Back to your regularly scheduled programing.

Well, I will say, it's hard to get too much into an existential crisis when you have patients like the one I had on Thursday.
Fifty-something schizophrenic guy who had passed out and fallen on his arm comes in, already fighting with EMS. Probably yelled at me about 50 times to bring him something to eat, each time I told him I couldn't until the doctor came to see him. He then preceded to ask everyone else who walked by for food, and then screamed at every male in scrubs "Doctor! Doctor! HEY! Come in here!". Um. Yeah. Nope, those are medics, but nice try. Any time I walked by his room, he yelled at me for various things, including a back rub, help holding his penis in a urinal*, help calling his sister, who he referred to as his "robot" (seriously, WTF?), and, you guessed it, something to eat.
Naturally this was the type of the day where it took the doctors 4 hours to see patients (not exaggerating), so the highlight of my day really came when this man urinated all over the bed and himself and then refused to let me clean him up or remove his pee soaked pants until I brought him a food tray. Wow. It took about 30 minutes of wrestling and bargaining to get him to take the pee pants off- luckily I got help from one of our housekeeping guys, who in no way had to do that, but he's just an awesome dude. In the process, we both got cussed out, kicked, and scratched while the patient informed us that we were going to jail. It was certainly a pain, but now whenever I start feeling bad about sucking at my job, I can at least take comfort in the fact that I don't willingly soak myself with urine to punish others.**
*During the struggle later on, I found out that his hand strength was just fine. Gross.
**Chances are, I'm going to hell for finding this funny.

I'm not gonna lie.

Sigh. This is where I show my humanity, I guess. Lame. I am getting my ass handed to me at this place. Like, in a big way. As in, I'm not sure I can do this. It's all really dependent on several factors. We're supposed to have 4 patients, sometimes it's more- I haven't had more than that yet, though. This job is a breeze depending 0n the doctor- some of them are very no nonsense and don't make you draw a bunch of unnecessary labs or do a bunch of stupid crap, and other are less that way. Sometimes you have nurse externs and paramedics or students to help- other days you have no one. Sometimes the patients are horribly sick and require lots of meds and care, other times, less so. Sometimes all of those factors come together into a perfect storm of you being totally fucked. Yesterday was one of those days for me. I was on top of stuff- I got a lot of my lines in before the doctors saw the patients, I was writing all this stuff down on my little task lists that I make, I was delegating when I could, but as my day went on, I got more and more behind. My first patient I got from the waiting room ended up not only having a small bowel obstruction, but also ended up being in DKA (this is seriously, like, my sixth or seventh patient with that. They FIND me)- so I ended up having to spend a ton of time with her- she had to have labs, urine, blood cultures later on, an NG tube, multiple doses of pain medicine, an insulin drip, antibiotics, fluids- i had about 4 lines going in at once- she was super hard to stick and i had to start a second IV for all the crap we had to dump in her- plus hourly blood sugars, and very nice but somewhat demanding family- that alone was a lot. Plus the doctor that day was discharging people before their treatments were even done, which sucks, because you have no grace period whatsoever- you have to work to get the discharge crap done and immediately end up working up a new person, which takes lots of time. So the whole morning it was in and out treatments and discharges with an ICU patient, and I was just scrambling to try and keep up with all the paperwork- as soon as one of my rooms opened up for 10 minutes they filled it with an ambulance patient with altered mental status and a blood sugar of 686 who did nothing but demand we bring him a sandwich (i'm not exaggerating when I say he asked me about 25 times- um, no, sorry, you can barely stay awake and have that blood sugar, you're not eating right now).
As soon as I caught up on that, my ICU lady got a bed, so I had to transport her myself because she needed constant monitoring. I finally ate lunch after that since I was about to pass out, and when I got back they had filled my rooms with people, one of whom spoke only spanish and another who was in a hypertensive crisis- naturally right then, my cranky hyperglycemic had gotten a bed, another patient needed to be discharged, and as soon as she left they put a woman in excruicating pelvic pain in the room without telling me. By that time our charge nurse had sent our only remaining extern to the floor to sit for a suicidal patient, my three patients needed meds and IVs and EKGs and the doctor was ordering more stuff, my hyperglycemic was now yelling and trying to get out of the bed with his monitoring equipment and demanding pain medicine for his toothache. I felt completely overwhelmed. It's times like this I screw up and start doing things wrong- I accidentally left a vial of labetalol in a patient's room and I gave morphine to my pelvic pain lady who was crying in pain before taking vitals because she'd gotten recent vitals in triage, I kept forgetting to put in orders- if I hadn't had my preceptor with me, I have no idea how I would have ever caught up.
I know there's going to be days like this that I don't have help. And I have no idea how I can practice safely. It seems I'm either cutting corners and playing with fire or delaying things that are really important. Everyone else seems to be able to handle it, and I have no idea how or why I can't seem to catch on. I'm naturally super disorganized and that all comes out when I get swamped and start panicking. It just sucks, because I work as hard or even harder than everyone else and I still feel like I'm so behind. The other interns in my group seem to have their shit together, I don't know why I can't seem to handle it. It just makes me wonder if I'm trying to break into this too early. I did really, really well in school, but I never worked as a tech or an extern or anything like that. I just wonder if I'm not ready, or whether my lack of self confidence is just screwing me. Ugh. More to come. Time will tell in the next couple of weeks, I suppose. This may end up as new nurse on a telemetry floor, however. I'm trying pretty hard not to give up.

But seriously. Eff you.

Wow. I just had my first serious hell no moment with one of my co-workers this week. It's a pretty big let down, too, because one of the reasons I got into ER nursing in the first place was the idea that a setting like this was so full of patient drama that nurses wouldn't need to create their own. Apparently not.
I already had issues with this person- he decided early on in the internship that it would be a good idea to give me and a bunch of the other interns shit for stuff we had no control over- but I had pretty much chalked it up to some stupid tough love crap and gotten over it. I hadn't had much exposure to him lately, but he was actually very friendly and helpful yesterday, so I was actually starting to think I may have been wrong. Again, apparently not.
Yesterday morning, I was taking care of a lady who was having severe back and abdominal pain. The doctor ordered 2 mg of Dilaudid, which I gave like I always do- slowly and diluted in 10 ml of saline. I was by myself in the room with the patient and her husband, and after I gave the Dilaudid she immediately got really anxious, her heart rate went up to 150 and she started breathing really fast. I opened the door to see if I could get help and ran back to the patient to calm her down and reassure her. I'm standing there and Mr. asshole nurse comes in, looks at the monitor, and asks me if I gave the Dilaudid fast. I told him no. He then asked if I diluted it, and I said yes. He asked me again if I gave it fast- no- and then he told me that sometimes people get anxious when they get Dilaudid or Morphine quickly, and walked out of the room. I honestly didn't even think twice about the fact that he did this in front of the patient and her husband- whatever- and I later found out it definitely wasn't me, since the same thing happened immediately after I discharged her- 4 hours after she had gotten anything. It seemed like she was prone to anxiety, was in pain, and I knew she had never gotten that drug before. Case closed.
I was going about my day taking care of my other patients when me preceptor sat down next to me and said, "So, Mr. asshole nurse told me you pushed Dilaudid fast on a patient?"
Um, excuse me? No. I told her no- he wasn't in the room- he asked me three times- and I told him I didn't. She informed me that he not only said that I did this, but that I was an unsafe nurse and she needed to watch me. Helll no.
This pretty much just led to a serious heart-to-heart with my preceptor, about the facts of life working here- the first of which is, that nurse is, in fact, a backstabbing ass. The second of which, no one is your friend and you shouldn't really trust most people. Bummer. Most importantly, though, I learned my preceptor rules and that petty drama is not exclusive to women.

oh hai, stupid

It would make sense that the day I see this


see more Lolcats and funny pictures

up our doctor's station, that I would also get the patient which I am about to describe, which, by the way, managed to totally screw my day by being a total dumbass.
So, this week, the ER was bananas. We have had holds a million because all our ICU and telemetry beds have been full. Yesterday a guy waited 30 hours for an ICU bed. On this particular day, we had tons of people get sent straight back from the waiting room without being triaged- this usually happens when people are either really critical, like chest pain, strokes, or asthma attacks, or sometimes if people are just puking uncontrollably and they don't want to clean that shit up in the waiting room, or other times if the triage nurses are being lazy. That day was the latter, for the most part. So I'm working on an ambulance with a shortness of breath/possible aspiration pneumonia patient, who I'm 95% sure was drunk, trying to get a breathing treatment from respiratory and trying to collect medical information from this inebriated man, when the guest relations guy comes and and tells me they've taken a patient straight back next door, a 19 year old female with nausea and vomiting for three days. So, my thoughts are whatevs- probably some dummy who was puking in the waiting room and doesn't know how to use a clinic- I take my time with my ambulance patient , put his chart up for the doctor and stroll in to this girl's room pretty leisurely.
She's sitting there in bed, talking to her brother and laughing, and I ask her, like I do everyone- "So, what's going on today?"
She looks up at me and says "Oh. Um.... I think I'm in that.. uh, Diabetic Ketoacidosis again?"
Um. WHAT? For the non medical folks, DKA is when people's blood sugars get super high and through a series of events I don't care to explain, it makes their blood extremely acidic and they get super dehyrated and can die without treatment pretty easily. I honestly didn't believe her at first, since most people in DKA are lethargic or breathing rapidly- until I looked at her triage paperwork and saw that our meter only read her blood sugar as "HIGH" which means it's over 650- it should be under 100.
At that point I freaked out and started looking for a line- naturally she had no veins and was terrified of needles, and all the IV badasses were in on a code so I was pretty much screwed for a while. I started putting the girl on the monitor and was asking her questions like when did she take her insulin last, how had her diet been, etc. Yeah. Um... Insulin.. let's see.. about 5 days ago? Diet... yeah... that's something she's "working on". It's pretty much cool except for the sodas. The whole time she and her brother are giggling about the kind of sweets she has eaten to get herself in this state. I finally get a medic in the room, who still can't find a vein, and we finally have to get a doctor to start an IV in her neck. Naturally, she's pretty upset about that- the whole time her brother is practically leaning over the doctor's shoulder because he "loves stuff like this". As all this is happening, I look down at her allergy band and see that it says "insulin". Dude. What. The. Fuck. Insulin? Seriously?
Yeah. So, apparently, she's allergic to it, but she takes it anyway, but it makes her "swell up, and feel worse that when she doesn't take it"? I specifically ask if it has ever caused any respiratory issues. No. So, the doctor orders fluids and regular insulin, another nurse goes to get it and asks about allergies first, to which she now replies she is allergic to insulin, but only regular insulin, and when she takes it she can't breathe. So we have to get a glargine drip from pharmacy, which naturally takes forever- in the meantime, we get her blood sugar back from lab- yeah. 930. I nearly peed myself.
When I go back in the room to get another tube to the lab for blood sugar, I tell her mom that she's gonna probably go to the ICU, to which the patient replies, "yeah, that's what they did last time." Really? Are you retarded? Apparently the first ICU trip wasn't enough to scare her straight. Her mom, rightfully so, was totally pissed. She's begging me as I draw blood out of her daughter's neck, to explain to her how serious this is, that she could lose her kidneys and vision. All I could manage to say was yeah, and you can die from THIS. NOW. All she could do was blink at me.
The last trip to the room, there were literally about six of her friends standing around asking me how old I was, could I get her some water, when was she going to get a room- all the time while I'm trying to collect blood, get vitals, and give meds. The whole time, her brother was standing in the doorway taking pictures of her for Myspace. It was all I could do not to smack them both. I just wanted to drag her out of the room and take her on a tour of all the diabetic patients we had in the ER that day- the missing toes, swollen legs, dialysis patients- HIPAA kept me from teaching a valuable lesson, damn it.

Most Hardass Patient EVER

So, we got this guy in a trauma room today who had come from his job as an auto mechanic because he had gotten his thumb stuck in some machine and pretty much taken off the entire part above the fingernail. It was enough that he had actually brought the part of the thumb with him so the doctor could sew it back on. So everyone runs in there freaking out and irrigating the wound and trying to medicate him and such- we ask him to rate his pain-oh, yeah- 1/10. Like, I would put my achy throat at 1/10 now, and this guy is bleeding and part of his bone may actually be sticking out. All he really said was, "Oh, I'm fine right now. Yeah, I hope they can put it back on. This is my texting thumb." All the while, just kind of grinning at the EMT students in the room. Anyone else I would have run a tox screen on immediately, but he was totally calm and coherent- I think he was just the ultimate badass.

OMGz.

A big apology to the 4-5 people that read this- I suck at updating lately. This week has kicked my ass. But! I'm learning lots! Lots and lots.
Highlights of the last few weeks:

A patient who came in for a shoulder he had pulled out of socket who I can almost guarantee was remarkably ghetto, even for where I work. He had all these awful tattoos of guns everywhere that no joke, looked like they were drawn by a 10 year old. They sent him straight back without triaging him, so I had to collect his medical history. Wowzer. Our conversation, as follows:
Me: Do you smoke?
Hilariously ghetto patient:Yuh.
Me: Okay! How many packs a day?
Patient: Uh, I don't smoke cigarettes.
Me (clueless retard): Wait, you don't smoke?
Patient: Naw, I smoke weed. A lot.
Me (worst poker face ever): Oh, Okay. That's cool.
I HOPE someone audits that chart, because it will totally make their day. Under Past medical history, the word "smoker" is circled, and written next to it is "Marjuana- "a lot"."
While realizing the hilarity of this, it was also a giant pain in my ass, because I later found out this guy had apparently burned one on the way to the hospital, which sucks, because I had to put him under sedation to get his shoulder back in place, and the rule is that you can stop taking vital signs when the patient returns to their original level of conciousness. Well, I really had no clue what the hell that was, so needless to say, I was in his room for-e-ver. I finally decided it was probably cool to stop taking vitals when he woke up and started trying to talk me into letting him out of the hospital 25 minutes after his shoulder reduction (in his words, his boo was waiting outside), regardless of how many times I told him only the doctor could do that. The best part of this whole situation was that before he left with his super pissed off girlfriend, he managed to kick an full urinal over onto the floor. Awesome.

Hrm. Other winners- jail patient who "tried to kill himself" by hitting his forehead really hard against a bedrail. Needless to say, it pretty much only resulted in a nasty lac to the forehead. FAIL. Although, I think he may have just been bored and looking for a free day, in which case, the joke was on us.

Patient who, when I asked her to pee in a cup for me, peed in the cup, dumped the pee out, rinsed the cup out, and handed me the cup. I'm pretty sure she wasn't all there, but it was still damn funny, especially since I didn't end up needing it.

Patient with abdominal pain in with her three year old who continously asked her- "Mama, you better yet? You need to poop mama? Go poop!" Cutest. kid. ever. Mom was super sweet, too, and her pain turned out to be gallstones- i.e., totally treatable. My favorite types of patients.

The most notable, this week anyway, was a lady who came in with altered mental status and progressively got more crazy and paranoid as the visit progressed. At some point she decided we were hiding her family somewhere in the hospital, and so she went out looking for them in other patients rooms. When the police tried to bring her back to her room, she kicked one of the cops in his junk and had to be cuffed to a wheelchair. I would feel bad about laughing, but the lady ended up being fine and coming to, and the cop who got kicked seemed more amused than anyone. He hung out at the nurses station and told us about it, saying "That old lady kicked me right in the groin! I ain't never been beat up by a senior citizen like that before, damn!" Indeed, sir, indeed.

I learned a very important lesson this week

Don't take the rooms right next to the nurses' station if you can help it. It's where they put all the crazy people.
I'm only taking two rooms at the moment (we eventually progress up to four), but somehow I ended up with not only a patient in methamphetamine withdrawals who I later found out had attacked some of the staff at another hospital, but a girl who post-ictally ( and possibly all the time) was so agressive that the last time she was in our ER, they had to put her under concious sedation to keep her from going bezerk, Wolverine-style, all over the unit. Awesome.
The meth detox guy was actually pretty nice at first- he was just super spaced out to a kind of scary degree. He had trouble completing sentences and was shaking like crazy, and eventually his very sweet, but rough looking girlfriend came and took care of him.
I wish I could say the same for my seizure patient. Apparently, she was a pretty regular customer because she isn't too complaint with her meds. She came in moaning and flailing and vomiting everywhere, and by everywhere, I mean all over the bed and herself. She kept getting out of bed and walking around complete with trail of vomit behind her- at one point sitting down in the nurses' station.
As all this is going on, my other patient starts coming out of his stupor and talking more clearly and angrily about how he wants to go outside and smoke a cigarette. I got an order for Ativan to help him with the tremors and agitation and then I went next door to help with the IV start on my seizure patient, who was already being held down by 5 people and had been stuck three times already, unsucessfully. Even our totally badass medic who has been doing this most of his life couldn't get an IV on her- the other nurses in the room finally started looking for a site in her foot. The whole time she was jerking around and screaming "Baby! Daddy! Oh fuck! That shit hurts! Baby that hurts! Aw shit! Aw fuck!" The first time they stuck her foot she yells "Hell no! Fuck that, give me back my arms!", then she gets one arm loose enough to fly forward and headbutt me in the shoulder while I'm holding her leg. Finally, badass medic tries on her arm one more and gets blood return, and by the grace of God, we get her Ativan before she pulls out the IV.
Just as she starts to take a nice nap, the guy next door is getting more pissed that he can't go outside with his IV and smoke- I calmly explain I wish I could let him but I can't, and that I have his chart up for the doctor to try and discharge him. He does that gabby hand motion at me and his girlfriend yells at him and asks me for more Ativan. I decide this is a good time to go to lunch.
When I come back 20 minutes later, he is livid and yelling obscenties and the police are there, because apparently he tried being rude to the doctor and didn't quite get the same response as he did from me. According to him, when he asked the doctor to go smoke, most assuredly with lots of colorful language, the doctor told him he didn't owe him anything and walked out of the room to discharge him. So he's sitting there screaming "Fuck that! Don't talk to me like I'm dumb! I'm only gonna have white doctors from now on!" (His doctor was white- he was just eastern European). Meanwhile, he has a 9th grade education and no insurance. I don't think you're gonna get that, man. The police officer calmed him down enough to let me take his vital signs and his girlfriend drove him back to the treatment center he came from. As he left, his started bitching to all the patients and family members in the hall who would listen to him, the whole time his girlfriend yelling at him to shut up.
After all this, I have to start a Fosphenytoin drip on my seizure patient because her level was 1.1(!) but- she was taking her medicine! She was just tired! Okay! She finally sort of came to at this point and I let her know that after the drip was done we would finally send her home. She gets on the phone trying to arrange her ride, screaming at the person on the other end for a few hours. She still hadn't gotten a ride by the time shift changed, but I did get her discharge instructions, which simply said- "You have to take your seizure medicine for it to work." Seriously. Nice.