In Response to the News That She Was Going to be Receiving Sub Q Heparin

Patient (who was in the ER for skipping dialysis x 3 weeks to go on a crack bender), with a mouthful of chewing tobacco: Heparin? In my belly? Uh-uh. That don't go in no shot. That only go in the IV for dialysis.

Me: Well, ma'am, I can guarantee you this is a pretty routine order for the prevention of blood clots in the hospital. You can look at the written order here if you like.

Patient: Naw. That don't go in a shot. I ain't takin' that. You nurses here are dangerous.

Me: Alright, well, I can't make you take it. I'm pretty sure skipping dialysis for three weeks didn't kill you, a DVT probably won't either. Also, I'm pretty sure you aren't supposed to chew tobacco in here.

...and end scene.

"We're In a Code"

Go ahead and turn your caps lock on now, butthurt commenters. Here we go.

So, as I may have mentioned before, last night sucked. Hard. I think we had about 4 intubations and 2 codes in the first 2 and half hours in addition to a bunch of other train wrecks and ICU holds that were already down in the ER at this point. At some point in the midst of all the madness, we hear them call a code blue to one side of our ICU (it's split into 2 big hallways) and think little of it. Even procedure whore doc, who usually is calling upstairs to see if they need intubation before the operator is even done announcing the code, payed little mind, as he's already intubated half the patients in the ER at this point and was over it. About half an hour later, they assign me an ICU bed on the hallway where the code isn't happening. I get my stuff together and call up there, and some chick answers the phone and is like, "Um, did you NOT hear the operator? We're in a code right now. Yeah. I think your report's gonna have to wait for a little while." Generally trying to be understanding, I ignore the fact that this woman is talking to me in the same way one would speak to a child who is interrupting the grown ups talking and say, "Oh, I'm sorry, I thought that was the other hallway." I swear I can hear her roll her eyes over the phone as she responds, "Well, up here we all come help", after which the B hangs up on me. Oh hell naw. Let me break this down for you, girl.

One, is it really necessary to act like that? If you'd just been like, "hey, we're all in this code, can the nurse call you back", this would not be an issue and I wouldn't have to make fun of you anonymously over the internet. But now I do. You brought this upon yourself. But seriously. I'm so sorry, I didn't realize the important ICU nurses were still in a code, which I wouldn't understand, because we don't do anything down here besides sew up boo-boos. Let me just get back to handing out ice packs and Norco until the real nurses can call me back and bestow upon me the honor of taking report. Meehh.

But the real point of the post is, how many of you does it take to code a patient? I'm gonna drop a hot opinion on y'all right now and say if it's more than 5, you're probably doing it wrong. I apply that rule to us, too. Okay, if you're coding a patient you need a nurse to record what's happening (1), a nurse to push meds (2) two to alternate between compressions and code gopher (3 and 4) and I'll throw a 5th in there to do other procedures or whatever or to bag if RT isn't there (which they are). Really four is enough, and we've coded patients many a time with three with no problem. If we're really in a bind, I've had days where it's me, super medic and a doctor where I push drugs and record and super medic and the doctor switched off compressions while the doctor ran the code. It's not ideal, but you know what? I would rather have that any day than 10 people in the room. Why? Because if there are 10 people in there, half of them are just standing around anxiously getting in everyone's way, and that is the most annoying shit in the world. If you are standing around in a code, your presence alone is not helping. You are making it worse because you are limiting flow in and out of the room, and you are sucking up everyone's oxygen and making it hotter in there. Get the F out.

If I am the recording nurse, I will actually tell people to get the hell out. If I am helping and a bunch of people come in, I will switch with someone and go take care of my teammates' patients while they're in the code while announcing loudly on the way out that the room is at capacity and the fire marshall is going to come and write us a ticket. In the ICU, I would think this is probably even more true because you often already have lines and an airway established. So you're doing compressions, pushing drugs, and recording . It shouldn't take that many of you. Plus the house supervisor, the chaplain, and everyone else and their mama is up there in your business once that shit gets called overhead. To quote my ICU buddy nurse XY, "It's an ICU room, not a clown car". Leave.

My second point is, that shit must be nice. It would be rad if we were coding one patient down here and if EMS showed up with another super sick patient we could be like, "Nuh-uh! We're in a code! You keep that out in the ambulance bay until we're done! What's wrong with you?" But it doesn't work that way. Sometimes we just have to bag with one hand and do compressions with the other and push drugs with one foot while hoping we remember all this crap, because every patient down here is crashing at the same time. It happens, and I don't feel sorry for myself about it because this is what I signed up for. But do I feel sorry for you when you are asked to step out of a code 15 people are standing around in to take report from the mean, ugly ER nurse so I can fill my room with the next code coming in down here? Nope! That's the way nursing goes. Dry your tears with your fancy cellulose dressings and pull up your disposable one use big girl panties that we don't stock down here and deal with it.

How You Know Your Night Truly Sucks

Last night was the worst. Like, very possibly in my top 5 shittiest shifts of my life. The ICU is full, which basically means we're boned. I thought I lucked out with the 2 code rooms, as I would be guaranteed only 2 ICU admits- unfortunately they were both enormous train wrecks with piles of comorbidities and families who were prone to anxiety while at the same time being unable to really grasp how sick their loved ones actually were. At least they were nice. Anyway.

At about hour 9 at one bathroom breaks and zero water or snack breaks, I'm mixing my patient's smashed BP meds in water so I can give them down the NG tube when I look at the monitor to see that his blood pressure has tanked for some unknown reason. As soon as I process the information in my brain, the next thought that pops into my head is "I wonder if I drank this if I would have a syncopal episode and be able to go home?" Mind you, this is never something I would do or even consider doing, but for some reason like, some other part of my brain took over and was all, "screw this! self destruct!!!" Luckily (?) the generally sane rest of my brain was like, "that isn't cool, plus you're not wearing your cute panties, so you can't pass out here," and I finished my shift relatively uneventfully other than the general awfulness.

So, I guess the moral of this story is, when your brain tries to kill you, it's time to stop picking up extra shifts.

Service Training in Action

Now that our patient satisfaction scores will actually affect reimbursement rates, Hood Hospital is trying to teach all of us ragamuffins down in the ER how to act right so our patients will be happier. Who better to teach us than a bunch of people from finance and upper management who have never taken care of a patient in their entire lives? I can't think of anyone with a better perspective. Anyway. They've been doing mandatory training the last month, and despite the fact I will never get those hours of my life back, at least the things these people think will work to improve our scores are hilarious.

The vast majority of the stuff they are trying to teach is are things that decent nurses already do. Hi, don't start a Foley with the door open, don't talk to the patient about your child support case, explain what the hell you're doing before you do it, maybe talk about the discharge papers a little while instead of just throwing them in the patient's general direction. Yeah, okay. No, the true comedy gold happens when these jackwagons present to us the things they actually think will make our patients happy. It's kind of sad, really, as they've clearly had many a meeting about synergy in healthcare and buzzwords or some other bullshit and come up with some stuff that they probably think is really fantastic and practical, only to be met by icy, dead silence or riotous laughter when they present it to those of us who actually take care of the patients.

So, with that in mind, ER BFF and I thoughtfully considered their suggestions and pondered how they might apply to the situations we encountered that weekend. Here's a couple I'd like to share with you.

"Mr. Homeless McCrackhead, you seem upset. Please allow me to listen without interruption about what the problem is. Yes, I can see you're very upset that we can't bring you a third sandwich and that the staff won't allow you to go into other patients' rooms to ask for their phone numbers. I'm so sorry this is happening to you. Let me see what I can find out for you about a bus ticket to that nudie theater downtown. Thanks for choosing Hood Hospital!"

"Hi Mrs. Abdominal Pain of Mysterious Origin with Multiple Non-Narcotic Allergies! My name is Hood Nurse, and I've been an RN for nearly 3 years and I have a lot of experience starting 24 gauge IVs and pushing Dilaudid through them. I see that Dr. Unnecessary Workup is going to be your doctor today, and let me just say that he comes highly recommended by other patients with problems similar to yours. Today we will use state of the art technology the perform several fruitless tests on you, and when they all come back negative, we will continue to take your pain seriously by giving you criminal amounts of IV Dilaudid. After a couple of hours, Dr. Unnecessay Workup will probably admit you for pain control to Dr. Spazz Hospitalist. I've heard many good sources that he has a pulse, and I've noticed he's been urinating on himself a lot less lately. Please let me know if there is anything I can do to make your stay more like a combination between a spa and a trip to Disneyland. I have the time. And for the 40th time this year, thank you for making Hood Hospital your first choice. We are delighted to take care of you again and hope we have this opportunity to collaborate in your care again soon."

"Mr. Drunken Head Laceration, I'm sorry you're not feeling well today. I realize that hitting and groping the staff might make you feel better. However, we're concerned about some possible issues to your health and safety, so we may have to use some state of the art leather restraints in your care today. We may call in the hospital police to help make your stay more enjoyable. They and their tasers have several years of experience dealing with patients a lot like you, and they are excellent at what they do. Now the doctor is going to use his excellent technique to staple your head closed. We will allow you to voice you concerns in the form of multiple obscenities screamed at the top of your lungs in an uninterrupted fashion, because we respect your point of view. Let me, as an agent of hood hospital, express how sorry I am that the doctor will not prescribe narcotics for your head laceration pain. It seems he is concerned about the possibility of mixing them with alcohol. I recognize that this is unacceptable to you, so I'd love it if you'd stay to talk to our house supervisor, who would be happy to provide you with a gift card to our on campus Starbucks. We'd be happy for you to enjoy a gingerbread latte on us for your trouble. Or, if you really do feel that you would prefer we, as you say, 'shove that up our asses', we would be happy to do that as well, if it would make you more likely to recommend us to your friends and family. As always, thanks for choosing us today!"

I don't see how communication like this couldn't fix all of our problems. I mean, obviously any problems we're having with feedback are certainly solely related to our shortcomings in communicating, as opposed to lack of staff, budget, resources, training, or reasonable expectations.

The Solution to All of Our ER Woes

So, obviously drug seekers are a big cause of frustration and wasted resources in ERs, but I think the number one thing that I deal with that tests my patience the greatest is the douchebags with no medical training that want to micromanage how you do your work. I had people like this recently who were seriously so ridiculous that they wanted to argue with everything we did down to the dosages and types of medications. Might I add, the suggestions in question- yeah, most likely would have been lethal. For a condition that is pretty black and white on how to treat. Rationale was given and was recieved with many a scoff. Efficient care was met with suspicion and hostility. I seriously have no idea what the hell these people's problem was. But, one of our doctors has suggested a solution that I think will please everyone.
He suggests that we can go ahead and just make all of our medicines and medical supplies available to everyone. You want 15 mgs of Dilaudid at once? Cool, go buy it and make it happen! You think you and your layperson family can manage your care better than all these dumbshits down at the ER? Go to the store and get all the supplies and meds you need, and see how it works at home. If it turns out to be harder than you think, you can always come see us, and maybe you'll appreciate the fact that we went to school for this for a reason and let us do our damn jobs. Hey, you can even pay by the hour to rent one our stretchers. You can pay another fee to have Pyxis access and you can pay us by IV set for every start attempt you make. At any time, you can opt to STFU and let us take over.
Look, I realize this is ridiculous, but I'm really curious how many people would call our bluff if we gave them the chance. I bet the attitude would change after about an hour. We'd just have to stock up on Dilaudid.

Overheard In The ER

Mother, angrily to her son who had promptly been discharged with zero tests or meds after checking in for "feeling weird" s/p smoking marijuana- "I TOLD YOU we should have taken the amb-a-lance! They take you more serious and they run more tests when you come in the amb-a-lance! This shit is ridiculous! Let's go home!"

Charting Fail

We have an agency nurse on day shift right now who is- let's say- a little special. We've had a couple of great agency nurses, but as a general rule, we don't exactly get the cream of the crop. This guys is right up there with the winner who finally got fired for getting in a screaming match with one of our NPs about whether it was kosher to give a gram of Rocephin mixed with 10 mls of sterile water IV push. Yeah.

Anyway, despite the fact that everyone who else who came here while we were still using paper charting a while back was appalled that we were so provincial and dated, this guy, who is allegedly a seasoned nurse, seems to be terrified of our computer charting. Since all but a handful of our portable computers broke within the first 2 weeks of getting them, it's not uncommon for us to use a piece of scratch paper while getting an ambulance started and put all the information in the computer later, key statement being put the information in the computer later.

If a patient has gotten there within an hour before shift change, this guy writes a bunch of shit in random places on a blank piece of printer paper and then hands it to you during report like, yeah, here's my assessment, bye. So, not only are you stuck with all the other crap he inevitably leaves you, but his charting too. It's whatever to me- I just collect all the information myself and put it in when I triaged the damn patient, because I don't really have time to sit down and decipher this Son of Sam looking shit that is supposed to be nursing notes. I got some time to look over some of this charting (?) the other day when I was helping a friend catch up, and it was pretty amusing. Among the vital signs and medical history, there were all these notes- I'm guessing observations or reports from EMS, one of which read "pt is tacky".

Tacky? Please elaborate, sir. Were you referring to her attitude or her manner of dress? I mean, she wasn't super cooperative, but I'm pretty sure the nursing home dressed her, so you should at least give her a pass on wearing a nightgown this early in the day. Certainly not any more People of Wal-Mart worthy than any of our other patients. Oh... did you mean "tachy?" Oh, okay. Yeah, maybe the avoiding putting stuff in the permanent medical record route is your best bet when possible.