ERNursey - An ER Nurse's Blog

Good Bye

noreply@blogger.com (ERnursey) — Sat, 28 Jun 2008 17:06:00 +0000

It's time for ERnursey to say goodbye. It has been great fun to be part of the blogosphere but what started out as a lark has started to take over my life. I'm spending too much time parked in front of the computer and not enough time getting off my duff and getting out in the world. I woke up awhile ago and realized that my children would be grown and gone in a few years and I didn't want them to remember mom spending all her time with the computer.

A heart-felt thanks to everyone who has taken the time to read what I have to say and comment. Good bye to all the other bloggers who got me started on the blogging road.

GOOD BYE EVERYONE, GOOD BYE!

noreply@blogger.com (ERnursey) — Thu, 26 Jun 2008 02:55:00 +0000

There are 1026 wildfires burning in California.

Yesterday there were around 800.

That means there are 200 new fires since yesterday.

That is pretty scary.

The air quality has been classified as 'very unhealthy' throughout most of the northern part of the state. Hospitals are beginning to see a surge in patients with respiratory complaints.

If things continue the way they are going we will soon see how woefully unprepared we are to face a disaster.

noreply@blogger.com (ERnursey) — Wed, 25 Jun 2008 02:38:00 +0000

This is a NASA satellite picture of California with pictures of all the fires - represented in red. Notice the smoke. I drove home today in an eerie yellow fog, ash falling gently onto my car. The interstate was strangely empty for a Tuesday at rush hour. Our ER is beginning to be over run by patients with respiratory issues - fortunately most people have air conditioning so they stay shut up in their homes with the A/C running. Many of the fires are burning in unreachable areas so they will just be let burn while the fire fighters concentrate on areas where dwellings are threatened.

And it is only the beginning of the fire season. At least 4 more months before will can expect to get rain.

More dry lightning is expected for the end of the week.

And we all thought earthquakes would destroy California.

noreply@blogger.com (ERnursey) — Tue, 24 Jun 2008 03:47:00 +0000

IS THIS THE START OF THE END OF THE WORLD?

Patient Privacy

noreply@blogger.com (ERnursey) — Tue, 24 Jun 2008 03:24:00 +0000

Let me tell you about one of my pet peeves. And it isn't drug seekers, migraineurs or fibromyalgeurs, it is patient privacy or the lack there-of.

I'm in a room with a patient with a vag bleed. The door is closed. The GYN cart is parked right outside. What would you imagine might be going on in there? Probably a pelvic right? So who in world would think it is OK to just barge right in through the closed door without knocking first? You would be surprised. That is why I always pull the curtain around the bed also, even though the doc's complain.

We're in the room with a code. The patient is naked and fully exposed as it is hard to do CPR through a blanket. Every person that enters the room or leaves pulls the curtain back and leaves it open. Lab, nurses, registration, residents, techs, Xray. There are a lot of them. Every time I reach out and pull it closed again. Each time with a little more irritation. If that was your mother laying there would you want her displayed naked for every looky-loo in the ER to view?

I have an elderly lady with a hemorrhagic stroke, she is pretty obtunded but I always assume the patient hears and might know what is going on. A resident enters the room, flips back the sheet and gown leaving her fully exposed and listens to her heart. He never speaks to her or tells her who he is and why he is there and then leaves the room leaving her gown up and breasts exposed! I flip out completely. Is that how you want to be treated if it was you laying in that bed?

For God's sake people, take a minute and do the right thing, pull the curtain, speak to the unconscious patient, keep people covered. Some day it might be you or your mother.

Bleah

noreply@blogger.com (ERnursey) — Sun, 22 Jun 2008 00:27:00 +0000

ERnursey has spent the last two days suffering from gastroenteritis. Let's just say I am a very bad tempered patient.

Zofran hasn't worked so I am trying to decide if I feel bad enough to try the Phenergan suppositories -so far not yet.

What I have not done is go to the ER. A little nausea, vomiting and diarrhea is not an emergency. And today I am managing little bits of popsicle, ginger ale and chicken broth so maybe the worst is over.

Meanwhile back to the couch.

picture credit

Nosebleed

noreply@blogger.com (ERnursey) — Fri, 20 Jun 2008 05:02:00 +0000

I had a patient that came in that had a trans-sphenoidal resection of a pituitary tumor. That means they punch through the bone above your top teethe to reach the pituitary gland that sits under your brain. Ouch!

She had recovered uneventfully and was at home recuperating when she developed a massive nose bleed.

I have seen some pretty bad nose bleeds but this was truly horrifying, she sat hunched over a basin with a steady stream on blood from both nares, spitting and coughing out blood and clots.

In addition to her obvious problem there was a big concern over her airway but if we laid her back to intubate she would aspirate blood. And a nasal intubation was obviously out of the question.

we have little devices that look like a Foley catheter that has balloons that you fill with water. It was very difficult to insert them properly with all the blood, the doc - normally very laid back - was tense. He finally got them inserted and inflated but she continued to bleed around them. Another nurse and I started 2 large bore IV's and drew blood for blood count, clotting factors and type and cross-match. Approximately 500cc of blood was in the basin.

Blood continued to flow around the nasal balloons. ENT doc arrived and removed them and packed each side of her nose with about 50 yards of Vaseline gauze packing. It looked horribly uncomfortable. The patients pulse had risen to the 140's despite fluid boluses so we hung uncross-matched blood on the rapid infuser - between the suction and the basin she had lost almost a liter of blood.

The packing didn't work either. Now the ENT attending had arrived. He removed the packing and inserted a Foley catheter into each nare. The balloons were inflated and the Foley's pulled tight and clamped outside the nose with hemostat to provide tamponade in the posterior pharynx then each nare was packed with more Vaseline gauze than you would ever imagine could fit inside one persons head. But, it worked! The bleeding finally stopped and the patient was transferred to the ICU for further monitoring and blood transfusions.

When we measured she had lost 2100 cc of blood!

image credit

Another Life Saved

noreply@blogger.com (ERnursey) — Wed, 18 Jun 2008 03:53:00 +0000

My third patient of the day came in because he hit his toe getting into the car.

Translation: Stubbed toe

Our Good Deed for the Day

noreply@blogger.com (ERnursey) — Mon, 16 Jun 2008 02:57:00 +0000

The ER staff performed our good deed for the day.

We had a homeless guy who was found by park rangers nearly unconscious in his 'camp.' He had a raging pneumonia as well as a nasty cellulitis and skin breakdown on his buttocks from being incontinent for several days. He responded well to fluids and was feeling better. He told us he had been 'on the road' for years and had been passing through our are when he got sick. He had set up camp in an out of the way area in a state park to avoid being rousted by the park rangers when he got sick. His illness progressed very fast and he became so weak he could not stand or walk. Unable to get to help, he lay alone in his camp figuring he was going to die there.

He was so matter of fact when he told us this, it was rather heartbreaking. What brings a person to this?

He was feeling better, vital signs had been surprisingly stable and he was admitted but holding in the ER. We tucked him in and asked him if there was anything else we could do. "I sure would like a bath." I offered to give him a bed bath but he really wanted to sit in a tub of nice hot water. "my bones ache and it's been a long, long time since I sat in a tub." He said, wistfully.

Well, what the heck. It was surprisingly slow in the ER, we had plenty of staff and - more importantly- no one was around in PT!

Two of us loaded him up in a wheelchair and took him over to PT where we filled up one of their big whirlpools and helped him in. We helped him wash and shave and then just let him soak for awhile.

He needed IV fluids, he needed antibiotics but the thing that made the biggest difference to him was a nice hot bath. It was nice to have the time to do it.

Wouldn't it be great to always have the time to give the kind of nursing care you want to give instead of rushing around pushing pills into people and filling out forms?

noreply@blogger.com (ERnursey) — Sat, 14 Jun 2008 02:49:00 +0000

This months candidate for Mom of the Year.

Good news! It's not just our government that are idiots.

How to guarantee you'll go to hell.

An Ambulance Transports.....a Dead Body?

noreply@blogger.com (ERnursey) — Fri, 13 Jun 2008 21:33:00 +0000

Now I've seen everything.

Recently I took an ambulance call that went something like this:

"This is unit X and we are coming from the local nursing home with a 92 year-old female that is pulseless and apneic (code word for dead) CPR is NOT in progress as the patient has a DNR. Our ETA is 2 minutes and we will give you the rest of the report in house."

WTF?

Well it turns out the patient is not only a DNR, she is a hospice patient who is on comfort care. She should have never been transported to the hospital but the ambulance was called. When they arrived the patient was clearly almost dead and they tried to refuse to take her but the nursing home staff was insistent so to avoid an ordeal they transported the patient, who died just as they pulled out of the facility.

The medics did the best they could but now here we are with a corpse that we will have to make arrangements for. Someone who should have been allowed to pass in peace, in their own bed. What kind of idiot cannot understand 'comfort care only' orders?

Shortly after this, the patients son - an attorney - arrived and he was livid that his mother had been sent to the ER. I don't think I'd like to be in the nursing home administrator's shoes right now, or the nurse that made the decision to force the ambulance crew to transport the patient.

California is Burning

noreply@blogger.com (ERnursey) — Fri, 13 Jun 2008 19:49:00 +0000

California is burning. According to Cal Fire, over 40,000 acres are currently burning with no estimate of full containment.

Two years of drought coupled with several months of intermittent north winds, which are very dry, have made California a tinderbox. The winds have fueled two of the current largest fires spreading them over 20,000 acres in just a couple of days.

It seems ridiculous that just east of us states are flooding while our state goes up in smoke.

Pray for all the firefighters.

Pray for all the people who live in areas of high fire danger - that is pretty much everywhere that is not in the middle of town.

Pray that all the morons that persist in throwing lit cigarettes out of the car window or mowing their tinder dry grass will get a clue.

Pray that we won't get any lightning storms in the mountains - lightning strikes cause fires that burn hundreds of thousands of acres every year.

Pray for rain- although it hasn't rained since March and won't again until October at the earliest.

Change of Shift

noreply@blogger.com (ERnursey) — Fri, 13 Jun 2008 00:01:00 +0000

The venerable Mother Jones hosts Change of Shift this week and it's a tribute to old school nurses. Check out the pictures she has found - I sure am glad I didn't have to wear a couple of those nursing caps!

Grand Rounds

noreply@blogger.com (ERnursey) — Wed, 11 Jun 2008 03:29:00 +0000

Grand Rounds is hosted by the famous Dr. Crippen this week. I really enjoy this blog, whenever I am feeling discouraged and disgusted by the state of American Healthcare I can read some of his entries and realize that we all have it bad.

When the precordial thump works

noreply@blogger.com (ERnursey) — Wed, 11 Jun 2008 02:49:00 +0000

I was chatting with my acute MI patient. She was halfway through her dose of thrombolytics and her presenting symptoms, shortness of breath, profuse sweating and vomiting, had completely resolved along with her ST elevation. Things were looking good.

Her husband of 61 years sat at her side. He referred to her as his 'lovely bride.' They had held hand for most of her visit. He was calm and supportive but underneath you could tell he was rattled by the fact that his wife was having a heart attack.

She was telling me a story about one of her grandchildren when she stopped mid-sentence and said "oh" followed by seizure like activity. I was stunned into immobility for what seemed like an eon but really was only a second. The monitor showed v-fib, a lethal heart rhythm where the heart quivers like jello without pumping any blood. Basically the patient in v-fib is dead and will stay there unless something is immediately done.

Before I could fully thing the situation through my arm shot out and socked her mid-chest (also known as a precordial thump.) I didn't even know I had planned it. In a simultaneous motion I reached out and hit the code button.

By the time I opened the defibrillator pads some sinus beats were appearing on the monitor . The doctor and the rest of the nurses arrived at the same time to see my patient miraculously wake up. She got transferred to another hospital where she got stented and I still get a card from them every year on the date of her cardiac arrest - the card simply says "I'm still ticking."

We are taught the precordial thump in nursing school, I've only seen it work this one time. I sure did have a hard time getting her husband to understand why I hit his wife.

An All Too Common Theme

noreply@blogger.com (ERnursey) — Tue, 10 Jun 2008 04:18:00 +0000

"Management wants us to do more with less and it can not be done."

Hospital administration can choose to spend the money to provide excellent patient care and customer service or they can cut the budget, slash patient care positions while continuing to give themselves big raises and bonuses. The can make sure that there are enough nurses, aides, ward clerks, Xray tech's, lab tech's, physical therapists etc. etc or they can cut those positions to the bone while making sure that the administrative assistants have assistants. They can provide excellent care or they can be slaves to JCAHO's bullshit mandates that do nothing to improve patient safety but do manage to generate ever increasing piles of paperwork.

Guess which path most hospitals choose to take?

Alcoholism

noreply@blogger.com (ERnursey) — Mon, 09 Jun 2008 02:22:00 +0000

When someone drinks to the point of shitting themselves........why do they keep doing it?

We routinely see drunks that have puked on, pissed on and shit on themselves and yet they turn right around and do it again.

I don't understand.

They drink so much that when their BAC gets down around 0.2 (two and a half times the legal limit) they start to have seizures.

They die alone in an alley in the cold, they die in the ER puking unstoppable torrents of blood, they die on the floor - skin yellow and bellies swollen with the fluid from their failing livers.

I don't understand.

It's not just the homeless. We've seen society matrons and CEO's in the same condition.

Alcohol is one of the deadliest poisons, it is easily available and socially acceptable.

I don't understand.

Polypharmacy

noreply@blogger.com (ERnursey) — Sun, 08 Jun 2008 15:57:00 +0000

since we went to the EMR I have come to abhor the 'big bag o' med's.' While I have never understood why some people have so many medications, and even writing it down was very time consuming, prior to the EMR we could just copy 'the list.' Now, with the supposedly time-saving and efficiency improving EMR (not!) has become a tedious, laborious, time-consuming task. And to make it even better, our computer medication reconciliation is not acceptable for an admitted patient, they require the special form so once a patient is admitted we must re-write the WHOLE DAMN THING!!!!!!

ARRRRGGGGHHHHHH!!!!!

I only have one request, could someone with a TEENY, TINY bit of common sense make the rules?

Unwelcome guest

noreply@blogger.com (ERnursey) — Sat, 07 Jun 2008 19:24:00 +0000

Being a beautiful Saturday I decided to take the kids and Kayaks up to a nearby lake. When I pulled the second kayak down off the rack I found a big, fat, juicy black widow spider on my arm! Fortunately I saw it right away and shook it off and stomped the hell out of it, but I'll bet my shrieks could be heard for miles.

Black widow spider bites can be very painful, I would just as soon avoid all that. Not to mention that I find spiders to be the most gross and creepy things ever - I'd take ten rattlers over on big spider any day.

I'll be calling the bug man first thing on Monday and in the meantime I'll be giving the garage a wide berth. *shiver*

Things that made me happy today, and things that didn't

noreply@blogger.com (ERnursey) — Sat, 07 Jun 2008 03:02:00 +0000

As I was driving to work today I passed a field of horse and their gangly-legged babies. The babies were all laying over flat on their sides, twitching their tales. It was apparently nap time in the nursery.

My third patient of the day called me a "fucking cunt" when I refuse to give him any narcotics until he produced a ride.

I parked by a Jasmine vine that smelled so heavenly I just wanted to sit there forever and breath that wonderful scent.

While I was helping another nurse clean an incontinent, demented 92 year-old nursing home patient she somehow managed to kick me in the chest. Who knew a wizened up little old lady had that much flexibility?

The wind was blowing and it cleared all the haze away so the mountain tops were so clearly visible they looked not more than a mile away. It was in the eighties and yet the peaks are still snowy.

I had to spend half of my shift in triage

I saw an eagle.

A four year-old puked down my leg in triage. I must be getting old, the reflexes ain't as good as they used to be.

The eagle had a big fish in it's talons.

I took me an hour after my shift was over to get all my charting and charges done.

One of the ER doc's brought in a bag of dove dark chocolate squares. Fabulous.

My tire was flat when I left work.

I have Triple-A. The tow-truck arrived 5 minutes after I called and I was on the road 15 minutes after that.

I guess the day ended up about even - I'm going to bed!

Contrasting Patients

noreply@blogger.com (ERnursey) — Wed, 04 Jun 2008 04:29:00 +0000

First nursing home patient of the day was sent in for vomiting twice. She had a UTI, no fever so we gave her a bag of IV fluids, and antibiotic and sent her back - the staff could have just as easily called her MD and taken care of that from the facility.

The second was sent in for not acting right. He was nearly comatose, skeletal and so profoundly dehydrated that his serum sodium was sky high - 179! He didn't get in that condition in the space of a few hours - it spoke of days of no fluid or food intake and gradually deterioration not recognized by the people who he depended on for care.

Patient one didn't need to come to the ER and patient two should have been there a week ago.

Grand Rounds

noreply@blogger.com (ERnursey) — Wed, 04 Jun 2008 03:02:00 +0000

This weeks edition of Grand Rounds is brought to you buy The Happy Hospitalist so 'turn off your dang cell phone' and head on over!

Once again the government proves that they are idiots

noreply@blogger.com (ERnursey) — Tue, 03 Jun 2008 03:33:00 +0000

Home dialysis. It is cheaper, safe, more effective and results in less hospitalizations.

In the article one of the patients had even returned to work, another was off all his blood pressure medications.

But it has to be done 6 times a week instead of the three treatments done in the dialysis clinic so Medicare won't pay for it.

They won't pay for it even though it is cheaper than the clinic treatments as well as savin money on hospitalizations. The government is made up of pencil pushing, bean counting MORONS!!!!!

h/t Kim

Why I got pulled into the office today

noreply@blogger.com (ERnursey) — Tue, 03 Jun 2008 02:51:00 +0000

The mother of the ten-year old OD patient summoned me as I was walking by. I entered the room where the chubby sullen patient sat with equally chubby, toothless and tattooed parents on either side of the bed. (And by chubby I might mean grossly obese.)

"he's trying to take his needle out." She told me, meaning his IV. I was taken aback for a minute, this was a TEN year old with a PARENT on either side of the bed and sure enough he had been picking at the tegaderm.

I told the mom "Well don't let him." Duh. to which she replied "oh I can't make him, he's ADD."

WTF?

I looked the kid straight in the eye and told him if he pulled out the needle I most assuredly would be back to put another one in AND tie him to the bed to prevent him from doing it again since he couldn't seem to control himself.

I also mentioned to the mother that drugging her child might not be necessary if she would engage in a little parenting.

The kid behaved like an angel for the rest of his stay with us.

The second comment earned me a write up from my director.

It was worth every word on the write up.

And for those of you who are confused on this issue, and apparently you are legion - if you would make your children behave they wouldn't need to be drugged into a near zombie-like state for some made up psych diagnosis.

Oh, and as an aside, if you are not working and the state is buying your groceries - you should not be morbidly obese. Apparently we are being over-generous with the food stamps.

Old Way, New Way

noreply@blogger.com (ERnursey) — Sun, 01 Jun 2008 01:38:00 +0000

To any state contemplating nurse to patient ratios, please learn from California's mistakes.

Old way: Med-surg floor with 32 patients would be staffed with a charge nurse, a unit clerk, two or three aides and 4 RN's. Each RN would have 8 patients but would have a clerk to answer phones and take off orders, aides available to answer lights, help with baths, transferring patients and passing trays. The charge nurse was also available to help with lifting and moving along with helping the nurses with med's and stuff.

New Way: Same floor. 4 RN's each with 5 patients, the other twelve-bed's sit empty because there is no staff. There are no ward clerk, no aides. There is a charge nurse that covers two units . No one to answer the phones, no one to help you with baths, lifting and transferring, passing trays or implementing orders. The charge nurse is supposed to be the break nurse. She is responsible for breaking 9 people whose break time amounts to 11.25 hours - not including her own.

If you are contemplating nurse to patient ratios make sure you include ancillary help into your ratios SO YOU DON'T GET SCREWED LIKE WE DID!