eloquently. As someone who can't go three sentences without swearing, I highly respect this quality.

2.Regretsy- Yeah, pretty much unrelated to anything medical at all, but an amazing blog that is so hilarious that it may or may not have made me pee my pants a little multiple times with laughter. For those of you unfamiliar with the concept, the author finds the most terrible, overpriced crap on Etsy, the Ebay of handmade goods, and makes fun of them. Fabulous.

3.Call Me Nurse aka Retired- Continuing the trend of me absolutely loving 100% of the Canadians I come into contact with, this incredibly nice and insightful lady was one of my earliest blog followers. She also has an epic blog of her own with lots of great stories about her nursing career, which was all over the map and a great reference for any of you nursing student readers trying to get a grasp on what you want to do with your lives. Unfortunately, the Canadian governing bodies that be are pulling some 1984 style tomfoolery with her at the moment, so she may or may not be on permanent blog hiatus. Here's hoping no- either way, read her archives.

4. NurseXY- Nursing student and future ICU murse, and wise beyond his years as a nurse. Also has quite the funny way of wording things. My favorite recently "It's an ICU room, not a freaking clown car". Yes, NurseXY, I think you'll do just fine.

5. What Claudia Wore- One of the many other non-med blogs I love. As a failed fashion design major, I have a weakness for fashion blogs, and as a child of the 90s, I have a serious weakness for funny blogs based on the clothing choices of characters in The Babysitter's Club series.

6. Push It! Push It Real Good!-Blog about the scariest subject ever to an ER nurse (cue ominous organ music)...Labor and Delivery. Written by a real world friend of mine with a pretty darn interesting perspective- she worked for years as a Doula and now works as an L&D RN in a county hospital that generally relies on a pretty traditional medical model, and fights the hella hard battle to give these ladies the option of a more natural birth. Overall sweet and well written stuff over here.

7.New Nurse Insanity- Fundus Chop!- I've linked to her before, but I'll do it again, damn it. Hilarious blog. Eerie personality similarities. Want to drink a beer with this person.

8.STFU Parents- Another frequently checked non med blog, devoted to oversharing as it relates to children on Facebook. Although the title may throw some off, I think everyone can agree with the sentiments present here- please don't take pictures of your children's shit and post it on Facebook. Don't take pictures of your child's head coming out of your vag and post them on Facebook. Thanks.

9. A Nurse and Her Camera- Funny blogger and a damn good photographer.

10.Glossed Over-A long time favorite blog- Wendy Felton is a totally BAMF. She reads tons of women's magazines and points out the ridiculousness while being angry and funny. She updates rather infrequently but for reasons that make me like her even more, alluding to some body issues all too familiar for me here. Overall awesome feminist writing that makes me slow clap in my living room to my houseplants.

Well, there you go. Go read all these lovely blogs and I will take a little more time to edit the 2 or 3 posts I started and ended up hating/realized they made no sense that actually related to medicine/and or my job.

Seperation

I wish it was easier to think of these patients in a vacuum. But it just isn't possible.

Like you, Mr. "Suicidal Thoughts". Maybe on a different day I would have believed you when you told me your mother had just died. Maybe I wouldn't have jumped for joy at feeling so vilified when the psych evaluation lady tells me that I was right to be suspicious because your mother has "died" now four times this year. Maybe on a different day I would have brought you the footies you requested, or the 2nd and 3rd sandwich tray and juice that you needed in order to give us a urine sample. Maybe I wouldn't have had quite such a crazed look in my eyes whenever I threatened you with a catheter when you still wouldn't provide a urine sample. Maybe I wouldn't have sternal rubbed you quite so hard when you refused to wake up for your urine sample or psych eval.

But today is not your day. Because the woman next door to you-the one who refused her pain medicine because she didn't want to get high? The one who hasn't asked for anything but has thanked everyone who has come into her room profusely? She's just found out she has an giant malignant mass in her abdomen. Every last drop of my compassion is with her. She carried it with her when she was taken to her bed upstairs, when she and her family all hugged me and thanked me for everything I had done-which isn't much, you see, because I've been tied up with your ass and the games you've been trying to run.

And with that in mind, it's really not so bad that I don't want to listen to your problems. Because thinking about the fact that you and your bullshit took a nanosecond away from this awesome woman who is legitimately sick- I'm doing you an enormous favor by not giving you the Ativan you requested IM via blunt fill needle to your face.

What do you want from me?

Being the mature person that I am, me and one of my work buddies have tagged a new name for the ICU in our hospital- the BU (Bitch Unit). Not to say that some of the people that work there aren't really cool or hard workers- there are always exceptions to the rule- but I swear when we bring people up they are just looking with everything they have for something, anything to whine about.

I took care of a guy today in my trauma room (along with my other 3 sick/crazy patients) who was a train wreck. He was delirious with a fever of 103.7- his blood sugar was high enough that the meter couldn't read it and his heart rate was about 150. I hung all kinds of fluids, did an insulin drip, gave pretty much every medication the admitting doctor ordered in addition to the 500 ER meds, sent the AM labs, started 3 IVs and labeled all the sites. Pretty much brought the guy up to the ICU spick and span with nothing for them to do. Now, while trying to get his temp down he happened to be stuck in the trauma room with the broken thermostat, because the ER is ghetto, so I just left him naked with a sheet on. I didn't bother to put a hospital gown on for the trip up because they always change it- I swear you could have a patient code in the elevator and those bitches would stop compressions to change the gown. So what do you think was the only thing they had to say to me when I brought the patient upstairs?

Yeah. "Where's the patient's gown?"

Really? Okay, fine. Nothing is going to make you douchebags happy, is it, so screw it. I'd get the same treatment from you turds if I stayed and did my your damn admission assessment for you and hung all your meds as if I brought the patient up with a field IV and no catheter and no information about the patient, so why put myself out? After all, I am just a lazy ER nurse.

Things aren't always what they seem.

I swear some nights I'm getting a message. Clear as day. Tonight it was to look a little deeper. I was trauma nurse, and it was altered mental status party 2010. First patient I got was a pretty simple low blood sugar. I'm getting her all fixed up when another patient rolls in- a guy in his 40s from a halfway house, again, altered mental status, cutting up, trying to jump off the stretcher to walk to the bathroom. EMS has zero history, and trying to collect it from the patient is about as effective as trying to collect history from the damn blanket warmer. Dude insists on peeing before getting in the bed, spills about half the pee on the bed, then proceeds to try and pull a cigar out of his pocket and light up in the room. Fabulous. I'm crabby because it irritates the shit out of me to take care of drunk and high people. The guy denies taking anything but has this weird acetone/boozy odor about him so I just assume he's probably drunk or huffing something and lying about it. He finally falls asleep and is pretty peaceful other than sitting up on the side of the bed to urinate every 30 minutes or so. I go about my day and am working on getting my low blood sugar lady upstairs to a bed when another nurse on my team brings me a critical lab value- sodium of 115- pretty low-on my "drunk" man. I finish up all my paperwork and look over in the room to seeing going pee again. That's when it dawns on me-shit, this guy isn't drunk at all, he's Diabetes Insipidus. I talk to the admitting doctor and we keep him down in the ER for another hour while he writes orders- the guy has made 4 liters of urine by the time I bring him upstairs. And his alcohol and drug screens are all negative. Shows me.

While we're holding him, I get another lady next door-called in EMS as an overdose. She is screaming and kicking the EMTs- we have to put on limb restraints before we can even move her from the stretcher to the bed. No medical history they're aware of other than some unidentified chronic pain that she's seeing a pain management specialist for. Her husband gets there and tells us it's happened before-she tends to take too much of her pain meds. He gives us her meds and she's taking 40 mgs of Oxymorphone a day and then Dilaudid for breakthrough pain. Holy shit. That pretty well explains it. We do an EKG and I bring the chart to the doctors- we've started a catheter and sent blood, but kind of as an afterthought I think, "Oh, well, we know what this is but I better do a blood sugar." Yeah, It's 37. WOW. I ask her husband- "Does she have Diabetes?" Yeah? Great. I run and grab some D50- as soon as I give it, the lady sits up, looks at me, smiles and says hi, as if this is the first time we have met. I guess for her, it was. She was pretty much totally normal after that. I got the whole story as I took care of her- apparently, she passed out about 5 hours before her husband called EMS. She had just taken her Dilaudid and Insulin and hadn't eaten. Her husband thought it was just the pain pills and planned on letting her sleep it off- when she didn't come around after several hours he decided to call EMS. Luckily, she did great and we discharged her- after a long talk about taking your pain medicine and Insulin with food.

I'm hoping this stuff will start making me think in terms of diagnostics a little differently. It's won't assume it's either this or that, but that it's all of the above until completely proven otherwise.