Chief Complaint of the Night

Which also necessitated an ambulance-
Itching rectum x 2 hours.
Yes, ambulances really do bring people to the ER for this.

Helpful Tips for Drug Seeker Carpools

Hey seeker carpool! What's up guys? Thanks for choosing Hood Hospital, and thanks for all riding together to reduce your carbon footprint.  Somewhere a baby seal is thanking you.  So on behalf of baby seals everywhere, I'd like to give you a few tips on how to make sure your next group narcotic errand might be more successful.
1. Do your homework- Okay, so obviously you guys have probably exhausted all the hospital options in the city you're from.  That's cool! You'd be surprised how many of our patients have come in from out of town to see a dying relative when their narcs got stolen on the bus.  Dude. It happens all the time. But here's the thing- if you're in a city you're unfamiliar with, maybe try to blend in a little bit where it's not completely obvious that you are out of your element because it kind of raises some red flags with the staff.  Especially if you were just here yesterday with the same complaint- when you're not around your people, you're a little more memorable.  Find your people. Use yelp or something.
2. The buddy system isn't always the right call- Okay, it's a little weird for you to all check in for similar complaints.  That's another red flag for us ER people.  So if you want to be less conspicuous, it's probably easier if you don't all check in in succession and then mention to me as I'm triaging each one of you that you're all from the same city that isn't this city.  Obviously you're together.  You might as well have all just held hands and sat in a circle while I took all of your vital signs and asked you which body part hurt and which controlled substance you are out of.
3. Creativity helps- Really guys.  Please come up with different stories on why you don't have your narcs.   I know you copied off each other. Sometimes I think you're not even trying.
4. But not too much creativity- If you're all coming in for minor prescription refill complaints in one car, you better coordinate your efforts a little better or know you buddies, because now the one asshole in your crew who got tired of waiting on his prescription who suddenly became suicidal is getting sent to the psych hospital.  You guys really should have talked about this on the way here.
5. Play it cool- Thanks for playing, but it seems that the doctor recognizes one of you from yesterday and has mentioned it casually to you. It's not totally a lost cause- your friends might still get something good.  Unless you act a fool and start cussing the staff and then run around the ER and rounding up your buddies to get them to join in the nonsense. Now all of you are getting escorted out of here with nothing.  Save for the "suicidal" one that is, who has so far received only a bag of norma-sal-line for his chronic pain complaint.
All around, it's a big bummer, especially with gas costing what it does this days.  On the plus side, you're in the right part of town to buy what you want if you've got cash on you.  Sorry guys, and better luck with your next field trip! Just make sure you don't come back to Hood Hospital, cause yeah, you're like banned for life and stuff now.

Positive Feedback

Eastern european doc of snake light fame, upon finding out that we had already carried out a bunch of verbal orders on a super sick patient: "Oh. I like you guys!"

It was nice to hear, as he's not really known for praising the staff, so when he does, it means he really thinks you've done a great job, but more so because he sounded EXACTLY like Borat. Seriously. It was awesome.

Free Medical Advice for the Kids

Okay, kids. If the date is April 20th, fill in any year you please, and one of your classmates offers you a baked good, say, a brownie, and after eating said brownie, you feel weird, chances are, yeah. You're probably high right now. I have several friends who experience this sensation regularly who tell me that eating taquitos while watching cartoons and then sleeping a long time may be helpful. Usually this is sufficient.

Rarely does this necessitate making your poor mom (who has work tomorrow) take you to the ER to wait for hours for a full cardiac and neuro workup which she will in turn have to pay for as well. Just sleep it off. Or, uh, go to a hospital where the doctor doesn't think CIPS are necessary for the chief complaint of "my head feels weird". Or stop taking desserts from the kid in the Bob Marley shirt.

Now that we've learned something, it's time for some bonus questions:

What is the appropriate gauge IV in this scenario?

If the pot brownie is ingested at 1400 and the average ER wait time is 5 hours, how long will it take for the patient to be asymptomatic and sleeping when the doctor comes to examine him/her?

What is the therapeutic affect of a banana bag on a 15 year old who ate a pot brownie?

Make sure to show your work.

Expert Level Tomfoolery

Okay, let me give you some background information first so you can really understand exactly how ridiculous this whole situation is. I know you're probably over me being all, "guys, Hood Hospital really blows right now", but no, truly, it does this time. All I'm saying is, when your ER is functionally shut down from 50 beds to 8 beds because all your beds are full of holds and 10 of them are ICU but there's still ambulances coming and 200 people a day are still checking in at the front being the triage nurse is terrible. Anyone's who isn't actively dying or on fire is sitting in the waiting room with double digit wait times, even the ones that came in via ambulance and need to be assisted to the bathroom. Every time they need to be assisted to the bathroom, you have to leave your little collection of patients you've started treating and monitoring in triage because there's no beds, hope they don't die, and then enter the waiting room to be cussed out by all the people that have been waiting since before your shift started.

So in the midst of all this, enter dramatic med seeker. He runs in in dramatic fashion complaining of some chronic extremity pain, which naturally, is 10/10. He is asked politely to be seated and wait for triage, to which he responds by not only adding chest pain to his complaint but by yelling at the top of his lungs for all the waiting room to hear "I'm having a heart attack!" Well played. Clearly we have a formidable opponent. Okay, let's get this emergent normal sinus rhythm EKG dance over with, shall we?

So as I'm hooking up the leads, homeboy starts in on how he took a cab here and didn't have money to pay the cab driver and how he was going to come in a get a voucher from us. WTF? I try to explain to him that we don't pay for people to bring us patients, but every time I open my mouth, he screams louder "I'M HAVING A HEART ATTACK!!!" Wow. At about that time the cab driver shows up with one of our police officers- apparently when the cab driver questioned his reverse voucher scenario, he threw his dollar store jewelry on the floor of the cab as "payment" and just ran into the waiting room, hence the emergent need to be triaged. Normal EKG notwithstanding, this guy continues to act a fool and scream at the officer to get the cab driver away from him because he's having a heart attack.

I assure all of them this is not happening, charges are pressed for theft of service, and in the process of all the drama and arguing, our officer finally asks this dude the million dollar question- why didn't he call an ambulance if the really thought he was dying? Uh, yeah, turns out he was right outside another hospital who wasn't giving him Dilaudid wasn't doing anything to help him. Rad.

Savvy master of free transport is then directed to the waiting room, at which time he adds on a few more complaints that change nothing. Once he figures out this isn't getting him anywhere, he throws the last hail mary out there- suicidal thoughts. Huh? My hearing is damaged from all these patients yelling obscenities at me all night. What, you're going to repeat that statement to anyone in the waiting room that will listen? Great, sit down in this chair right by the triage desk and this here nurse is now also your sitter. Hope you weren't planning on using those Camels in your pocket, sir, because that isn't part of suicide precautions. If you thought he was finished NOW, you underestimate him, because he then started screaming, having fake auditory hallucinations (while still able to request an Ativan shot to "calm him down ") that spontaneously resolved when he was told the police officer would be coming back to see him if he didn't stop making a scene. Seriously?

I've seen a lot of strategies employed by fools to get ahead of legitimately sick people in the ER but I think this is the most I've ever seen used at once. I really think the only option he didn't exhaust was faking a seizure. Maybe he was saving it for day shift.

Letting Go

This is a a post I've been thinking about for a long time, but real emotions take me a lot longer to process and express than I usually have time for. Also, I'm about to get all religious on you. Consider yourself warned.

Where I work, we see a lot of death and dying. Or rather, near death and dying. A large portion of our population are nursing home patients. Most of them are dealing with some degree of dementia. Virtually all of them have no hope for recovery. Virtually all of them are full codes.

They come in, thin and frail, covered in bedsores, mouths crusted in weeks worth of oral secretions, breathing their last breaths. Their families come in droves. They insist on intubation. They want everything done. They pray for healing over the brittle shells of the people they loved. The process is sad and cruel, difficult to watch.

I have no doubt in the power of prayer, but what they pray for puzzles me. I think back to my first job in high school- watching the young kids in my church's nursery. One of my charges was a sweet, tiny little boy with severe cerebral palsy. He didn't speak words, and his doctors speculated he was blind, but he could hear and responded to every little sound. He would smile at the voices of his kind, gentle parents and giggle at the tickling and teasing of his doting older brother. He loved music and would often grin and make sounds along to what he was hearing. He'd stay behind in his chair while the other kids went over for communion, and I'd stay with him- on the days he fussed, I would sing to him. I took care of him at home every now and then when his parents went out- they always joked that he had a crush on me.

He started getting sicker a little after I went away to college. I visited him in the hospital during Christmas break-he was discharged on hospice care a few days afterward, and a little while after I'd returned to school my mom called to tell me that he had died. I came back into town that weekend for his funeral, still confused and sad. I remember looking at his parents and wondering how they were keeping it together.

My rector gave the sermon that day, and he talked about how much our little man loved being pushed in his wheelchair with someone running behind him, and how much he would giggle at the feeling of the wind on his face. He talked about how heaven as we believed in it was a place beyond the limitations of our broken physical selves. How we become whole and perfect. And he talked about this sweet little boy, and how he was there, running around at last. I cried as I watched it in my head. I still cry thinking about it today, thinking about my grandfather, unable to recognize any of us through the fog that was Alzheimer's at his death, back to building his complex models, back to wiring little devices, back to fixing my and my brother's toys as fast as we could break them.

We say we believe in these things, and we love these people so much. How could we deny them their eternal reward for the selfish purpose of clinging to their broken bodies a little while longer?

On the other hand, last week, I took care of an older lady in the early stages of dementia. She was dealing with a score of other medical problems, none of which were immediately fatal, but enough that she was living in a nursing home. This particular night, she had taken an unexpected turn for the worst and came to us with agonal respirations and a thready pulse. Her family and neighbors flocked to her bedside. Except this time, not to futily try to hold on, but to wish her goodbye. Her son sobbed as he talked to her, telling her that it was okay to go now. About what a great mom she had been, and about all their loved ones who were waiting for her. He even talked about her rotten little dog that she had loved so dearly, and how he was ready for her to come home. They covered her with kisses, and she died within a few hours. This has seriously been one of this most memorable and oddly, most beautiful experiences of my nursing career. I was able to walk the family through what was happening, to comfort them and assure them that they were doing the right thing. I will always remember them and I think her son will remember me too.

I don't want to sound all angel of death here, but I guess my point is, if we say we really believe in a higher power and a better place, why do we struggle so when the time comes for someone we love dearly to go there? Also, that I'm seriously considering quitting ER to become a hospice nurse.

Prioritization

I'm for serious, y'all. Tonight marks the closest I have ever gotten to just beating the living shit out of another nurse in front of a patient.

It was the perfect storm. Charge sends three ambulances to our pod at once- it was me, usually charge nurse buddy, and the worst agency nurse in the history of nursing. So, okay, let's do the math here, one per nurse. Except all my rooms are full, so my buddy gets two and I help her with one, except worst agency nurse ever refuses to start her ambulance because she's too busy applying a knee immobilizer and fitting crutches or some other non emergency crap. The two ambulances my buddy is dealing with are a trauma twofer, who, by the way, had absolutely no business coming to our not-trauma-center ER, but unit number fucktard doesn't seem to understand that smelling like alcohol does not mean the emergency is not real (hi, blood coming out of the ears is a BAD sign you guys). Luckily one of the patients is not sick. The one with the bloody ears... yeeeah.

And the one I started. It's a bad sign when your patient is grey and you can't get an O2 sat and also they're breathing really fast and I think this might not be related to the slightly elevated blood sugar, but thanks again fire rescue.  So cool ER doctor orders the kitchen sink in labs, we scramble to do them while agency nurse shops for microwaves on the inter webs (because why the fuck not), and what do you know, it's already 715 and dayshift is here to take report!

Oh, BTW, so sickly grey dude is probably looking so sickly and grey because his hemoglobin is 3. Why? I don't know, but we better get a type and screen before he gets to the pearly gates. Enter dramz. Day shift princess prances in as me and usually charge nurse buddy are trying to get blood to come out of this dude with no circulating volume so we can send a type and screen and get the life saving blood and shit, and she immediately starts passively aggressively chastising us because 1)the room is dirty and 2)the patient isn't in a gown. Really? WTF. Girl, I'm gonna need you to sit down there in the corner for a while and study your BLS book and not speak to me again until you have absorbed and fully processed all the information contained within. Okay, are you ready? Let me explain my thought process with this patient. When I am the sole person in the room with this patient, and I notice they are breathing real fast and stuff- B- Breathing-I will apply some oxygen and that will help. So, I then notice the patient is kind grey and his cap refill blows and the blood pressure is in the toilet-C-circulation-so I opened up the EMS fluids and I started another IV and I got those labs which have already been run. Now the blood pressure is better, but it turns out that this patient needs blood, which we're working on, so we're still on C for circulation.

Am I getting through to you? Basically, G-gown and P-picking up the trash come way the fuck after C in the alphabet so please stop embarrassing yourself by concerning yourself with this frivolous crap in front of your peers. Thanks. I explained all of this to her with my verbal filter, which I am not using now (does not stand up to bourbon), and THE ONLY thing she managed to gather from this conversation was that one of us needed to change the triage code in the computer. At that point, my buddy basically had to drag me out of the room to keep me from slapping her, and then as we were trying to catch up on an hour's worth of charting, she was trying to rope us in to trying to put a draw sheet under this patient.

WTF. That's really scary and I honestly hate to see what will happen when someone sends homegirl a critical patient all by herself and she actually has to manage their care. Obviously, the patient will die, but their corpse will in a fresh new gown, very easy to move up in bed and will have an allergy band if appropriate. I bet the doctor will really be impressed while they are coding the patient as rigor mortis sets in.

Chief Complaint of the Night

"Um, yeah, do you guys do like testing and stuff to see if people are able to have kids?"

NO.