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.

Is it just me

...or does everyone else in ER despise triage. When I say despise, I mean despise. In the word of my brother, " I hate it. I wish I could hate it to death." A quick explanation for those who don't work in ER, triage is the god forsaken hellhole where you go and sit in a box and see people for the first time when they come in. You collect their information, you take their vital signs, you listen to why they came and then you decide whether you're impressed by their complaint. If you are, you call your charge nurse and try to convince him or her as to why this person might possibly die if left in the waiting room. If you aren't excited by their symptoms, you tell them as tactfully as possible that no, you actually aren't dying right now but you might die later, so go ahead and have a seat out there for a while. No, I don't know how long.

For a while there, I seemed to be the new person to stick up there. You have to have a year of experience and take a stupid class, although I was getting stuck up there pre- stupid class. For whatever reason, I seem to be the only person in my internship that gets put there- they've oriented another friend of mine but she hasn't ended up there yet. Different story for me I'm afraid- and unfortunately, my night to go to triage seems to be Sunday night, the busiest one out of our week. I guess I should be flattered that they trust me enough to do the job, but every time I go I seriously feel like I'm being punished. I can't tell whether it's just me or if this is truly the most terrible job in the entire world, but here's why I hate it, in a handy numbered list:

1. The Drama. Hooollly crap. You don't know drama until you've been to triage. Especially at hood hospital. Our wait times, on a good day, are about 2 hours. On a decent day, it's about 6. The worst I've seen it was 16. Naturally, no one wants to wait that long. So what can you do? Give the performance of the year in the triage booth, and then try to earn your lifetime achievement award in the waiting room. Wretching loudly in order to bring up what is essentially a loogie is an old favorite. Wheeling around in a wheelchair when you don't need one is also popular. My personal favorites are fake syncopal episodes or fake seizures, which are pretty quickly cured with a good sternal rub. Of course, when all that fails, nothing beats sliding onto the floor and rolling around while moaning. If it doesn't get you back to a room faster, at least the academy will love it.
2. The Hatred. I work with lots of people who can get cussed out by a patient and not bat an eye. Let me just say I am not one of those people. No matter how much of a front I put up or how much of a crazy asshole the patient is, it still hurts my feelings and I do still take some of it to heart. The likelihood of having something awful said to you increases to the millionth degree when you're up there. It's almost as if everyone assumes you aren't actually trying to help them, but you're just trying to keep them waiting longer. From what I can tell, your attitude makes no difference. I triaged an elderly hispanic lady the other day whose daughter had checked her in for nausea and vomiting. We were packed that night, and literally every room was about to be filled with ambulances. The lady was fine- a little dramatic but not the worst I've seen. Her daughter was a douchebag. She's telling me a bunch of crap at once, despite the fact that mama is totally capable of talking herself- that's minus some points right there- but keep bringing up the fact that her mother is a diabetic. I am sweet as possible to them, I get mom a Zofran tab, I get mom a blanket. I tell them I am very, very sorry but there are lots of sick people here today and we physically do not have a room right now. "Not even for a diabetic?" she asks me in a tone that actually means "Are you effing stupid?" This is after she has told me that she thinks her mom is just sick because they ate Mcdonalds and her system wasn't used to it, and showed me a full bottle of Phenergan that no, they didn't try using because we can give medicine in the ER. When I told her a lot of our patients are diabetic and diabetes does not guarantee you a room, she gets on her cell phone to update the rest of the family- she's speaking Spanish but I hear her drop a key word -"perra". Oh yeah, okay. Listen lady. I don't even speak Spanish, but I know you just called me a bitch. But I guess that's okay behavior since I'm just the mean, stupid triage nurse, right? The death glares I get from people I've sent out there every time I get a new patient to triage and the general level of hostility in our waiting room is a whole other post, so I'll just mention it here briefly.
3. Pediatrics. Children scare me. I swear triage is 50% children, and half of their parents leave with them before being seen. This means I see a disproportionate amount of sticky little people who move all the time who scream and kick and are impossible to get vitals on. Side note: I don't hate kids, I just hate taking care of kids.
4. Boredom/Loneliness. Part of the thing I adore about my job is team nursing. I get to work with a group of people and we have fun together and help one another. Supposedly, there was a day in time that there more than one nurse in triage. I'm not sure I believe it. Kind of like how we were going to have a second triage nurse at all times for about 2 months now. This means if 15 people check in over a period of 30 minutes like they like to do, you better just work faster, because there is no one to help you. This also means that you better have a good book up there if it slows down, because there is no one to talk to and management took away the one perk of triage- Minesweeper. Bastards.
5. Stupidity. I always thought there was some stupid people that came to the ER my first year as a nurse. Turns out I had no idea. The things people check in for and leave before waiting to be seen are mind blowing. Who would've though that someone would go to the ER, get a prescription for Elimite to treat their nasty scabies, and then check back in for the same scabies a few days later because the prescription was more that you wanted to pay and you insist on having your scabies treated at the ER. Really? I swear a die a little inside every time someone checks in for something like this.

I'm sure there's more, but just talking about this makes me tired and a little sad. I'm gonna go get a beer and see Inception now.

A little warning would be nice....

Listen. I know it's hard to plan for cases where you end up with a patient who had to be picked up and taken to the hospital by the city light rail police because he thought it would be a good idea to take a couple of sleeping pills before getting on the train- I mean, who hasn't done that, I do it all the time-but I wish some people had to carry a little more information about their conditions.

Let me be more specific. I wish people who have spent 20 years combined at the state mental hospital for repeatedly masturbating in public were required to carry a little card or something with a note to the effect of "Hi, my name is Mr. Creeper Jones, and my number one favorite hobby is whipping my junk out and jerking off in front of strangers. You, as the healthcare professional taking care of me, might be interested in this information. Nice to meet you."

That way, we might be slightly more mentally prepared for walking into the room and finding you with a sterile glove on one hand watching the Disney channel with your pants off. I'm just sayin'.

I can't make this shit up.

When I was graduating school and reading med blogs, I always assumed that a bunch of shit was fictional. Or that when I started, I could never write my own successfully because I wouldn't have enough material. I was dead wrong, but sometimes I wish I wasn't.
Like tonight. When I got stuck up in triage on the 3rd drunkest day of the year, and my first patient at 715 was already tanked. Like, couldn't even stand up straight. Yeah, she checked in because her toe hurt. Her toe hurt because two days before, she was sliding down the stripper pole and work and her acrylic toenail came off and now it was "oozing infection". She was so wasted and/or stupid that she was talking about what they needed to do to start her IV. I wish I was really that creative and I could make up stories like this one. But no, it's true, this person actually exists and probably has children. God help us all.

OD formula

I'm still beta testing this. I've noticed a problem in overdose cases where the number of meds people say they took does not reflect reality accurately. Here is my suggestion:

Number of meds pt states they took/ (number of outgoing phone calls from room+number of visits this year+number of requests related to food or socks)

If none of the above apply, take the original number and move on to the next step.

Subtract one point for each family member present.

Subtract two points for patients between the ages of 17 and 25

Add one point if they took prescription vs. OTC meds

Subtract 5 points for trying to leave.

Subtract 2 points for each time you have to call the police.

Subtract a point for every time you have to ask for a urine sample.

Subtract a point for every other drug on the urine drug screen (THC doesn't count in my system, because it's absolutely insane that Marjuana isn't legal yet)

Add one point for blood alcohol level twice the legal limit or greater.

Subtract 3 points for people with blood alcohol at or below the legal limit who act way drunker than they really are.

Subtract 5 points for fighting with the significant other in the room.

That's the basic outline. Try this in your hospital and let me know how it works for you. I'll make a nifty bar graph and include it in my fake thesis.