Nursicle

Nurse on the Witness Stand

2016-09-10T18:53:00.001-07:00

Some nurse friends recently asked me what ever happened to my Nursicle Blog. I'm shocked to see that it has been more than three years since I have made an entry.

I recently made a reply to a friend's blog after she posted about sexual assault. She expressed thoughts that the unpunished harassment of adolescent girls by pubescent boys creates a climate where inappropriate behavior flourishes. Not all rowdy teenagers become rapists but we live in a world where teasing, "accidental" groping, body shaming and bullying happen way too often. I will post that essay in this blog also but I have one experience with a rape victim that really stood out in my mind.

Early in my career on a midnight shift, I had a patient who's boyfriend threw her out of his car and drove away dragging her along the road. She was understandably shaken up and arrived bruised, bleeding and distraught. I asked her to change into a hospital gown so we could check her whole body for any injuries. She refused to remove her slacks. I wondered if her reason for not wanting to undress was because she'd been raped. I asked her about this and she denied that she'd been sexually assaulted which I dutifully charted.

She was ultimately discharged and I charted that when I got her up from bed she was unsteady on her feet. She became more sure on her feet in a minute or two and went home.

Much to my shock, a few months later, I was served with a subpoena at work (my one and only). I was horrified to learn that I was requested to testify for the DEFENDANT in a sexual assault case! The patient I had cared for later reported to the police that she'd been raped. The defendant was using my charted statement that she'd been unsteady as proof that she was intoxicated and therefore unable to clearly remember what happened.

This experience taught me many things. Firstly I was painfully aware that my charting was not as comprehensive as I would have liked. I was glad that it was not under scrutiny for malpractice.

In addition, I learned not to rely on the physician's charting to fill in any holes in my documentation. The doctor who cared for this patient was an elderly moonlighter who, according to one of my colleagues, had forgotten more medicine than our younger MD's had learned. He hadn't spent a lot of time with the patient and didn't pursue possibility of sexual assault at all.

I was very nervous about having to testify. I certainly didn't want the slime-ball rapist to get away with his crime and vowed to myself to be as unsupportive as I possibly could. We did meet with the defense attorney prior to our part in the trial to "go over our answers". This rehearsing, to me, felt like cheating. My goal was to be a help to the victim.

The courtroom was not like I'd seen on TV. For one thing, the witnesses are not allowed into the courtroom during the testimony of others. I sat on a cold, marble bench in the hallway while I nervously waited my turn. There were no spectators in order to provide for the privacy of the victim.

Inside, I answered the questions truthfully and I tried not to glare at the perpetrator with the disdain I felt. At one point the defense lawyer asked me if I thought the patient was drunk. Now nurses have drummed into their heads "If it wasn't charted it wasn't done". I turned this around on the witness stand and said assertively "If I thought she was drunk I would have charted that!"

I'd like to be able to say that my fiery testimony sent that despicable excuse for a man up the river for a long time. Honestly I don't remember reading of the outcome of this case that happened over 30 years ago. Of all the rape victims I've cared for this was the only time I was needed in court. Some women refuse to involve the police but we always hope they change their minds.

2013-12-27T15:19:00.003-08:00

Rotavirus is Going Around (to the tune of Santa Claus is Coming to Town)

You'd better not wait
You'd better run now
Before its too late
And the bathroom's not free
Rotavirus is going around!

We're going a lot
Many trips to the pot
Our bellies sure do gurgle a lot.
Rotavirus is going around!

There's nasty diarrhea
And really stinky farts.
You'd better not come visit us
if you don't want to start...

The run for the pot,
Poopin' a lot,
Tummy cramps and your
Social life's shot.
Rotavirus is going around!

Nurses Make it Better

2013-11-17T17:26:00.000-08:00

Nurses have many ways of comforting patients. It's much more than giving medications. When I was a school child I remember going to the nurse's office and how nice Miss Cole brought me to a cot and tucked a warm blanket around me.

After having my first baby near midnight of an exhausting day, my lovely nurse helped me clean up then tucked me into bed. When I told her surely I'd like to be wakened for the five am feeding she said "sure thing" but knowingly let me sleep right through it. I was glad for the rest. I needed it.

Not long ago I was brought a patient with flank pain by ambulance. She was in obvious pain and seemed close to tears. As I introduced myself and began caring for her I assured her we'd help her feel better. She was seen by the doctor promptly and before long I was giving her some pain medication in her IV.

She said she wanted to share something with me. She warned me that I'd probably think she was crazy but wanted to tell me anyway. It seems her mother had died during the past year with a long battle with kidney disease. It had been a tough year because she missed her mom very much.

When she began, the night before, having pain in her kidney area, memories of her mothers illness came back to her. She became terrified and desperately prayed that her mother could comfort her. The next day her pain continued and again her prayers were for something to ease her worries. "Send me some butterflies Mom" she'd said. Her mother had really loved butterflies.

This is not me.

Earlier that morning, when I was getting dressed, I hesitated while choosing a scrub top. I went back and forth between two tops finally settling on the one with a butterfly print. When my frightened patient saw me wearing butterflies, she said she immediately felt comforted. She knew her Mom had sent them. Humbled to think that my choice of clothing was influenced from above, my eyes began to tear up. I assured her that I didn't think she was crazy.

The next time some administrator starts trying to send nurses back to wearing white I plan on relating this experience. I've been told many times by patients that they like to see bright and cheery uniforms.

The best part of my job is to see someone who comes into the ER in pain, frightened or in medical distress and turn the situation around. I get lots of opportunities to do this.

“I've learned that people will forget what you said, people will forget

what you did, but people will never forget how you made them feel.”

― Maya Angelou

Make Yourself Right at Home

2013-02-18T19:36:00.000-08:00

Note the horror on the child's face.

Not everyone is comfortable being a hospital patient. Being in the ER can bring about a lot of fear and anxiety. For some, even wearing a hospital ID band is scary. One lady told me recently that her mother refused to wear the ID bracelet because she didn't want to stay overnight in the hospital. The other day a man told me "I'm not wearing it. I weight 240 lbs. You won't lose me". I'm not sure why a simple plastic bracelet symbolizes forfeiture of any right to say no to anything else.

Many people are surprised when they are asked to disrobe and get into a hospital gown. Do they think doctors have x-ray eyes? I've seen people put them over top of their clothing. Do they really think they need an extra layer? I realize that your average hospital gown doesn't offer much in the way of modesty but I wonder why some patients, usually men, tend to put them on with the opening in the front even if I've told them to put them on with the opening in the back. I'm really not interested in having your package flashing about. If you're sitting down, the rear opening doesn't show.

Sometimes a person's fears are manifested in clinical findings such as an abnormal blood pressure reading. "White coat syndrome" is recognized as a real result of hospital anxiety. I got this definition from Wikipedia -

A little white coat syndrome?

In studies, white coat hypertension can be defined as the presence of a defined hypertensive average blood pressure in an office setting but not at home.
These people are usually managed by keeping track of their blood pressure themselves at home when they are aware they have this problem. Its nice when they let me know to expect a high BP reading.

I've had more than one person who was a known "fainter". I remember one man with a laceration who came to the ER for some stitches. His wife cheerfully let us know right away that he would be fainting at some point. She had some errands to run and said she'd be back. The man was just fine during the procedure. After it was over he became pale and sweaty. He had been sitting up and let us know that he needed to lay down. Sure enough he passed out for a few minutes. Just then his wife phoned. "Has he fainted yet?" she inquired. We let her know that he'd done it and was starting to feel a little better. She returned soon after that and the man sat up, apologized for scaring us and we sent him home. I appreciate when people warn us of tendencies to do this type of thing. It saves us a lot of tedious paperwork which is required if a patient passes out and lands on the floor.

No more interruptions here.

We often see the warning signs of impending fainting on either patients or visitors. They get pale, sweaty and have a slightly greenish tinge to their complexion. We encourage them to sit or lie down. Often this symptoms is from low blood sugar and we can fix up the problem with a few minutes of reclining and a lollipop. Occasionally we get a family member that refuses to believe there is a problem. "JUST #@*%$#@$! TAKE CARE OF MY WIFE!" ( this usually from the big burly type). The diatribe is usually followed by a thump of his head hitting the floor. More than once, as we were so busy with the patient, the fainter had to lie there for a few minutes till someone was available to pick him up. At least there are no more interruptions while the person is unconscious.

Cultural differences can sometimes be obstacles to patient comfort. Once I had a patient who was Romany, more commonly known as a Gypsy. I brought her into the orthopedic room and she became incensed that I put her in such a filthy place and stormed out. I didn't find out the reason for this until some years later when I read a book on nursing implications of various cultures and ethnic groups. Apparently the Romany culture has a tradition that what is above the waist is considered clean and what is below the waist is considered dirty. The orthopedic room had racks of crutches hanging on the wall. Because the bottoms of the crutches, albeit unused, were hanging high up on the wall she felt that the place was dirty. Interestingly enough, a similar practice is observed in operating rooms. Surgical staff hold their hands upright after scrubbing, gowning and gloving up as anything below the waist is considered non-sterile.

I try very hard to pronounce names correctly. I sound out the names phonetically and usually I do pretty well with most European and Hispanic languages. Asian languages are more difficult. Once I went to the waiting room and took a wild stab at a very long Cambodian name. The patient and his companion looked at each other and began laughing hysterically. I have no idea what I said in their language but they clearly enjoyed it. They also had no trouble realizing for whom I was calling.

Sometimes I feel like I must be speaking martian or some obscure language because of the responses I get such as this conversation as I was escorting a very ill patient into the triage room in the ER.

Nurse: Would you like to lie down?
Patient: I'm not getting down on this floor!

Another interaction was in the Behavioral Care Unit where the security guards prohibit hot beverages in case an angry patient wants to use the hot coffee as a weapon.

Patient: May I have coffee?
Nurse: I'm sorry, hot beverages are not allowed.
Patient: What about tea?
Nurse: Not if its hot.

To a patient with some stomach discomfort I was dispensing a combination of three liquid oral medications we call GI cocktail. Many people ask me what is in it but not this time.

Nurse: Here's your GI cocktail.
Patient: Why do they call it GI cocktail?
Nurse: Because it is for your gastro-intestinal problem.
Patient: Oh, I thought it was GI like in the army.

Then a patient who felt culinary treatment was what we do.

Nurse: Because you are anemic I will be giving you a blood transfusion.
Patient: If I'm anemic shouldn't I have some liver?

This same patient was hoarding a stack of alcohol wipes under her covers. I discovered them while I was remaking her bed when she was in the bathroom. She was a little tremulous because she was an alcoholic who hadn't had a drink in two days. I was afraid she'd start sucking the alcohol out of them. I got rid of the wipes and a little later she asked me for some more saying she was very warm and wanted to wipe them on her forehead to cool herself off. I gave her a cool wet washcloth instead but I warned the nurses on the inpatient unit to be keep an eye on her. I also suggested to the admitting doctor that she might need to be medicated for her alcohol withdrawal before she had DT's.

We did have an incorrigible alcoholic patient who would drink mouthwash, vanilla extract or anything else he could get his hands on. One day we found he was taking the wet wipes in the bathroom which we stocked for patients to clean their skin before providing a urine sample. He'd take a bunch of wipes and put them in a specimen cup with a little water and drank it down.

We expect children to have fears at the ER but sometimes they behave better than the adults. I had a 22- year old patient not long ago who refused to get up to the bathroom with her IV attached to her. She said defiantly "I'm not moving with a needle in my arm!" She was holding her arm out stiffly and I explained that the needle had been removed at the time of insertion and all that was inside her vein was a small plastic catheter. Her mother rolled her eyes and warned me not to try to change her mind. I did disconnect the IV bag and tubing from the catheter and she decided she could manage to get up. When she came out of the bathroom she was confronted with a seven year old girl who was waiting her turn to go in. The little girl was holding onto her IV pole with the bag hanging on it that was infusing into her. The child seemed to take the whole situation in stride and this was noticed by the young woman who became less cantankerous.

Loaded with ink but scared of needles?

Injections, blood tests and IV's are pretty common in the ER. I'm always surprised by people with dozens of tattoos who tell me they are afraid of needles. They claim that "those are different" but I have trouble drumming up sympathy when I can hardly find a bare spot to inject. Then there are times when there is no bare spot.

Once I had to give a patient a tetanus shot to a man with lots of ink. I pulled up the sleeve on his upper arm and found a large tattoo'd image of Jesus wearing a crown of thorns with drops of blood running down his forehead. The ink was expertly done and I just couldn't bring myself to give an injection into the face of the suffering Jesus. I switched to the other arm which had the image of an evil clown and was happy to give the injection there.

On the other hand some patients make themselves very comfortable even during a short ER stay. Some bring books, newspapers or lap top computers. They help themselves to plug in a charger for a smart phone or game console. One day I went in a room and saw the patient had a charger plugged in to something on his ankle. He was on probation and if his detention ankle bracelet went dead he might have ended up back in prison.

I brought my book and my phone to keep me busy.

Some people are so at home they have a regular picnic in the ER. They send out or ask us for food for the whole family. This can get out of hand when the take-out food has strong aromas that are causing other patients to feel worse. When your stomach is upset and you're vomiting the last thing you want to smell is someone else's greasy french fries.

I'm happy to feed hungry patients but I'm stymied by people who let me know as soon as they get there that they are starving because they haven't eaten since yesterday. Why not? If they were too sick to eat at home why are they instantly able to eat at the ER before we've even done anything to make them feel better? Then some people seem to feel if only we would feed them they wouldn't need any other treatment. I often have to explain when we must not give them food or drink because of their condition and/or impending surgery. I hate to be the bad guy but sometimes I must seem like one.

For those in the ER who can eat, we keep cold cereal, Jell-O, fruit cups, some sandwiches, apple juice, ginger ale, milk, coffee, tea bags, graham crackers, saltines, peanut butter and jelly, We also have small cans of chicken soup that can be heated up. It's not very exciting food but it is immediately available. A tray from the dietary department can take a while to arrive but we do order them for people who can't eat what we have on hand. When I first started working in the ER we rarely fed people. The general attitude was "this ain't no restaurant". It was felt that like with stray cats, if we fed people they'd keep coming back for more. We do get some "regulars", usually chronic alcoholic and homeless, who show up repeatedly at mealtimes. But hospital food, even a simple sandwich, just isn't worth making a special trip for most people.

We make a lot of effort to control pain. When patients are evaluated we ask them to rate their pain on a scale from one to ten. After they get medication for their pain we like to document that their level of pain has decreased. It's not a flawless system. Some people have difficulty quantifying their pain. Others try to inflate their number to be seen more quickly. I am skeptical when someone complaining of 10/10 pain is chatting happily on their cell phone, munching a bag of Cheet-os, and has perfect make-up. Seasoned ER staff are not swayed that easily. If I have only one bed available I'm going to pick someone who looks sicker rather than judge strictly by the numbers.

Why we do what we do.

One of the best parts of my job is to take a patient who is obviously suffering when they arrive and do whatever is needed for them to feel better. When I was an EMT for a volunteer ambulance it didn't take me long to notice that a frightened patient with pain could actually start to feel better after basic care and an encouraging word or two. I could see that my work could make a difference. This is part of why I decided to become a nurse. When I can turn tears to smiles it makes my day. A warm blanket, a pillow, an ice pack and words of comfort often help as much as all the medications and treatments. Many careers don't have the opportunities to see such rapid results of their labors. Some days we are rushing around so much that I forget to notice. When I get one of those smiles it warms my heart and reminds me why I chose to work in the ER.

Techno-Nurse.

2013-02-01T14:03:00.000-08:00

Using a PDA to scan a patient's name band.

These days it is hard to avoid dealing with electronic equipment in any type of nursing. There are wound vacs for severe skin infections. Very few vital signs are taken with manual devices. Drugs are dispensed via machine. The patient ID band has a bar code and many nurses dispense medications by scanning the patient and the drugs to make sure they are delivered correctly. Laboratory techs also scan bar codes. Robotic surgery is becoming common. There are bed and chair alarms to warn if a patient takes an unauthorized walk. IV's are nearly all on infusion pumps.

I stopped wearing a watch long ago and rarely need to use one because so much is done electronically. I hardly ever take a pulse by feeling someone's wrist but if I do I use the stopwatch on my smart phone. I also use my phone's flashlight to check a patient's pupil reactions during neuro checks. I have several useful apps for converting pounds to kilograms, centigrade to Fahrenheit temperatures and figuring out due dates for pregnancies. Looking up unfamiliar diseases or drugs on google is faster than the computer references on the PC's we use. Nearly all charting is done on computer. This has impacted me so much that I no longer have a "writers bump" on my third finger that had been the result of years of hand-writing nurses notes.

Early in my nursing career I decided to take a very comprehensive ICU nursing course. Some of my co- workers said they'd never want to work in ICU because they want to care for people not machines. Back then we still did a lot of things manually. We counted drops on our IV's instead of using a pump. We used glass thermometers that needed to be shaken down. Blood pressures were taken with a sphygnomanometer that usually had a large column of mercury. We gave bed baths with real wash cloths. We gave back rubs. It was a different world. In the ICU loomed cutting edge technology.

There really is a person here.

Indeed I did learn to deal with cardiac monitors, respirators, invasive pressure catheters and computerized charting. We still wrote nurses notes by hand but medications, fluid intake and output were entered in the computer by our computer techs. Vital signs for patients with arterial lines or swan ganz catheters were automatically charted every 15 minutes and additional readings could be taken at any time with a push of a button. Cardiac outputs were calculated by the computers. I embraced all this enthusiastically. A few years later, when I moved from an intermountain west city to the suburbs in the northeast I was shocked to find not all intensive care units used computers. I did adapt and found that good outcomes could result with less electronic intervention. In any case no matter how much paraphernalia is attached to a patient, a nurse must not lose sight of the person attached to all the wires and tubes.

Asystole or loose wire?

For instance when alarms go off and the monitor shows an ominous flat line I first look at the patient. If he's talking I take that as a pretty reliable sign that his heart is still beating. When I see what looks like ventricular fibrillation on the screen and the patient is laughing and joking around I check to see if all the wires are still attached rather than charging up the defibrillator paddles. I once had a patient who, instead of using nurse call light, just wiggled one of his electrodes to make the alarm go off. He was pretty good at simulating ventricular tachycardia and it got our attention the first couple of times he tried it. In CCU the nurses knew to ignore the alarms caused by patients brushing their teeth.

We also need to be on top of ancillary staff who might not know to correlate abnormal vital signs readings with patient conditions. Sometimes inexperienced aides will chart a critically high or low blood pressure, heart rate or temperature without giving it another thought. We used to have ear thermometers that tended to read low if the battery was getting weak. If you have a temperature of 92.4 on a healthy looking person in the middle of the summer its best to double check. At least it would be nice to mention it to the nurse. Equipment does fail from time to time but sometimes it is working just fine even though it may not appear so.

CLEAR!

One night many years ago in the ER we got a patient in by ambulance in cardiac arrest. The EMS crew members were volunteers and there was no paramedic to give medications or shock him. The protocol then for what appeared to be flat line on the monitor was give some epinephrine IV and defibrillate since a flat line might be a very fine ventricular fibrillation. We did just that and when the first shock was delivered, the patient's body just lay there. Usually after being shocked the body arches up off the table. They show this on TV medical dramas all the time. The doctor ordered another shock. Nothing. "Get another defibrillator" yelled the doctor. We did. Same result. "Someone get me a !@#%^&#^& defibrillator that works" she screamed. Another set of paddles were charged up. There was no movement after this shock either but this time a few little curls of smoke were rising up off the chest. The third machine was definitely working.

Upon further examination of the patient early signs of post mortem lividity, pooling of the blood due to gravity, were present when we turned him to look at his back. The patient had been dead long enough that rigor mortis had begun which explains why his body didn't react normally to the defibrillation.

It also follows that diagnostic tests don't tell the whole story. Once I had a patient who complained of back pain. The doctor ordered xrays and when I was placing the films onto the light box for the doctor I was shocked to see the distinctive image of a bullet. "My God" I exclaimed. "No wonder he has back pain. He's been shot". Good sense hit me before I ran for the doctor. It occurred to me that if there was a fresh gunshot wound I'd certainly have noticed some blood somewhere. The bullet was from an old injury and was left in place because it was too risky to remove.

There is still abundant need for human contact in medical care. While we do have a lot of technology to deal with it doesn't run by itself. There is no replacement for the nurse or doctor's sense of smell, touch, hearing and general gut feelings. In the ER we make a lot of treatment decisions before the patient is even hooked up to anything. We may not have a complete diagnosis in the first 15 seconds we see a critically ill patient but we do recognize when we need to mobilize our resources rapidly.

NURSICLE post published in Advance for Nurses

2013-01-28T18:00:00.000-08:00

I was thrilled this month to have my blog post "They've Got Our Backs" from December published in a real magazine! One of my co-workers suggested I submit the article to several nursing publications. Advance For Nurses published it in their January issue for the northeast region. This is my first actual published work.

Here is a link to the online version. I was surprised that they published the entire article as written and used three of my photos. No edits! I can't deny this was truly exciting for me.

Here is the link for the online version.
http://nursing.advanceweb.com/Archives/Article-Archives/Theyve-Got-Our-Back.aspx

Thanks Roger for the encouragement!

Flu Flu Go Away

2013-01-25T19:33:00.000-08:00

We're in the middle of a particularly virulent flu season. This year my hospital made the flu vaccine mandatory for employees. Any worker who could not get the vaccine because of allergies or other health reasons are required to wear a mask for the duration of the flu season. Likewise, anyone who refuses the immunization must wear a mask. Naturally some negative feelings arose from the policy.

Keeping patients and visitors safe.

I was surprised to see the above sign on the door as I went in to work the other day. Since we in the ER have been inundated with cases of the flu, I felt this might mean I shouldn't be working because I have been exposed multiple times. Yeah, right.

Spit spreads death. Pretty succinct.

Posting signs to prevent spread of infectious diseases and nurses wearing masks are not new phenomena. These masks these nurses wore did not protect them because the cloth was too porous to prevent the tiny virus molecules from passing through. Yet photos of those days show widespread use of masks by policemen, transit workers, bus passengers and school children. Today we don't see masks beyond the walls of the hospital but at least a lot of stores and public buildings offer antiseptic hand wipes. We can prevent transfer of infection from doorknobs and shopping carts.

1918 nurses wearing isolation masks.

Early 20th century public health warning.

This sign from a theater in Chicago has a lot of good advice. If you're sick, go to bed. Also spitting was deemed extremely hazardous back in 1918. These days people are usually not spitting indoors, thank goodness. I went to a crowded pharmacy to pick up a prescription a couple of weeks ago. There was a long line of customers and many were coughing and sneezing. I decided to go back to my car and use the drive up window rather than risk prolonged contact with all the germs flying around.

Sign from an 1918 orange crate.

Polio was transmitted by respiratory contact yet other precautions were commonly recommended.

In the mid 20th century Infantile Paralysis or Polio, was a frightening threat. Before the vaccine in the 1950's people avoided public pools, air conditioned theaters and other public gathering places during outbreaks.

Tuberculosis is not as much a threat in the USA as it once was. However in the 1980's we saw a resurgence as AIDS patients succumbed to TB. These days most cases of TB are immigrants from 3rd world nations. We have special masks just for this type of patient and isolate them in a room with negative air flow. This means the air is exchanged through the venting in the ceiling preventing exhaled air from sneaking out the door. Our ER has only one room that functions this way however.

In the ER contagious diseases are unavoidable. Colds and flu are commonly transferred to the staff. Viral gastroenteritis is less obvious and it can make the rounds of the ER workers as well. Of course if we contract these type of illnesses at the beginning of the outbreak we've got plenty of antibodies built up when the season is in full swing. I'd like to say that we take our own advice and stay home when we are sick. Naturally using too many sick days is frowned upon so we tend to minimize our down time.

We try to encourage people to cover their coughs and wash their hands. We hand out masks to coughing patients as soon as they walk in the door. This is often met with resistance. Some patients refuse to wear them or use them incorrectly. Not everyone will cover both their mouth and nose. When foreign travel brought us SARS a few years ago we stepped up our screening questions for those coming in with respiratory illnesses. Since people are often contagious before the symptoms appear it is helpful to know if they've been exposed.

These days we're seeing dozens of cold and flu cases every day. We do our best to isolate them but that becomes difficult when we run out of beds. Coming to the ER is a waste of time for many of the patients who have been sick too long for the antivirals to be of any use. We have been handing out a lot of the anti-flu medication Tamiflu which is supposed to temper the symptoms and shorten the duration of the illness. It must be given within two days of the onset of symptoms to be effective. For those who develop pneumonia or are dehydrated there are things we can do for them.

We do a rapid-flu swab in the ER to find out for sure whether or not a patient has influenza. The reactions are interesting. I think some people are disappointed when they find out they don't have the flu. I guess a positive result would justify how lousy they feel.

On the other hand, I think I might feel worse with a positive test. Once I had a really nasty cough and my husband complained that my hacking was keeping him awake at night. He asked if I could please ask one of the doctors at work for something to stop all the coughing. I did hit up one of the doctors for a prescription but he insisted I get a chest x-ray. I looked at the film with the doctor and he pointed out the pneumonia. I suddenly noticed I had pain in my chest right where the pneumonia was. It was funny how it never hurt before I saw it on the x-ray.

People have a hard time accepting that they're not really going to feel better for a week or so. The majority of people though will do just fine if they stay home, rest and drink plenty of fluids.

I get my flu shot annually although I didn't for a few years. Once, many years ago, I got the worse flu of my life soon after getting my shot. I blamed it on the immunization but it I probably just got exposed too soon after getting it. It took a couple more cases of nasty flu years later which changed my mind. Since I've been taking the flu shot I have avoided the worst of the influenza outbreaks.

The hospital has been very full of admitted patients. Nursing homes who send patients with the flu won't take them back until they've had the five day course of Tamiflu. We've ended up cordoning hallways and waiting room space with extra stretchers for the overload of patients. Its been pretty hectic.

I saw someone die the other day from multiple organ failure caused by massive sepsis from the flu. It was pretty sobering. We may not have the numbers of deaths as they did in 1918 but the flu still can kill.
The 1918 flu was spread far and wide by soldiers in WWI. Close proximity in troop transport ships caused huge numbers of influenza victims. The past holiday season had the same effect. Crowded airports, planes, shopping malls and houses of worship brought a lot of people together. The nasty influenza monster continues to mutate and elude our efforts to conquer it.

They've Got Our Back.

2012-12-29T19:03:00.000-08:00

Good wishes from nurses in California.

The victims of Sandy Hook

Its been a while since I've posted anything on this blog. My last entry was on 12/13 entitled Holidays can be Horror Days in the ER. The very next day was more of a horror day than I had imagined. You see I work in the ER where victims of the Sandy Hook School shooting were brought. I'm not ready to write about what it was like in the ER on that terrible day just yet. I will be soon. What I do need to write about is the incredible outpourings of love and support from around this country that have been sent to the ER staff at Danbury Hospital. It has been like nothing I have experienced before.

News trucks with satellite dishes in the hospital parking lot.

In the 30+ years I've been an ER nurse there have been many "mass casualty" events. This term can refer to fires, building collapses, gas leaks, carbon monoxide exposures, boating accidents, shootings and multi-car pile ups. Many of these occurrences have been newsworthy and some have received national attention. In fact, there was one time we had a mystery patient who was the subject of the TV show "Unsolved Mysteries" back in the 1980's. What was different about December 14, 2012 is that the events were so horrible that the news became viral before much was known about what was actually going down at the scene.

Almost instantly, it seems, the ER was getting phone calls from across the country from other ER's offering support. A hospital in Massachusetts wanted to send food for the ER staff. This was the first of many calls we received from other health care facilities, emergency medical services, religious organizations, and post-traumatic stress services.

Words of love from Colorado

Pizza sent from Alabama

Greetings and good wishes


Anonymous gifts of coffee and donuts given in memory	of those who were lost.

Pictured here are cards, letters, pictures and words of encouragement from all over the country. The remarks are tender and touching. Some are from ER's who had experienced similar events. From Colorado, the ER's who cared for the Columbine and Aurora victims. From Virginia, the ER who cared for the Virginia Tech victims. An ER in Huntsville, Alabama sent pizza. We also got pizza from hospitals in Texas and New Hampshire. An ER in North Carolina offered to send nurses to cover shifts of anyone who wanted to go to memorial services. Children drew pictures. One letter was from an inmate at the Idaho State Correctional Facility. He wrote a long missive about not losing hope.

We received bouquets of flowers from the town of Newtown, the Connecticut chapter of the Emergency Nurses Association and multiple individuals. The ENA also sent us the largest fruit arrangement I've ever seen. Someone, I have no idea who, sent a large box of Music CD's with the song "Hallelujah" and words of hope on the label. We have received meals from local schools and churches. Huge pans of lasagna and baked chicken were delivered for all three nursing shifts so that nobody missed out. There were faxes from hospitals all over Connecticut and beyond.

I've been humbled by all of this. I had never considered doing such a thing for strangers in other ER's. Columbine, Virginia Tech and Aurora had been through what we had experienced. Those nurses and others who sent us their love and gifts must have received similar support and were paying it forward to us.

When the next major traumatic event happens, and we know there is always another around the corner, I will remember how we were hugged from afar. My heart will be open to those caregivers who are dealing with the shock and the sorrow that accompanies such occurrences.

There are a lot of emotions we are dealing with right now. We've grieved, we've raised money for the victims, we've prayed. We celebrated the holidays knowing that so many families were torn apart. As emergency workers we often have to suppress our feelings in order to function in the midst of a crisis. We've been reminded to remember to take care of ourselves. I want to say thank you to all those who have shown us so much love and kindness.

Holidays Can Be Horror Days

2012-12-13T17:42:00.002-08:00

Watch those fingers!

In the past 34 years of being a registered nurse I've worked my share of holidays. This past Thanksgiving I had the day off but even when I'm not working I pretty much know what will show up in the ER. In fact most holidays have patterns that repeat year after year.

On Thanksgiving mornings there is a lot more cooking going on than usual. People who never cook will try and impress their families with a holiday feast. They pull out seldom-used sharp kitchen implements that are wielded enthusiastically. Typically in the early hours of the day we see a fair amount of food preparation injuries. We usually get a few lacerations from cooks cutting up vegetables. Occasionally someone drops a turkey on their foot with painful results. People are not used to lifting a 25 pound bird and are surprised at how heavy it is when you add weight of the stuffing and the cookware. Burns from hot gravy or a steaming pot of boiling potatoes can round out the day. Deep frying a turkey in the back yard is becoming more popular and the number of mishaps gets greater every year. Last year someone not only had the turkey burn up but set fire to his garage as well.

Deep frying a turkey can be tricky!

Non-food related injuries can be from pre-dinner backyard football games or holiday traffic accidents with or without alcohol. The occasional family altercation can bring us business too.

During the afternoon the visits slow down as people are eating their bird and trimmings. After everyone has recovered from their tryptophan coma we begin the next phase of the Turkey Day Marathon. There is a round of indigestion cases followed later in the evening by heart problems originally thought to be indigestion. Some victims with vomiting and diarrhea from food poisoning due to improperly cooked or stored food are inevitable as well.

On any major holiday there is always at least one poor grandma or grandpa that the family hasn't seen in a while. When their loved ones finally pay attention to them for the big day the "concerned" family finds that the dear old thing has faded a bit since the last big get-together. Surely a trip to the ER is what is needed to put the roses back in the cheeks and perk up Nana or Poppy.

Even worse is when someone brings the old folks in and insists they be admitted because the family is going on vacation and needs to park Grandpa for a week or so. Sadly, I've even seen families leave an elderly person at the ER without giving a working phone number to be contacted when its time to go home. We nail these types by filing elder abuse papers for abandonment but plenty still try it.

I did work "Black Friday" this year and it can be just as black in the ER as it is at Walmart. All those people who "shop till they drop" end up you-know-where. Since so many have the day off those who aren't shopping find they have time to get things checked out they hadn't had time to tend to on workdays. The majority of the patients tend to have minor problems but the sheer volume of patients can be overwhelming. A general trend of people avoiding us on the actual holiday because they suspect we'll be busy feel that it will be less crowded the day after. Most people are surprised that this is not an original idea on their part when they see the masses of other patients who had the same plan.

Cozy congregations can get overheated
when this many people show up.

On big church holidays like Christmas or Easter congregations have more attendees than usual. Many go to their services fasting. Folks get crammed into those pews pretty close together and inevitably we people faint from the warmth of an overcrowded chapel and a low blood glucose. Major Jewish holidays can have the same sequelae.

Holidays are often difficult for those who have lost loved ones. Depression can peak for many during celebrations when missing family members. Suicide attempts increase and psychiatric facilities are full. Days that should be full of joy and happiness can be unbearably painful for the troubled and the lonely.

Christmas, New Years Eve and Saint Patrick's day, among other yearly fests, are often occasions to drink lots of alcohol which naturally brings an increase in alcohol-related accidents. We generally see a fair amount of intoxicated people in the ER but holidays generally bring out more of the amateur drinkers rather than our routine habitual drunks.

Many indulge in foods that they normally don't eat. That juicy beef tenderloin, luscious shellfish and even the Hickory Farms Beef Stick can cause flare ups of gout as a post-holiday treat. Those ubiquitous cookies can tempt even the most diligent diabetics leading glucose levels out of control. Secret ingredients of some holiday treats might bring on allergic reactions to unsuspecting snackers. One of my co-workers swears his mother-in-law is trying to do him in with her peanut encrusted shrimp. He is allergic to both nuts and seafood but every year she insists he should try it anyway.

Sometimes in the middle of a "code brown" or when trying not to get splashed with vomit it is hard to remember that it's Christmas. In can be difficult keep the holiday spirit "in absentia" when you're missing all the fun at home. On the other hand, in the afternoon, when the kids have started fighting with their cousins and your mother-in-law starts in on her usual critical diatribe it can be a relief to have an excuse to get out of the house. Hopefully somebody else will do the dishes and gather up the debris of wrapping paper and empty boxes.

Of course being a patient on a holiday isn't fun either. Whatever your personal holiday traditions include a trip to the hospital probably wasn't planned. No matter how sorry I feel for myself, I know I will get to go home after eight hours. We usually have toys to hand out to children who come in the ER. Santa might make an appearance and hospital food is revved up a notch to be more festive. Many of us wear holiday scrubs and we all put on our cheeriest smiles. Our hospital has a multitude of chaplains from many faiths and they do a great job of reaching out to everyone.

Of course the Mayan calendar ends on 12/21/12. Maybe nobody will have to work on Christmas this year. Happy Holidays!

People Bring Me Presents

2012-10-29T18:39:00.000-07:00

During the many years I have been an ER nurse I have spent a fair amount of shifts at the triage desk. We greet patients, assess the urgency of their afflictions and initiate the care they will receive in the ER. Sometimes we redirect them to Radiology, Maternity or another hospital department. At times patients bring me supporting evidence to prove the seriousness of their condition. I just love when I get presents.

I've received a number of "critters" i.e.spiders, ticks, bedbugs, lice, snakes and other assorted varmints who've bitten somebody. The best scenario is when the perpetrators are already dead and/or in a sealed container. I'm less than thrilled with specimens who are still kicking in a wadded up Kleenex or a Zip-loc bag. It does help to see the snake to discern if its poisonous. Spiders too may or may not be lethal but I'd rather not find out by getting bitten myself, thank you.

A few people wrongly assume if they bring a tick we can test it for Lyme's disease and save them the trouble of having to take medicine. Not all ticks carry the same diseases. What happens is that we look at it and say "yes, it's a deer tick" and the patient still needs a blood test to identify any tick-borne disease. Fortunately I've never been handed a dead chipmunk or a rabid bat but you never know.

Some people come armed with evidence of gastrointestinal problems. More often than I'd like to remember someone has brought a tissue with blood they've wiped off their behind. Are they trying to avoid the inevitable rectal exam? It won't work. The doctor is still gonna check up there.

I also don't need to see the leftovers from a meal someone ate that is suspected of causing food poisoning. The hospital does not have a lab to test food. Neither do we want to deal with it after its been regurgitated. So if you vomit in the car on the way to the hospital don't save what came up for me. Just tell me about it. I'll believe you. Besides, chances are you'll have a repeat performance after you arrive.

My least favorite present is when someone coughs up a lugy into a hanky and hands it too me. Every nurse has something that they have trouble dealing with and for me its sputum aka phlegm, chest boogers, hacky snacks, etc. GAG!!!!!

We ask people with abdominal pain or back pain to give us a clean catch urine sample. No matter how precisely I give instructions for this there are always those who don't get the message. We give out some wet wipes for them to clean off their skin before urinating, a sterile cup and a biohazard bag. I don't want the wipes back after they're used but sometimes they are returned in the bag with the specimen cup. Then there's the mavericks who will ignore the cup entirely and bring me a bag of urine (or did they pee in the cup first and then dump it into the bag). I have no idea.

Sometimes people bring in a urine sample from home and use whatever container they happen to have around like an empty pickle jar or a Tupperware bowl. I hate to disappoint them after going to so much trouble but we need to use a sterile container.

One day a police officer, who must have felt he was about to unveil the clue that would close an old murder case, brought me part of a fossilized mandible. He asked if I had a pathologist handy to examine it. Covered in dirt, the jawbone was about four inches long and had several molars that were too long and narrow to be human. I hated to burst his bubble but I had to tell him it looked like he'd dug up part of somebody's long departed pet dog.

For years pharmaceutical representatives would stop by hoping to catch the ear of one of our physicians. They are supposed to make appointments and not drop in unannounced. However, if they had any good pens or other freebies I might see if I could find someone. The newer ones took a few nudges before realizing they needed to make it worth my while but they usually had something to offer. Passing out free stuff is now illegal for the drug reps. I miss the free pens but we don't do as much writing by hand these days anyway.

Less than welcome are the germs we can pick up at triage. One of our nurses has made it her quest to get sneeze guards at the desk. She loves to point out that the average salad bar has more protection than we do. Lots of sick people tend to hack and wheeze on us before telling us their problems. We hand out isolation masks to these coughers and sneezers but some feel insulted at this. We have several dispensers for hand gel and signs to encourage hand-washing or coughing into an elbow. In spite of all these precautions we still end up catching a lot upper respiratory infections. When we get exposed early in the cold and flu season we usually build up an immunity before the winter is over. Flu shots help too and we're all strongly encouraged to get one. In fact this year the flu shot is mandatory. If we refuse to get one we have to wear a mask during the entire flu season, roughly from November till March or April.

Traumatic amputations of fingers and, less often, toes, can be caused by various power tools, especially snowblowers. A good number of victims or bystanders bring along the severed body part for us to reattach. When I say that someone gave me "the finger" it isn't necessarily a bad thing. (Sorry, its a pretty lame pun). More often than not, the digits are too mangled for successful re-implantation. A chain saw or router makes an very nasty jagged wound but a deli slicer makes a nice straight cut. Usually only the fleshy part of the fingertip is cut off in a meat slicer but rarely have I seen a doctor try to sew that back on.

What can be helpful is a bottle of cleaning fluid or other chemical that was splashed in someone's eyes or accidentally ingested. The labels usually have helpful information or a phone number for the manufacturer. This facilitates proper treatment in a timely manner.

People who were discharged with crutches occasionally bring them back after they don't need them anymore. We don't dispense used medical items so I advise the individuals to donate them to an appropriate charity.

Then there is a fair amount of paperwork that shows up to the ER though it usually belongs somewhere else. People come with their hospital bill to either pay or protest it. Then there are insurance forms that require a doctor to fill out certain parts. For the record, doctors NEVER complete these forms themselves. Occasionally a process server stops by to serve a subpoena. This happened to me once and I was amazed that when the man who gave me the subpoena also gave me a dollar. (Apparently its an old custom).

Sometimes we do get actual gifts. A grateful patient might bring us flowers, cookies or candy. One sweet little old lady was so happy with her care that she brought me a couple of handmade angel Christmas ornaments that she'd crafted herself. I cherish them and they hang on my tree every year. Christmas comes only once a year but in the ER we get presents, welcome or otherwise, all year long.

Nursing School is No Piece of Cake

2012-10-13T17:58:00.000-07:00

A friend of mine, who is currently enrolled in a college nursing program, recently had her first clinical experience. She felt pretty nervous and was sure she wouldn't sleep at all the night before her first day in uniform. I started to think about my foray into the hospital world under the intense scrutiny of my instructors.

People with undergraduate degrees in many academic subjects do homework, take tests and write papers. They never have to perform difficult hands-on tasks with a obsessive-compulsive teacher looking over their shoulder. Of course a high level of supervision is necessary to keep the student nurse from accidentally killing someone. Grading for the clinical rotations is strictly subjective because that's the nature of what we do. We need to be accurate in our assessments of our patients, we must administer medications correctly and make people feel comfortable. We must encounter bodily wastes without cringing, or inappropriate remarks. We put our hands and stethoscopes on complete strangers to assess their biological functions. We must respect the dignity and privacy of our patients yet we must research their medical chart for every nuance of their physical and emotional condition. These skills are not easy. I'm not saying a degree in English is simple but if you don't parse a sentence correctly nobody dies.

Patients were assigned in the afternoon and a trip to the hospital was required the night before clinical to peruse the chart. We then went home and looked up all their medications and diagnoses and wrote everything up on index cards for the next day. The idea was to be prepared to care for the patients needs and understand their condition.

Some of our clinical instructors were supportive and inspiring. Others seemed rigid and extremely picky. Our OB instructor was newly pregnant for the first time. Frequently needing to deal with her morning sickness, her focus was not with my class. While some instructors obviously had not done a real clinical shift in decades, some of the younger ones were concurrently both teaching and working as staff nurses. One of my favorites had been recently discharged from the US Navy. She still wore her long-sleeved military white uniform dresses. She said they "wore like iron" and hated to give them up. Finally one day, to our delight, she showed up in a stylish new uniform with pants.

They were there to teach but also to decide if we had the proper personal skills for nursing. Not everyone who succeeded academically could deal with pain, pungent organic odors or critical situations. There was always the fear of being tossed from the program if we screwed up or showed signs of weakness.

Most nursing students I see these days wear some type of scrubs. I'm rather envious about that because I really hated my student uniform. Our decidedly uncool uniform was medium blue cotton/polyester with a Peter Pan collar and a pleated front placket with white buttons that hid a zipper underneath. The sleeves had pleats in the back for movement and a buttoned half belt at the back waist. An embroidered school patch was on one sleeve. We could wear the A-line dress but also had a choice of the pantsuit version which was a little less dorky but more expensive. The top was just one of the dresses cut shorter. The pants were white polyester with stitched creases and a rear zipper. Some of the girls who wore these thought the zipper was like a front fly and found out otherwise when the stitched crease was going up the backs of their legs. We wore white leather shoes (no sneakers or clogs). Pantyhose could be either white or beige. Caps were optional and rarely worn. We had a few male students and their uniform top was minus the pleats and pearl buttons. .

Our daily grade for clinical could be affected by any sub-standard interpretation of the uniform. Points could be lost by forgetting our name badge, our shoes being dirty or, like I did once, forgetting my button-on half belt. (I think I may have lost it in a laundry accident). One of my classmates forgot to take her badge off her uniform on laundry day and it melted in the dryer. It was still wearable and, although a little skewed like a Dali painting, was still legible. Her instructor tried to penalize her for this but she successfully protested.

Someone lost his removable male body parts.

For injections practice we used an orange or a little pillow called a jelly belly (prior to this name being used for candy). We performed certain skills on a lab partner before we were allowed to do them to actual patients. We practiced taking pulses, temperatures(oral only) and blood pressures. There was a special three way stethoscope that was used so the instructor could listen in and make sure our blood pressure reading was correct. We had no digital equipment at all. Our thermometers were all the glass kind with mercury inside which required shaking down prior to use. Young people don't know what I mean by shaking a thermometer since mercury has been specified as a hazardous chemical. Ask your grandmother to show you how to do this since she probably still has one of those old thermometers in her medicine cabinet.

We gave each other bed baths, back rubs, sugar pills, injections and changed their bed linens (while they were in the bed). We had lab dummies to practice on as well, especially for doing urinary catheters. Our dummies looked like a giant Ken doll but were unisex with removable male anatomy. The female body parts were a lot easier to figure out than on a real person. Our teacher told us girls to go home and check ourselves out with a hand mirror to get a better idea of what the real thing looked like. The men in our class had no problem with this type of research.

This nursing lab used the Acme inflate-a-patient for practical learning.

To begin with they purposely chose patients that weren't too sick but couldn't go to the bathroom by themselves. This insured we'd have to deal with bedpans right away. We started with orthopedic surgery patients. My first had a total knee replacement. These days most surgery patients get out of bed before their anesthesia completely wears off. Back then that kind of surgery bought the patient a few days of strict bed rest complete with bed baths and bedpans.

A classic in stainless steel.

I should mention that those old stainless steel bedpans WERE cold. There were a lot of jokes about us keeping them in the refrigerator. They did hold up well under the heaviest patient though. Besides that, if you dropped one on the floor the noise could wake the dead, a handy thing to have if someone was a little too sleepy. But I'm digressing.

When my mother heard I was giving shots soon into my clinical she was worried. "What if you inject someone with an air bubble and kill them"? (Good old Mom was always there to look at the bright side.) When it came time to give shots for real the teachers kept close at hand to make sure we gave them correctly. I can still hear the voice of my instructor saying "aspirate", meaning to draw back on the plunger prior to delivering the medicine.

Not surprisingly, we all tend to associate receiving an injection as a negative experience. Most people don't routinely stick other people with sharp objects. So as I was preparing to inject my lab partner with a syringe full of sterile saline I was a little apprehensive. I was delighted to find it didn't hurt me one bit. My partner didn't seem to mind all that much either, although knowing I was on the receiving end of her first injection caused me a little angst.

We were taught a whole little ritual when giving a shot in someones butt. We pulled the curtain closed around the patient's bed for privacy. We drew back the blanket and sheet to modestly expose only the small target area. Next was to check the anatomy for proper placement, clean the skin with alcohol, pull the skin taut, say "little poke" or something similar, then aim, inject, aspirate then push the plunger, quickly withdraw and massage the site. We repeated these steps saying them aloud like a mantra. Unfortunately the actual situation did not always play out as programed.

My first real injection was to be given to a man who was about to be discharged from the hospital. I went to his bedside with my instructor right behind me. The man was standing up already dressed in his street clothes ready to go home. I explained that I needed to give him an injection. He said "fine" then unbuckled his pants and let them fall down to his ankles right there in the middle of a four-bed ward. This situation was not in the script. I froze because I didn't know what to do next. My instructor calmly drew the curtain closed and asked him to lie down on the bed. I took it from there.

My next injection was a pain medication for a man who was very sick. As I drew back his covers I found that this big burly man had a pink bunny rabbit tattooed on his buttock. My natural reaction would have been to laugh but since the man did not look like he was in a mood for humor I struggled to restrain myself. My instructor did not look the least bit amused so I was glad I went the more serious route.

I found surgery difficult during my clinical rotation. We practiced and practiced putting on sterile gloves and gowns without contaminating ourselves. We practiced surgical hand scrubbing. Then we were unwrapping supplies and tossing them onto a sterile field. I'd often miss the table and throw something on the floor. Besides, all that surgical gear was hot to wear. My eyeglasses kept steaming up. There were special masks that were supposed to prevent that complication but I always found my self looking through fog. I didn't like standing for long periods of time. The surgeons tended to use cryptic hand signals rather than ask clearly for what they wanted (like in the movies). We were told to make sure we ate breakfast before coming to the operating room because we were likely to pass out if we had an empty stomach. Someone always seemed to be shouting at me to stand somewhere and not touch anything. Since we were in a major teaching hospital there were plenty of interns and residents in training who also got yelled at. I always felt out of place there and have never had any desire to work in surgery ever since.

OB was another place that didn't feel comfortable for me. Like the operating room, the delivery area has a lot of opportunities to be in the wrong place. Women in labor are often, justifiably, cranky. I was standing back, observing one such woman who looked straight at me and asked me what the hell I was doing staring at her. I ran out tearfully to my instructor who thought I should have been more assertive. I liked caring for the babies but dealing with the parents was more difficult. We all had to give a class on bathing the baby, using a real baby to demonstrate, to the new moms and dads. I made the mistake of letting on that it was my first time teaching the class. One father then sarcastically said "Oh, great, she's going to teach us and she doesn't even know how". I mentioned that I had worked as an aide in the nursery and that I'd given lots of baths. It was just the teaching that was new. It didn't matter. The class was a fiasco. I did everything wrong, I couldn't give the right answers to any questions and my instructor had to bail me out. I did learn a great piece of advice from this experience to never let anyone know that I am doing something for the first time.

My pediatric rotation was at a wonderful children's hospital. I was amazed at how much faster children recover after surgery when compared with adults. On the whole, sick children tend to smell better than sick adults. You also get to have (therapeutic) play time. I didn't get a chance to feel over confident though because I had a few challenging patients. I remember one little boy who I attempted to medicate with some oral medicine that had a yummy grape flavor. He was around two years old and had no intention of taking anything I was giving out. I tried, along with my instructor and his mother, to get him to take the medicine. We chased him around his room for about 15 minutes. Finally, as we were all sweating and getting nowhere, my instructor told me to chart "patient refused medication" and just forget the whole thing. I hadn't known that refusing was allowed because I'd never dreamed of saying no to any medicine when I was a child. I was quite surprised to hear from my instructor that she thought I'd make a good pediatric nurse. When I reminded her how I'd had trouble medicating my little patient she laughed. She assured me that I had done as well as anyone could.

Psychiatric nursing frightened me terribly. This was in no small part the fault of my mother and my aunt. My mother, who felt my desire to be a nurse might be frivolous, had my aunt, a nurse in a psychiatric hospital, give me a reality check. After hearing all her horror stories I was petrified.

Utah State Mental Hospital

We were given a choice of the state mental hospital, which looked like a good location for a sequel to "Psycho", a pediatric psychiatric inpatient unit or an adult unit at the teaching hospital. There was no way I was going to be sent to the state hospital. I was sure it would be like the Jack Nicholson movie "One Flew Over the Cuckoo's Nest". I had no desire to see disturbed children at all so I picked the teaching hospital which I considered the lesser of the evils. At first I was a little worried because all the patients seemed to have problems similar to what "normal" people had. Some even hit quite close to my own problems. I became concerned that I might belong in there with them. My instructor reminded me that I was coping with my problems while the patients could not.

No Chuckie for my clinical!

Eventually I saw more bizarre cases. I even got to observe EST, or Electro-Shock Therapy. An elderly woman was brought into a room and placed on a bed. She was connected to electrodes from a machine that looked like an old radio from the 1920's. The woman was sedated by intravenous medication and given the shocks which caused her to have a simulated seizure. I felt like I was watching Dr. Frankenstein trying to reanimate a corpse. All we needed was a little climactic music at the end.

ELEVATE ME!

I've noticed here that I've referenced three movies in one paragraph. Perhaps this seems a little over the top, dramatically speaking. My imagination does run rampant.

I'm no expert on nursing education but it seems like there have been a lot of changes since I graduated over thirty years ago. These days new graduates usually have an orientation period in a new job that lasts six months with an assigned preceptor. In my first job we had no more than two weeks orientation. We might have followed a staff nurse for a few days but that was all. I recall that it was only a couple of months till I was in charge on the floor during the evening shift. Rather frightening isn't it? If you ask nurses trained in a hospital school of nursing in the 60's you'll find they took charge of a whole floor when they were still students. We've evolved to a more cautious approach for safety in our litigious society.

Our practical training was difficult but mostly I enjoyed applying what I'd learned in the classroom. I tended to get sleepy during boring lectures in college. (I still have that problem in staff meetings.) Clinical mostly was more stimulating except for one time. After each shift we'd meet briefly with our instructor one-on-one for a "post conference". We'd discuss how we did with our patients and get counseling on what we needed to improve. One day I was so exhausted that I nodded off while my instructor was talking to me. When there are only two people in the room this is hard to hide. I'd kept my head propped up on my hand but my eyes drifted shut. Fortunately she was the understanding type and suggested we conclude our discussion the next day.

Its been a long time but I still remember how I felt taking care of my first patient. Everything in my memory seems larger than life, the room, the bed, the bedpan, even the patient. Mainly what was big was the leap between being a lay person to becoming a nursing professional.

The Latest Great Plague

2012-10-04T08:11:00.000-07:00

This week I took care of two patients who have been HIV positive for nearly 30 years. Back in the early days of the AIDS pandemic nobody expected to be alive 30 years after contracting the virus. People born after 1980 can't imagine what the medical world was like before HIV reared its ugly head.

I once read a book on the history of plastic. It revolutionized marketing. Imagine today buying crackers scooped from a barrel into a paper bag. We wouldn't want to buy Twinkies or Oreos that weren't hygienically wrapped. Imagine if every grocery product that comes in a plastic bottle was in a glass bottle instead. Think of how heavy your grocery bags would be. We want to see our meat when we purchase it but we don't want to wait in line at the butcher counter for it to be wrapped. Without plastic we would never have had home photographic film, video tape, Lego blocks or Hefty garbage bags. On the other hand, we would not have immense quantities of plastic waste to deal with. The impact was huge. The contrast before and after AIDS was every bit as extreme as life before and after plastic.

Before we knew how HIV was spread there was fear. Many were so afraid that they abandoned clinical nursing. I remember having a very sick isolation patient in ICU. The housekeepers were afraid to clean the room and kept asking me what illness the patient had. I suspected the cleaning wasn't getting done properly. The particular hospital where this happened actually got a commendation from the hospital accreditation board for the excellence of the housekeeping department. I felt like I should be a whistle-blower because I knew a dirty little secret. Once I crumpled up a piece of paper and threw it in the corner of an isolation room just to see how long it stayed there. It didn't move for a week. Eww!

All blood products were found to be contaminated in the early 1980's. Arthur Ashe, former professional tennis player, contracted AIDS from contaminated blood when he had a blood transfusion during open heart surgery. Fear was so rampant that blood donors felt they were at risk. The virus was first detected in hemophiliacs in 1981 but HIV testing for the blood supply was not available until 1985. A fellow nurse had a hemophiliac son who often required injections of factor 8, a blood derivative, to treat hemorrhages. When he was identified as receiving a dose from an AIDS infected donor she feared the worst. With no diagnostic test available, only T-cell counts gave any reliable indication that someone had been exposed. This poor mother went through years of anguish first because of the lack of information and later because of discrimination from her son's school. Many religious zealots touted AIDS as a curse upon sinners. Innocent children were explained by these fanatics as unfortunate victims included in the "scourge".


Nurse giving back rub to a patient	Walter Reed General Hospital 1922

Because of our fears some medical workers were afraid to touch people with AIDS with or without gloves. Nursing care basics like bed baths and back rubs were done wearing full isolation gear or not at all. We lost much of the hands-on TLC that nurses have always given.

The paranoia extended to those who had not been diagnosed but were felt to be potentially infected. One hospital where I worked sought to identify people who either had the virus or had a risky lifestyle. People who abused drugs, were incarcerated in prisons or had multiple sex partners (whether gay or straight) were assigned a letter B as a prefix of their permanent medical record number. This label did not last as there were obvious objections to what resulted in discrimination. Eventually UNIVERSAL PRECAUTIONS were adopted assuming that everyone was potentially infected. Adopting this standard of care led to a lot of changes in how we worked.

We did not always wear gloves for everything. In fact, we were not allowed to use gloves any old time we felt like it because of the cost. We definitely did not glove up every time we touched a bedpan or a urinal. When I first entered the medical field in the mid 1970's we did not fear body fluids like we do now. Gloves were only used for isolation or for sterile procedures. We washed our hands and that was enough. In fact, when I was being taught by the enterostomal specialist how to do colostomy care, she insisted that we NOT wear gloves. She stressed that a patient with a colostomy may have difficulty accepting their body image. If we wore gloves we might make them feel "dirty". She felt with proper technique we wouldn't contaminate ourselves.

There were no hand gel dispensers before AIDS so we used regular soap and water. I mentioned to a young coworker today that hand gel didn't always exist. He gave me a bewildered look and asked when it started being used. According to Wikipedia, Purell hand gel was first marketed in 1996. Another source said 1988 was the year it showed up which still places it a good eight years after the AIDS pandemic began.

Hospital housekeepers never wore gloves before HIV. Certainly police officers, dentists or paramedics didn't wear gloves. Young people today probably never saw a dentist who didn't wear a mask yet in my childhood there was no need.

Unfortunately when the AIDS paranoia was in full swing some medical personnel didn't know when to take off their gloves. Many would keep them on constantly not realizing that touching a doorknob with a contaminated glove wasn't doing anybody any favors. This type of thinking has not completely disappeared. I saw a patient's private aide the other day who kept using hand gel while she still had her gloves on.

Sterile gloves were once almost always made of latex and were powdered to make them easier to slip on. Non-sterile gloves used for isolation were made of cheaper vinyl and rarely fit very well. AIDS caused a huge increase in the use of latex gloves as well as latex condoms. Initially there was such increased demand that the cost went up. New rubber plantations were needed to produce more latex. With the increased use came increased sensitivity. People started having allergic reactions. The powder was found to aerosolize the latex particles so they became inhaled and more likely to cause anaphylaxis. Removing the powder helped but eventually hospitals had to change to other types of gloves. Nothing used since then has been as flexible or fit as well. The newest nitrile gloves are better but still haven't come up to the feel of good old latex. Catheters, tubing and other latex-containing products were replaced by items made of silicone, vinyl or other synthetics.

Needlesticks have always been a hazard of working in a hospital. Back in the 70's we often had needle crushers for disposal. If there was no crusher we simply broke the needle off. The idea was to make the dirty syringe unusable if it should fall into the hands of a drug user. We are no longer allowed do this for a couple of reasons. First, the act of breaking off a needle or crushing a syringe may cause injury. Any contaminated body fluids might be sprayed around when the needles are broken. We now toss them directly into a sharps disposal unit whole. We used to recap needles but often a nurse would puncture his/her finger when attempting to replace the cap. Recapping is not allowed anymore either.

For used needles and blades we never used to have the puncture-resistant disposal containers we see now. Back then we might use an empty plastic bottle or metal can. These were just added to the regular hospital trash. In the early days of the AIDS era finding used syringes and other medical waste on beaches caused closures of shore front recreational areas. Now sharps containers are regulated. Tops must not allow a hand to retrieve anything from inside. There is a line for maximum capacity to prevent overflow. They must be labeled by the disposer and are required to be incinerated. In NY state all hospitals and nursing homes are required to accept used needles (in a sealed, puncture-proof container) that people use at home.

Now we have red trash receptacles for hazardous waste. This was not always so. When a patient was in isolation we would double bag their trash and their laundry. Otherwise garbage was garbage and there was no distinction. We did not always put blood or urine specimens in plastic biohazard bags.

These days we have blunt needles for drawing up medications and needleless connectors for IVs. Our syringes for injections have retractable needles. Various other devices are used for IV catheters and vacutainers to prevent a bare, used needle from being a hazard. Starting IV's while wearing gloves was difficult until we were supplied with IV dressings that could be handled without sticking to the gloves.

In the pre-AIDS era we ER workers would wear blood as a badge of courage. We did not wear personal protective equipment or PPE for traumas. We plunged bare-handed into the fray and thought nothing of it.

One of my nursing school classmates lost her contact lens in a patient in the operating room. This led to a ban on students wearing contacts but nobody even thought of suggesting goggles.

These days if a dentist pulls out a tooth it is considered medical waste and must be disposed of properly. I've heard of children who were expecting to bring home their tooth to put under their pillow had to make other arrangements for the tooth fairy. .

My first job as a nurse was on a surgery floor. I had more than one post-op patient who'd asked for and received their gallstones to take home. Some claimed they wanted to have them made into jewelry. In any case, some patients thought it was nice to see the culprits that had caused them so much pain. Like the teeth, I'm sure nobody is allowed to keep their gallstones any more.

When I discuss how we used to do things, most young nurses are horrified. They claim they would never have been so cavalier with body fluids as we once were. In truth we all used the best techniques we knew. When we were confronted with a new and frightening disease we learned and adapted. Medicine changes so rapidly that in 30 years what we do now will seem barbaric by comparison. There were times in the distant past (not in my lifetime) when surgeons operated in street clothes with bare hands. At one time needles were cleaned, sharpened and reused. Medical discoveries like vaccines and antibiotics helped millions fight diseases we rarely see in the 21st century. Children in the 1950's nearly all contracted measles, mumps, and rubella. I've never seen any of these since I had them myself.

While HIV still has devastating impact in many parts of the world, with proper treatment it is not a death sentence. A vaccine and new treatments are on the horizon and someday, perhaps, it will be eliminated. Around the corner though, there is some new plague warming up to surprise us.

How On Earth Did That Happen?

2012-09-26T19:52:00.003-07:00

Temptation for a small finger.

Once when I was a small child, we were eating lunch at a diner. Restless while waiting for my food, I started fiddling with the things on the table. A sugar shaker, like the one pictured on the right seemed like a great place to stick my little finger. It was much easier on the way in than it was on the way out and my finger became stuck. My memory of the incident is limited to being in the bathroom with my mother running water over my finger in the sink. She was able to remove the top of the shaker but peeled off much of my skin in the process. In the ER we call this a de-gloving injury.

Back in the 1950's people didn't run to the ER with just any old thing. My mother took me to the drug store and asked the pharmacist what to do. The story goes is that he told her to apply Vaseline to my finger and wrap it up with gauze. This apparently worked well because today my fingers are all nicely intact.

My mother taped up most of the lacerations my brothers and I incurred. She preferred to do this herself because she didn't want us to have scars from the stitches. Mostly she did a great job except for the time my brother put his arm through the storm door and my father was ranting hysterically while she was taping up the wounds. For anything on the face she would defer to a professional and take us to the doctor's office. The exception to this was when my brother ripped up his finger in a wall-mounted manual can opener (don't ask me why he kept turning the thing after it started to hurt). That time she went right for the ER.

Most people wouldn't guess that a jewelry store would be able to cut off a ring that was stuck on a finger. That's just where my mom went when her finger swelled up and she couldn't remove her wedding ring. My mother is not an anomaly. In fact some people doctor themselves pretty nicely. I've even seen home-applied sutures (using fishing line). This type of self-sufficient behavior is getting rarer all the time though.

These days people tend to go directly to the ER for most predicaments because their private doctor usually can't (or won't) help them. Most offices don't have any kind of X-ray machine. It's rare that a pediatrician does any suturing. When people get things stuck where they don't belong, where else would they go?

From time to time we get a patient with an insect in the ear canal. Ear wax supposedly has a chemical that repels bugs but the occasional brave cockroach may check in anyway. This isn't hard to remedy if you have the right tools and the patient is usually extremely happy without their little passenger.

Children love putting things up their nose or in their ears. We have special tools to retrieve things from noses but sometimes a little trick works better. I have the child lay down and have the parent blow into their mouth (like artificial respiration) while blocking the unobstructed nostril. The object comes flying out the nose and we have a happy child and relieved parent. (They still get a bill of course).

Traditional fish hook removal

Fish hooks can be nasty annoyances. We see a lot of them stuck in various body parts. Most practitioners push the hook further till the barb is past the skin. The barb is then cut off and the hook is then pulled back out. One of our doctors, who is an avid fisherman, has a technique to remove the hook intact. It is such a slick trick that I couldn't even figure it out the first time I saw him do it. He pulls traction on the hook with a piece of string which pulls the barb backwards then whips the hook out with another piece of string. I can't adequately explain the technique because I don't really understand how to do it but I can tell you it is pretty amazing to watch. To the fishermen who treasure their precious lures, it is a miracle.

Ring removal without cutting the ring.

I do know how to work a little magic myself with some string, or actually umbilical tape. Rarely used now to tie off an umbilical cord before cutting the baby free from its mother, this narrow cloth tape is still handy to have around. Sometimes a person with an injured finger is hell-bent on not cutting off their ring. If greasing it up with lubricant fails to do the job the finger can be compressed with the umbilical tape. A piece is slid under the ring and pulls the ring over the wound up part. Usually the technique causes increased pain in the process but to some, preserving a priceless family heirloom is worth a little extra pain. Flat dental floss would work for this at home. I've never tried to use a ring-cutter on anything made of titanium but when looking for a picture of this technique I found mention of titanium being more difficult to cut off than gold, silver or platinum.

Speaking of jewelry, one of our nurses went to a conference for emergency nurses and came home with a pamphlet "Piercing and nursing implications". I hadn't really run into any problem with body piercings but sooner or later this knowledge will come in handy. For one thing an MRI can't be done with certain body jewelry left in place. The magnet heats up the metal and can cause burns to sensitive areas. Emergency surgical procedures might require removal as well so it is important to learn how the things can be unhooked. The pamphlet showed me that people do a lot of crazy stuff to their bodies. It helps to have this type knowledge ahead of time to facilitate keeping a straight face when I encounter it in person.

Now some individuals are not satisfied with traditional types of personal pleasure and get themselves in difficult predicaments. One doctor I worked with told us of a man who came in to the ER with a drinking glass up inside his rectum. The patient's story was that the glass was on a chair in the bathroom. The man said he got out of the shower, sat down on the glass causing it to slip inside. Skeptical about this chain of events, the doctor asked the patient's wife what she thought about what her husband had told us. She laughed and said "Oh, he's always shoving stuff up there".

This type of thing usually requires going to the operating room for removal. Over the years I've had patients with a zucchini that had broken in half, a roll of quarters and a homemade foot-long Naugahyde dildo. This last item came as a surprise when we saw it on his x-ray. The "victims" story was that he had been attacked in a park with a fireplace poker jammed up his butt by gay-bashers. There was no evidence of any trauma at all so we felt there were some holes in his version of the event. The surgeon told me that he removed the foreign body by first using a lot of mineral oil for lubrication then hooking it with a long instrument to slide it out.

We often get children who swallow objects. Some things can pass harmlessly through the body. Others like button batteries or pills need to be removed before the body can absorb the chemicals. Safety pins or other sharp objects can get stuck and there is also a risk of aspiration of the item into the airway and lungs.

Cuban cigar tube

Less common are adults that swallow foreign bodies. We used to have a
frequent visitor from a psychiatric facility who would swallow nearly anything. Harold swallowed screwdrivers, ball point pens, pocket change, silverware and anything he could get his hands on. His x-rays usually showed an interesting jumble of objects and we always looked forward to seeing what he'd gotten down each time he came in. I always thought it was unfortunate that he couldn't have channeled his talent in a circus act but I guess show business isn't for everyone. Occasionally the sharper objects perforated his stomach or intestines risking peritonitis. One of my favorite incidents was when he swallowed some metal cigar tubes with handwritten notes for the surgeon and pathologist inside.

Harold was required to have two guards with him at all times but he still managed to get his hands on objects and swallow them down rapidly. One time in the ER he grabbed a magazine from the counter, rolled it up and jammed it down his throat. Too big to make the turn to the stomach, it didn't get down very far. The ER doctor was able to fish it out with some long handled ring forceps and happily posed for a picture with his catch of the day! Alas, our relationship with Harold was broken off when the psychiatric facility closed down. He was transferred to another institution out of our area.

Whether motivated by obsession, curiosity, or a little thrill, humans often get into precarious situations. When they can't undo things by themselves, we go to work.

Oh No. It Isn't Painless.

2012-09-21T17:51:00.000-07:00

Title song from M*A*S*H

Songwriters: MANDEL, JOHNNY / ALTMAN, MICHAEL B

Scene from M*A*S*H 1970

Through early morning fog I see
Visions of the things to be
The pains that are withheld for me
I realize and I can see

That suicide is painless
It brings on many changes
And I can take or leave it if I please

I try to find a way to make
All our little joys relate
Without that ever-present hate
But now I know that it's too late, and

That suicide is painless
It brings on many changes
And I can take or leave it if I please

The game of life is hard to play
I'm gonna lose it anyway
The losing card I'll someday lay
So this is all I have to say

That suicide is painless
It brings on many changes
And I can take or leave it if I please

The only way to win is cheat
And lay it down before I'm beat
And to another give my seat
For that's the only painless feat

That suicide is painless
It brings on many changes
And I can take or leave it if I please

The sword of time will pierce our skins
It doesn't hurt when it begins
But as it works its way on in
The pain grows stronger watch it grin, but

That suicide is painless
It brings on many changes
And I can take or leave it if I please

A brave man once requested me
To answer questions that are key
Is it to be or not to be
And I replied 'Oh, why ask me?'

That suicide is painless
It brings on many changes
And I can take or leave it if I please

'Cause suicide is painless
It brings on many changes
And I can take or leave it if I please

And you can do the same thing if you please

Suicide Is Painless lyrics © Warner/Chappell Music, Inc.

Pretty depressing song, isn't it? Successful suicides leave a lot of pain for those left behind. Even worse is the agony of a failed attempt gone wrong. Many wake up angry because their efforts to kill themselves have been thwarted by their loved ones and by medical intervention. Then there are those that miscalculated. Doing yourself in can be harder than it seems.

I had a patient many years ago who checked himself into a motel. His plan was to drink a bottle of Drano. He did not die but he did have severe alkali burns to his mouth and throat. We prepared to send him to the burn unit and he shook his head dejectedly. "I just thought I'd drink it and be dead" he said to me. My heart ached for him. There would be a lot of difficult days ahead for this man.

You wouldn't think that a BB gun would do enough damage to kill anyone. One man who apparently thought it would work shot himself repeatedly in the abdomen. He must have had the type of gun that allowed multiple pumps to increase the power. His wounds were not lethal but he did blow enough holes in his intestines that he needed a permanent colostomy.

I had several coworkers who'd had similar stories to one I'd experienced. A young man tried to shoot himself and aimed his gun into his mouth in the direction of his brain. He missed his brain but shot off his face. If his life was bad before this tragic event it must have been exponentially worse afterwards.

One situation never fails to mystify me. A person who has taken pills or taken some other suicidal action calls 911 or a family member for help then violently resists the ER staff's efforts to reverse the effects of their attempt. I can understand a change of heart but why ask for help if you don't want it?

Alligator forceps.

We get a lot of depressed patients who are "cutters". They are mostly young and females are more common than males. Usually they inflict minor wounds on their limbs but aren't really suicidal.

One night a male cutter had done enough damage that he needed stitches. There was a security officer nearby while the physician's assistant carefully repaired the wounds on his arms. He was restless and talkative and made a lot of bizarre comments.

Suddenly the man jumped up and grabbed a wrapped instrument from the counter. He waved around the alligator forceps and said he intended to stab himself in the heart. He became louder and more threatening. The unarmed security guards were unable to subdue him and he began carrying out his threat. He plunged the forceps deep into his chest and began to bleed from the wound. The situation became a standoff as he shouted that he would stab anyone who approached him. Ultimately the police were called and an officer fired a Taser gun to bring the man down.

The patient was relieved of his weapon and the medical team sedated him. He had punctured his pericardium (the lining around the heart) and had an air leak. He was rushed to the OR by the trauma team who were able to successfully repair the damage.

Today a suicidal, 20-year old man jumped the rails of a monorail at the Bronx Zoo and climbed over two fences, one of them electric, to get to the tiger enclosure. Thrilled with a mid-afternoon snack, the tiger began to maul the man. Zoo workers used CO 2 fire extinguishers on the tiger to keep him away from the man until he could roll under a fence to safety. Although taken promptly to Jacobi Hospital, the man later lost a leg that was too damaged to save.

I've heard there is instructional literature available to guide those who want to end it all safely and neatly. I don't expect Google to be of much help but I'm sure there are lots of resources to access this type of information online. Of course some people have psychotic states and hear voices telling them to harm themselves. Rational planning would not necessarily be possible in that frame of mind. Psychiatry is an extremely difficult field, in my opinion. Treating an infecton or a fracture is easy in comparison because you can physically see when the affliction is fixed. There just aren't any band-aids that will fix a broken soul.

Shift Happens

2012-09-06T17:30:00.004-07:00

Hospitals are open 24/7. Does that surprise anyone? A former schoolmate of mine was shocked when she graduated college as a nurse and was offered a position on the night shift. She replied "You want me to work WHEN?"

Sometimes the only openings available to the new nurse are the evening or night shifts. Some hospitals will only hire for multiple shifts, which is what I did in my first RN position. I absolutely hated switching shifts mid-week and I lasted only six months before I took a 3pm to 11pm position that didn't require alternating with another shift.

First of all I should admit that I'm not, never have been and never will be a day person. I actually remember the first time my mother woke me before dawn for school. I thought she was out of her mind. "Its not morning" I exclaimed. "Its still dark". I felt betrayed at the age of five. Hospitals tend to start their day shifts at 7:00 a.m., which except for a couple of months per year, requires getting up in the dark.

My first RN job alternated between 7am-3pm and 3pm-11pm shifts. I would usually get scheduled for a couple of day shifts in a row and then an evening shift. I'd have one day off then have to go back for a day shift. After getting off work at 11:30 at night I usually needed a little time to unwind enough to sleep. I'd be up till 1 or 2 in the morning and sleep in the next day. Of course since I didn't get up till 10 am or later I certainly didn't feel tired enough to go to bed at a reasonable hour. I'd be awake till after midnight then struggle to open my eyes at 5 am to get ready for work. I asked if I could do alternating weeks of day and evening shifts but that was supposedly impossible.

I never felt completely rested One morning, after hitting the snooze button on my alarm, I actually dreamed that I'd gotten up and gone to work. When my phone rang at about 7:30 I jumped out of bed, ran to the phone answering "3-West" and said my name. The voice on the other end said "No, you're not here. You're still at home". I opened my eyes and sure enough I was in my kitchen in my nightie. Clearly something had to change. The hospital would allow me to work all evening shifts or all night shifts if I wanted. I chose 3-11 and it fit well with my personal circadian rhythm. I was much happier.

I did my share of night shifts though. I first worked some when I was in college. I had a part time job as a nurse's aide. I worked out of the float pool, meaning I could be assigned any number of places in the hospital. I liked doing night shifts in the nursery once in a while. It had the advantage of being brightly lit at night (were you surprised when you brought your baby home that it liked being awake at night? There's a reason for that). We'd bathe all the babies on the midnight shift because the mothers were sleeping. Also we didn't have doctors showing up to do rounds.

The city hospital where I worked had a big nursery area and often we would have 20 or 30 babies. At any one time several would be crying so it was easy enough to stay awake. If I was really tired I'd sit in a rocking chair with a fussy baby and prop my feet up on the lid of the trash can. Not a bad scenario for working. At 5:00 am though all the babies went out to their moms. We'd wheel all the little ones down the hall and sit back in the nursery for about 30 minutes and then start collecting them up again before the pediatricians started morning rounds. During this 30 minute break staying alert was difficult because the nursery was so quiet. One night I was extremely sleepy and another aide looked at me oddly and said "I don't know what to say to you. You don't make any sense". I didn't know what she meant until I caught myself yawning in the middle of a sentence. When I stopped yawning I started talking about a completely different topic. No wonder she thought I was nuts.

When home in bed, after a long night with crying babies, I sometimes forgot I'd come home. If I heard the phone ring I'd jump up because I thought I needed to pick up a crying baby. My roommates found this quite amusing.

I later worked nights in the ER and in ICU. Sometimes twelve hour shifts, some ten hours and some eight. I liked best when I went to work in the early evening because everyone else was still up. When I went to work at midnight however, I'd feel a little sorry for myself because I knew that most people were already in bed.

There were nights I could have used toothpicks to keep my eyes open. I remember once I'd laid my head on the counter at the nurses station. The edge of the counter was sharp and digging into my forehead. It really started to hurt but I just couldn't seem to pick up my head.

5 a.m. was always my worst time when I started working nights. Around then I'd get a little sick feeling from being tired. Eventually one's stomach adjusts to being up all night and eating a chili dog in the wee hours seems like a great idea.

Driving home after a long night shift could be risky. More than once I sleepily drove right past my street. I habitually left work with a full bladder thinking that the urge to pee would keep my eyes open. Other times I'd be so wide awake I'd lay in bed staring at the ceiling. When I was doing 12 hour night shifts I felt an urgency to go right to bed when I had another late shift the next night. If I'd had some critical case right before I went home I'd still have too much adrenalin keeping me awake.

The rest of the population doesn't coordinate well with people who sleep in the daytime. People knock on your door, mow their lawns and insist on phoning at the wrong times. I remember my mother calling me right in the middle of my sleep time and then getting annoyed if I nodded off in the middle of the call. "Are you listening to me?" she'd say. I would remind her that I'd been sleeping but she just would keep talking anyway. Eventually I started unplugging my phone but then I'd forget to plug it back in after I got up. Naturally Mom then thought I must have died because I didn't answer the phone for three days.

In spite of my dislike of leaving my nice, warm bed on a cold and lightless morning, I've worked day shift for 26 years. You see, I married an early riser and so I sacrificed my internal clock to coordinate with his. When we were first married I worked nights. My hubby was great about letting me sleep in the daytime. Once though I woke during the day to what sounded like a cat in serious pain. I found it was my husband listening to his stereo in the next room with his earphones on. He was singing along with Jimmy Hendrix and it was not pretty.

I used to cook meals in my Crockpot while I slept so we could have a hot dinner without much last minute prep. This was a fine idea unless I got up in the middle of the day for something. The food smelled so delicious that I'd suddenly become ravenously hungry and couldn't get back to sleep.

Another hazard of working nights is when you try to do something normal in the daytime without getting any rest. Once we took a trip to Sesame Place, an amusement park, on a day after I'd worked all night. My husband drove but I was never very good at sleeping in the car so I didn't get any rest during the 2 hour drive. The park is very kid-powered and had a lot of places for them to run, jump, dance around and swim. One area the kids loved had huge cargo nets which we all climbed together. I lost my grip and rolled down into a low pocket in one of the nets and by now I was really, really tired. In this recumbent position, which would require strength to extricate myself, I felt like I'd rather just lay there and take a little nap. Of course our kids thought this was hilarious and jumped on top of me.

Exhausted night nurse stuck in a cargo net.

Exhausted night nurse's children enjoying her plight.

Night workers get used to attending events half-asleep and don't remember anything that happened while they were there. Sometimes they sleep through loud action movies. I even slept through my first root canal. Having a social life is tough for singles. Dating is difficult unless you date someone who works the same shift. As I said, I eventually decided that I needed to be a day person even though deep down I never will be one. I tend to be a night owl on my days off while my husband tends to get up early even when he is on vacation. I consider myself lucky that I start work at 8 am instead of 7 am because it's a little more light in the morning.

Some nurses work nights for most of their careers. Those who do this tend to sleep a lot less than the rest of us. They also get paid more money. I think they're worth it.

A Fly on the Wall

2012-08-31T20:06:00.002-07:00

Quite a few years ago one of our ER patient care technicians showed up for his shift with a new haircut looking like DeNiro as Travis Bickle in "Taxi Driver". I can't imagine the impact this look would have on the patients. The rest of the staff expected our Nurse Manager to go ballistic when she got him into her office. I could just envision her flushed ears and the thin-lipped grimace that usually preceded disciplinary diatribes. The next day the tech showed up for work at the usual time, the Mohawk just a vivid memory. Overcome with curiosity I had to ask him what she said. He replied that she was very calm and said that he just didn't look very professional. He had to admit she was right and agreed to cut his hair.


"you talkin' to me?"

DeeDee, a fellow nurse, wore a lot of jingly bracelets, her sunglasses perched on the top of her head and a white sweater over her shoulders with the sleeves rakishly tied in front. She kept her curling iron plugged in in the bathroom in case she needed a touch-up mid shift. She was a shameless flirt with most of the doctors. I was very new at this particular job. One morning I noticed a lot of angry whispering going on between the nurses. I started feeling a little paranoid and asked one of the other nurses if I was the reason everyone was upset. Her curt and cryptic reply was "I'll say this once. Watch out for DeeDee!" I was relieved to find I was not the cause of the problem but never learned any more about the situation.

While taking care of an uncooperative drug-crazed patient one night our ER doctor came to my rescue. I was trying to start an IV as the man thrashed around. It was a struggle trying to keep his arm steady. I got the needle in but hadn't yet taped it down or connected it to the IV fluid. Meanwhile he grabbed the leg of my pants and gathered the fabric into a bunch in his hand. His grip was so tight that I couldn't keep my foot on the floor. I wobbled on my other foot trying desperately to keep the IV from falling out when Dr. S, seeing my plight, picked up the man by the shoulders. He shook him back and forth while shouting "LET GO OF HER YOU SON-OF-A-BITCH!" This did not make the man's arm any easier to hold on to but he did let go of my leg.

One night, many years ago, a couple drove up to the ER in a very tiny Volkswagen Beetle. The woman had dislocated her hip and she was unable to get out of the car. She also wasn't wearing any pants. The young nurse naively asked "What were you doing?" Those old VW's were not made for romance.

While waiting for a severely injured patient to arrive, I went in the Trauma room to check if everything was set up. In the room was the (older, married) attending trauma surgeon and the (young, single and provocative) X-ray technician. They were having an animated conversation and suddenly became silent and exchanged furtive glances when I entered. I hadn't heard a thing but they did look very guilty.

We try to keep track of our patients but every now and then we misplace one. Many years ago on a very busy night shift a female psychiatric patient was in a room at the end of a hallway. A security guard was posted outside her door and there was no way out of the room without going past the guard. That's what everyone assumed. The nurse went to check the patient and found the tiny room empty. After a few frantic seconds the nurse glanced upwards and saw the ceiling tile that had been moved. She climbed up onto a stool to look into the ceiling and found the patient tucked up nicely inside. The nurse remained there engaging the patient in conversation. They even sang a few songs and eventually enough trust was established for the woman to allow her extrication from her hiding place.

Once in a while a patient can be your best assistant. I had a long-time IV drug abuser who needed blood work to be drawn. When the lab technician arrived in the room the patient refused to let her touch him. Junkies can be very protective of their veins. They don't want anyone messing up their pipeline to paradise. This man had massively scarred arms that had no veins that were accessible. He suggested he be allowed to draw the blood himself. The tech asked me what I thought about this and I said "why not". The only vein he had left was in his groin. I handed him the needle and he skillfully punctured his femoral vein. I passed him the various tubes which he filled as we directed him and the job was done without any difficulty.

The human element injects much color and humor into life in the ER. We say all too often "You can't make this stuff up". I wouldn't believe it all myself if I hadn't seen it.

More on the Capless and Capeless

2012-08-23T16:25:00.001-07:00

My previous blog entry was on what nurses wear these days. In reality I'd never gotten around to what we wear now but was still discussing how nurses used to dress. I clicked on PUBLISH POST before I'd intended so I'll continue the subject here and now.

Basic medical scrubs

Inmate chic

Its amazing to me that typical nurse attire isn't all that different from the latest trends in prison wear. Scrub suits initially were used only in the closed environments of the operating rooms or in obstetrics. They were affordable and easily laundered. In the late 1970's their use expanded to intensive care units where they became more visible to hospital visitors. When husbands made the jump from pacing the expectant father's waiting room to bedside labor coach they were given scrubs to wear. The new dads found the scrubs made dandy pajamas and brought them home. By the early 1980's scrubs began to have street appeal which led to thefts from the laundry. It got so bad that even SOILED scrubs were stolen from my hospital. Eww!

Initially only available in blue, white or green the manufacturers expanded their colors as they became more popular. Prints became more varied and ultimately licensed images were used. Today scrubs come in every design from NFL logos to Disney characters. Every holiday from Valentine's Day to Christmas has themed scrub wear.

Decades have come and gone since all-white nurses uniforms were required. We were first allowed to wear colored tops but still had to wear white pants. Ultimately the white just went away with little fanfare. The hardest transition was from dresses to pants.

scrub dress

In the 1950's and into the 1960's women wore dresses everywhere. The Pantsuit was a radical change in women's wear. Since nurses do a lot of bending over it makes perfect sense to wear pants. Shorter hemlines in the 60's and 70's were reflected in nurses uniforms but made it difficult to move around without flashing everyone. Yet when nurses started wearing pants some hospital administrators didn't go along. I knew older nurses who were handed white scrub dresses and told either to change or go home. These women persevered and pants became the standard. I didn't mind wearing dresses but these days I don't miss dealing with pantyhose.

Cotton scrub dresses were nice in the hot months. We'd borrow them from the OR and wear them in the ER. Once when I was younger I had put on a scrub dress for work that was really too short for me. My roommate pointed this out and suggested I change but I ignored her advice and went off to the job. I should have listened. A few hours into my shift we heard the sounds of a vehicle being driven at high speed outside the ER doors. A man had been shot in the chest. His friends loaded him up into the back of a pick-up truck and sped to the hospital. He was bleeding terribly and his heart had stopped beating. I jumped into the truck, knelt by the patient and started doing chest compressions while somebody else manned the airway. I was painfully aware each time I bent to do a compression my dress was displaying a great view of my butt. There was a lot of commotion so I'm sure nobody was standing around staring but I still felt embarrassed. When we had enough help available we moved him to a stretcher and brought him inside the building. I'd like to say that in spite of the valiant sacrifice of my dignity we saved the man but he was shot right through his aorta and did not recover.

Doing this in a short dress might put your undies on public display.

She prefers the nurse with the colorful scrubs.

Lately we are hearing rumors at my job that the hospital administration wants nurses to all wear the same (and probably unflattering) color. Patients and visitors do often have trouble identifying who does what. Since everyone from housekeepers to physicians wear some type of scrubs it isn't surprising that this is a concern. While I can appreciate the need clarify who we are to our patients, I see the positive impact of cheery scrubs. Wearing tops with familiar characters can make children smile. Many adults tell me they'd rather see us clad in something colorful rather than scary white. Just the other day a female patient told me that my bedazzled scrub jacket was the only thing that made her smile that day. (My daughter felt the unquenchable urge to add a few rhinestones to my jacket.) The term "white coat syndrome" refers to anxiety at the doctor's office or hospital. A significant rise in blood pressure can result from this. A large part of my job is to put my patients at ease. What I wear can help replace tears with smiles. I don't want to give that up.

What Nurses Wear These Days

2012-08-22T02:59:00.003-07:00

A smorgasbord of nurses caps

When we baby boomers were small children the typical nurse looked a lot different than the nurse of the 21st century. The traditional look of white uniform and cap exists in our memories but not in our lives today. I think the old style uniforms did command a certain amount of respect but I prefer more modern nurse attire.

The most identifiable feature of old-style uniforms was the nurses cap. Today it is hard to realize that there was a time when few people left home without a hat. President Kennedy sounded the death knell for men's hats when he attended his inauguration bare-headed. Through the 60's we changed a lot. Bras were burnt, hair became longer, tie-dye was born and hats were all but abandoned. Nurses just followed the general trend toward hatlessness.

Many caps were unique to a particular school of nursing. Often they were earned in stages. First the cap itself then the stripe. Some schools had several colors of stripes indicating each year of training. The black stripe was the crowning achievement. Capping and stripe ceremonies celebrated training milestones. Generic caps were available but many nurses proudly clung to the cap of their alma mater even if it looked like a cupcake or a paper airlplane.

I remember my aunt picking up her starched caps at the Chinese laundry. They came pressed flat and were folded into shape at home using special buttons. Some students in my graduating class asked if we could have a "white ceremony" and get our pins and caps. We were told that a university did not do that type of thing because it was not "academic" enough. We did have an official school cap however. I wore one for a little while after I graduated. One of my nursing instructors gave me a hint on how to glue on the stripe. She suggested using surgical lubricant which I found worked very well.

My cap did not come apart to launder so I soon gave it up rather than deal with getting it cleaned. By then caps were not required and it seemed like more trouble than it was worth when I kept getting it caught on IV hooks. In spite of the inconvenience, I feel that my cap did clearly identify myself as the RN to everyone.

Although the nurses cap has been obsolete for decades it remains an iconic symbol of the nurse. This young girl probably will never see a real nurse dressed this way. It does nothing for our professionalism that there are a lot of "naughty nurse" costumes available. (All include caps, of course.) You never see naughty doctor or naughty firefighter costumes, No naughty accountants or auto mechanics either. Hmmm.

Another lost relic is the nurses cape. Now I never got to wear one of those as a nurse but I did wear one in a play once. I was playing the part of a Salvation Army type worker. Several mothers of cast members loaned us their nurses capes for the play. They were heavy blue wool lined with red fabric. I felt very dashing while wearing the cape and I'm sorry they disappeared before I could acquire one.

One friend told me that for her capping ceremony her class marched in dressed all in white with their capes turned back over one shoulder to show the red lining. They made quite an impressive spectacle.

The whole idea of nurses wearing white escapes all logic. I suppose the idea was to represent cleanliness and purity with virginal white however difficult it may be to keep clean. Back when laundering of white clothing meant using bleach it must have been easier to deal with stains. By the time I was wearing white nearly all uniforms were make of polyester fabric which would turn yellow fairly quickly after using bleach.

One day, when I was still in school I worked part time as an aide. Near the end of a shift I was emptying a surgical drain belonging to a post-op patient. The drain was connected to a "Hemovac" which looked like two pancakes with springs in between them. There was a little cap through which the bloody drainage could be removed for measuring. This particular time I had emptied about eight ounces into a measuring cup when I slipped and knocked the cup over. My entire front was completely blood soaked from my chest nearly down to my knees. The patient's family became frantic because a couple of drops landed on the patient's sheepskin (a now-outmoded fluffy comfort pad.) Feeling I deserved some sympathy, I turned to show them the extent of the mess I'd made of myself while easily dabbing the few drops of blood from the sheepskin.

I went out to the nurses station and one of the RN's told me to use hydrogen peroxide to get the blood out. It was great advice and it took about four bottles to remove it all. My uniform was soaking wet by the time I'd finished. It was a very cold winter day and I didn't want to go outside wearing a dripping wet uniform so I put on a patient gown and pajama bottoms. I had my coat on but I was a little worried that somebody might think I was an escaping patient.

White uniforms definitely needed more upkeep and frequent replacement than darker colors. Besides, wearing white didn't really guarantee a germ-free nurse.

Death Be Not Proud At All

2012-08-16T18:39:00.000-07:00

By the time I was eighteen years old I'd only seen one dead person. My grandmother died when I was fifteen years old and I attended the wake and funeral. Actually my father had died five months earlier but I was having difficulty facing his demise and I couldn't bear to go and see him. By the time my grandmother died I felt ready to look at the face of death in person.

My grandma did not look like I remembered her. The mortuary makeup artist got her look all wrong. Her nose was too pointy. In spite of her appearance as someone else's grandmother I couldn't get over how many people said the same thing. "Doesn't she look natural?". I didn't think she looked natural at all. I hated that phrase then and still do today.

Since that day I've seen dozens, maybe hundreds of dead people. First as a crew member of a volunteer ambulance corps, then as a nurse's aide, nursing student and thirty-four years as a registered nurse. Rarely a person just looks like they could be sleeping. Usually though there is no mistaking death. It isn't pretty.

My first cardiac arrest on the ambulance corps was an elderly man who'd been playing poker with his friends. He keeled over at the card table and we responded. It was my first time doing CPR on a real person. I did mouth-to-mouth resuscitation at the scene while someone else set up the ambu-bag. His whiskers scratched my cheek. There was a rumbling down below. I smelled beer and approaching vomit. It was before HIV/AIDS and we weren't so worried about body fluids back then. Luckily I got out of the way before anything erupted. We continued CPR and brought the man to the hospital. We remained by his bedside through the resuscitation attempt. I looked into his eyes at one point and his pupils were "fixed and dilated", a code phrase meaning "Elvis Had Left the Building:" and that he was gone. His face said to me "I'm done". I did not feel that we had failed him. We did the best we could. It was his time to go.

Sometimes the ambulance responded to a scene where the patient had already had stiffened with "rigor mortis". We would not attempt to revive the person but would stand by until our city police surgeon arrived. I remember one day when this happened three separate times in succession. We didn't have much chance to save lives that day.

After I was going to college and in the nursing program I worked as a nurses aide part time. We hadn't really talked about death in school. We were mostly concerned with learning how to give injections, dispense medications, sterile technique, nursing care plans, fluids and electrolyte balance, bedpans and bed baths. When we spoke of death we learned of the stages of grieving as outlined by Dr. Elizabeth Kubler-Ross. Nobody ever told us what to do when it actually happened.

So one day I was working as an aide and I had a very obese elderly woman who'd had a massive stroke and was completely unresponsive. She was a DNR, meaning that if she died, we would not try to change her mind. We would not call a "Code 99" or do CPR. She snored loudly like a wounded walrus. She was not expected to last long but we took good care of her. We'd turn her every two hours to prevent bedsores and check her vital signs twice per shift. .

I had bathed her, turned her and had done everything she needed. The second time I did her vital signs I noticed something while I was taking her rectal temperature. I dutifully held the thermometer in place but saw she wasn't snoring loudly anymore. In fact she wasn't breathing at all. The first thing that crossed my mind was how stupid I was to be taking the temperature without noticing she had died. I found this funny but knew laughter was not appropriate. I tend to laugh when I get nervous and I didn't know what to do next. Nobody had ever told me what to do if my patient died. With a burst of horror I wondered if my positioning of her had actually caused her to die. I didn't panic. She was a DNR so I knew I wasn't going to get into trouble. I gathered my composure and went out to find the nurse. Having trouble deciding on the correct way to say this I blurted out "Mrs. Baker has expired". I thought this sounded official enough. The nurse reacted calmly and I learned a lot during the flurry of activity that followed.

In my next nursing class I brought up the subject of dying. "We should have covered this before now" I said. We discussed death briefly but we never did have an actual class covering care of the dead. I suppose they thought we'd learn on the job soon enough.

In my student clinical experience I took care of an elderly widow who'd had an infection of her big toe that spread to her foot, then her leg. She'd had a series of amputations. Each time the surgeon went a little farther north on her body but her diabetes and other factors prohibited the wound from healing. One day as I was assisting her to bathe she asked me how her body looked. I was surprised at this. She asked again what I thought of her body. I looked at her soft, pink skin that had obviously never tanned. Over eighty years old, she looked twenty years younger. I told her she was beautiful and I meant it. The next day I went to clinical and found she'd died during the night.

I was shocked. I hadn't expected her to die. She didn't look like she was dying. It came to my mind the reason she'd asked me about her body. She knew she was going to be seeing her dead husband soon. She had been worried about how she would look when he saw her. I'm sure he would have agreed with me that she was beautiful.

I've seen more than once that a person who knows that death is near has some influence on when it will happen. One man made this crystal clear to me. He had had a rough hospitalization with bleeding due to liver problems. He had been in and out of intensive care multiple times. He'd be stabilized in ICU and when improved he'd be transferred to the step-down unit where I worked. We'd tune him up enough for the regular floor then we'd transfer him out but soon the bleeding began again. This vicious cycle was wearing him down. He and his wife finally came to a decision that the next time he started to crash he would not be resuscitated.

It was in our step-down unit that the final showdown started. He was bleeding from his esophagus and from his rectum. He was pale and clammy. His wife was at home and we'd called her to come in when the bleeding began. The man was so weak and hypotensive it seemed his time would run out but he stayed with us. He kept saying "I hope she hurries up. I can't hold on much longer." He did not want to die without saying goodbye to his wife.

We watched him struggle for what seemed like hours but was probably less than one hour. Finally his wife of fifty-odd years arrived at his bedside. We let them have a few minutes alone together. Before long he was gone but he'd said his goodbyes.

Back in the 1980's in the ER I was taking care of a Roman Catholic priest. He was having cardiac problems and would suddenly become unconscious for a moment right before my eyes. Since he was connected to a cardiac monitor I could see that his heart was still beating. I'd give him a little shake and he'd open his eyes not knowing what had happened. Looking back I think he may have had an embolism blocking his carotid artery. We weren't using clot-busting drugs back then for this type of thing nor were we doing emergency embolectomies to remove a traveling clot.

There just wasn't much to be done so I tried to keep him involved in conversation. I talked endlessly to keep him from dropping off to sleep. I must have sounded like a blathering idiot because he asked me "Do you think if I fall asleep I'll die?"

"Of course not!" I lied shamelessly to this man of the cloth. "I just like to gab". I knew I wasn't fooling him at all. Before long he went unconscious again. He deteriorated rapidly until he had a cardiac arrest and we could not resuscitate him. While death is never easy to accept, it is more difficult to watch someone go from speaking normally and then quicker than lightening be gone.

After a hospital patient dies and any family has left the patient is taken to the morgue to await the medical examiner or the mortuary transport. In my first hospital the body was transported in a special morgue stretcher. There was a metal tray that was surrounded by a frame. A long, fitted sheet draped over the frame and since it was flat on the top it looked like a rolling table. I don't think it fooled anybody because it looked like something out of an old horror movie.

One Saturday afternoon after a patient had passed away I called the nursing supervisor to accompany the transport tech to the morgue. She was having an extremely busy day and would not be able to go to the morgue for a long while. Since we needed to move the body to free up the bed she suggested I go myself. I'd never been there before so she coached me on what to do. She said first, open the lockers till you find one that is empty. (I didn't like the sound of that at all.) Then just slide the body inside. It sounded pretty uncomplicated. So the tech and I escorted the ersatz Trojan Horse to the eighth floor morgue.

I should say that this was the only hospital I ever saw where the morgue was not in the deepest, coldest, creepiest part of the basement. Instead it had windows with a panoramic view of the city. Since it was Saturday, the place was deserted. In fact, someone had waxed the floor and the place gleamed in the mid-day sunshine. There were about ten or twelve rectangular drawers built in to one wall. These were the dreaded lockers I'd been told about. I held my breath and was relieved to find the first one I chose was empty. Inside were metal rollers onto which the tray from the morgue stretcher would slide right in.

In this particular hospital we brought the patient to the morgue wearing only a hospital gown. Usually we transferred the body by lifting with a sheet. We did not wrap them in the body bags that are used in every other hospital I've seen since then. On this day I made the mistake of taking the patient's foam egg-crate pad along with the sheet. Perhaps I felt the body would be more comfortable with a cushion for the last ride. I don't know what I was thinking. When it came time to slide the tray into the locker, the foam pad stuck out too far on the sides and we had trouble getting it in there. To make matters worse, the shiny, waxed floor was so slippery that our feet kept sliding while we tried to stuff the body in. Again, my nervous laughter got the best of me. The situation was so ridiculous I couldn't help it. After a struggle we got the body inside and slammed the door shut before it could pop back out again. I raced out of there to get back to the world of the living.

Sometimes death comes as a welcome relief after a long illness. The face looks peaceful because there is no longer any pain or suffering. Other times the face looks almost surprised with eyes and mouth wide open. Some people just look very tired. Trauma patients can be almost unrecognizable due to disfiguration from their mortal injuries. Yet an electrical lineman who'd been electrocuted had absolutely no sign of injury except two tiny wounds on his feet where the current went to ground.

While death is never easy, nobody expects us to last forever. It is difficult to say goodbye to someone we've loved for a lifetime. However, the senseless demise of a young person hits us especially hard. One day we had a trauma patient who'd just picked up his new motorcycle from the dealer. It was one of the super-fast Japanese bikes. The nicknames for these are "rice-burners", "crotch rockets", "donor cycles" (implying the potential for organ donations) or the "Kawasaki death bike". Nobody needs a motorcycle that will do 200mph. This young man drove his brand, new motorcycle into a guard rail and an early grave. He'd never even got the thing home.

Another time a young women was brought in in full cardiac arrest. Her beautiful, young body was a little too thin. She'd been anorexic and bulimic. The electrolytes in her body were so depleted that her heart could not function. Anorexics do not see themselves as we see them. They struggle for a perfect body that only exists in their own mind. They are not seeking death but all too often it finds them.

One day I was eating lunch with a few other nurses in our little lounge off the ER. Suddenly an unfamiliar nurse popped in the door way and asked "Which way to the morgue?". Everyone looked up to see she was holding a bundle about two feet long. Nobody spoke for a moment and then one of us got up and showed her where to go. We all looked at each other stunned by the little neatly-wrapped package which surely contained a little body. None of us had any appetite for lunch after that.

ER nurses are accustomed to seeing death but when it is a child, none of us are immune to the profound sadness of a life lost so soon. There are no words to console a mother who must hand her baby over to the nurse and leave for home without it. It never gets easier to hear the unashamed sobs of a bereaved father. Parents are supposed to outlive their children. We do what we can to soften the blow and to guide them through the sad days that lie ahead. We give hugs, kind words, a cold drink, some tissues and shed a few tears. We allow the family to spend time with the body and say what needs to be said.

Though we nurses must be strong for those that grieve, later, when we least expect it, we cry at silly things. For many years I could not watch little children on a carousel without crying. I'd cry at parades, especially if a band played The Battle Hymn of the Republic. Other nurses sob when watching a chick flick or when reading trashy novels. I've seen more than one nurse who could no longer work in the ER after unexpectedly losing a loved one. Sometimes we find our bank of compassion overdrawn and need to move on. We cling to our personal beliefs to help us cope when the unthinkable happens. If this life was not followed by another realm there could be no comfort in the face of death. I feel sorry for those who feel those they've lost are gone forever.
Death is not a final destination but a transfer on our journey. There are no round-trip tickets so we don't get to know what is ahead until we get there. Every last one of us will find out eventually.

School Nurses

2012-08-08T22:36:00.002-07:00

South Park school nurse.

My first glimpse into the world of nurses was at school. I don't remember being sick all that much but I do remember that the nurse's office was a pleasant respite from the demands of first grade. The room was quiet and I could be the center of attention. Miss Corn was sweet and comforting with a smile, a warm blanket and a listening ear.

My days as a nurse malingerer came abruptly to a halt when Miss Corn was suddenly replaced mid-year with a decidedly uncheerful Mrs. Reed. Rumored to be a former army nurse, she didn't put up with any nonsense. If you showed up to the nurse's office you'd better have real symptoms.

In my third grade year I attended a four-room schoolhouse that didn't even have a nurse full time. Once a week a nurse would stop by and spend a few minutes in each classroom to check if any of us had any communicable diseases. (This was before vaccines eliminated measles, mumps, rubella and chicken pox from normal childhood experience.) I found it hard to come up with an affliction spontaneously when she dropped by and besides any attempts for sympathy were in earshot of my entire class. One time I remember showing her that I had a minor burn on my arm but she shook her head implying I'd have to do better than that. .

The school nurses would supervise token physical exams from the school doctor once a year if your parents didn't have your pediatrician fill out an exam form. We lined up for a cursory check-up that lasted about five minutes. I felt the worst part about this was the public announcement of my weight. Still, it was a break from the classroom.

In the sixth grade all the girls in my class were gathered together for "the menstruation class". Permission slips were needed for this and our mothers could attend with us, if desired. This was long before school had any true sex education and there was no mention of what was happening to the pubescent boys. The nurse assured us she was there for assistance for our "female needs". This class was followed by a revealing tell-all in the girls bathroom. Those of us who had reached menarche prior to the class telling us how to do it showed off our superior knowledge.

Never athletically inclined, I managed to injure myself in gym at least once per year in high school. One time I was doing a vault, slipped off the horse and hurt my arm. I lay there moaning on the mat and the nurse showed up. She lifted up my arm by the fingers which increased the pain significantly. She then slid a huge inflatable splint over my arm. It was clear plastic and extended at least two feet past my fingertips. My mother came to pick me up to take me for xrays and the huge blimp-like thing could barely fit into the car. The nurses in the ER were amused by the splint. They'd never seen anything like it. Another time I hurt my neck in a poorly executed tumbling move. The nurse's exaggerated explanation on the phone had my mother convinced that she'd find me paralyzed and in traction. I got some xrays at the ER and survived neurologically intact.

The nurse's office in my high school had the only restroom that was not vandalized. Often paper towels were only available there. One time I had pink eye and dropped by the nurses office. My eyes were a little gooey and I needed a wet towel but I had not planned on trying to get out of class. When the nurse saw me she indignantly informed me that pink eye was a contagious disease and I was dripping germs all over her sink. She insisted that I go home and was not allowed back in school for five days. I thought this a tad excessive but who was I to argue.

My daughter was also a nurse malingerer. I was surprised to find that she visited her school nurse every single day in the second grade. She and several of her friends made routine check-in stops. More social than medical, her visits were usually made during recess.

School nurses in fictional literature.

When she was in middle school my daughter kept complaining to the nurse about her knees. I tried to ignore this assuming she was just trying to get out of gym. I grudgingly took her to an orthopedic doctor who felt there was nothing correctable. I got a second opinion and found that she had a condition called plica bands and had ligaments that pointed her kneecaps in the wrong positions. This ultimately needed surgery on both her knees when she was in high school.

During the years of the knee ordeal she spent a lot of time in the nurse's office for pain medication and ice packs. She became adept at evaluating the complaints of the endless parade of students and probably could have dealt with most of them as well as the nurse did. She was there when one boy came in complaining that he was foaming at the mouth. He was not having a seizure and certainly didn't have rabies. Apparently he had dosed off in class and a little drool leaked out of his mouth. The nurse offered a cot to lie down but my daughter said she'd have just sent him back to class.

I should mention here that being the offspring of a nurse has its disadvantages. I never became overly upset with minor injuries or illnesses at home after working all day at a trauma center. My response to my kids wanting sympathy was usually "Is there bleeding or are any bones sticking out?" In my daughter's short lifetime of generally underwhelming afflictions she learned to be skeptical of the whining of her schoolmates.

School nurses seem busier now than when I was young. More children with special needs are mainstreamed these days. Many of those special needs require intervention by the school nurse. Lice infestation seems much more common now. I don't ever remember being checked for lice in school but my kids often came home with a note saying there had been another outbreak. More kids need breathing treatments, medications, glucose testing and injections. Kids with ADHD were not considered to be medical problems but disciplinary concerns when I was in school. Now they're all on pills. Sometimes lots of them.

One time I went as a chaperone when my daughter's class went to Ellis Island and the Statue of Liberty. In my group one of the children had ADHD. The school nurse handed me a stack of small envelopes containing all the pills this child would need during the trip. There was at least one pill every one to two hours. Since I'm a nurse it seemed like a good idea for me to dose out the pills. A nurse I am but I'm not used to spending eight hours supervising six children one of whom never stopped talking and running around. He was a sweet kid but I was exhausted by the end of the trip after three boat rides and two islands. I didn't lose anybody but I came close a couple of times.

One school nurse near where I work in the ER had a creative budget idea for ice packs. Rather than purchase reusable ice packs that she'd never get back she used ordinary kitchen sponges which were soaked in water then frozen. She'd pop one into a plastic bag and it would last till the child got to the ER. Cheaper than chemical instant ice packs and neater than ice cubes which dripped everywhere it was an environmentally sound idea. We'd send the sponges back with the child but if lost they only cost pennies to replace.

I like the idea of being a school nurse when it is summer vacation. I'd love to have two months off every year. It's not an easy job and for the most part the nurse is by herself handling whatever comes in her office. It's almost like a mini ER. The nurse has a lot of children that need intervention during any given day either scheduled or otherwise. I think they earn those summers off.

BYOB (bring your own bedpan)

2012-07-29T20:21:00.003-07:00

Lets face it. Health care is expensive. That's why so many people can't afford to be sick. Don't worry, I'm not planning on going political here. My focus is on the effect of shrinking medical budgets has on the way nurses function. We are constantly asked to do more with less. Sometimes poorly conceived cost-cutting measures don't work out too well.

I was once working for a nursing agency and was sent to various hospitals in the area. The county medical center was my first experience with a hospital run by a government organization. I was a private duty nurse for a teenage patient with a head injury. The patient required hourly neuro checks which included looking into his eyes with a flashlight to check if his pupils reacted normally to light. I could not find a flashlight in the room so I asked one of the nurses on the floor for one. She told me that the hospital had used up their entire flashlight battery budget for the fiscal year. She suggested I flip the overhead lights on and off in the patients room instead. This was hardly adequate but I had no choice. I found they'd also used up their budget for coffee cups and if a patient (or nurse) wanted coffee the only option was small plastic drinking cups which did not hold up well with steaming hot contents.

I later worked at the same hospital for a brief time in my only foray into middle management. I was the assistant head nurse in the ER. One way I attempted to improve organization of the department was by stocking linen in each of the ER treatment rooms. This saved steps by avoiding the schlep to the linen cart each time one needed a clean sheet. I was told by the hospital laundry czar (an unofficial title) that I was hoarding too much linen and that wasn't allowed. I didn't react well to this type of barrier which expedited my return to the rank and file.

Hospitals use a lot of tissues and paper towels so this is a great place to save money. One place I worked had facial tissues that were so cheap the perforations between the sheets were incomplete. When one tissue was plucked from the box a whole string of sheets followed. Some tissues are so abrasive that one could easily sand off their eyelashes when wiping their eyes. It's not unheard of to find little bits of wood fibers visible in the paper towels. Someday we might be picking splinters out of our butts if the toilet tissue gets any cheaper. We once had some low-budget bathroom tissue that was so hard to unroll that you ended up with little shreds in your hand. One hospital administrator put her foot down at that. She said she was late for meetings because it took her ten minutes to pull out enough tissue to do the job.

Our hospital used to have a huge laundry area where we not only did our own wash but actually took in more from other facilities. Laundry is tracked by weight. For years now we've only been allowed to use thin flannel blankets in the ER because the regular blankets are too heavy and thus cost too much. One time our EMS department tried to keep their own sheets separate from everyone else's to control their laundry budget. To do this they dyed sheets a flashy dayglo orange for their exclusive use. Unfortunately the dye was not indelible and rubbed off on people's clothing. After complaints from angry patients wanting reimbursement for ruined garments they rapidly gave up the orange sheets. I don't think they lasted more than a week.

Normally we use pre-assembled aluminum crutches in the ER. They come in three or four sizes and adjust quickly to individual height with the push of a few buttons. Someone once decided that these were too costly and we were stuck with wooden crutches that were more labor intensive. They had to be taken apart and reassembled to custom fit to the patient. There were a lot of thumb screws and washers that needed to be kept track of and it was a big hassle. The ER techs, who did most of the crutch fitting, figured out that the increased time it took them to adjust the crutches actually made them less cost-effective than the aluminum ones. They were able to convince management to go back to the old crutches.

Some years ago the hospital downgraded the quality of our specimen cups. They were impossible to seal completely and they leaked. When we placed specimens in a bio-hazard bag to send to the lab there were always stray drops of urine in the bag no matter how careful we were. The lab techs get cranky if you send them leaky cups. They tend to send them back and have you try again. It was a big time-waster so I embarked on a personal crusade to correct this. I was serving on a product review committee run by the head of purchasing. I had brought up the subject of the leaky urine cups and was essentially ignored. One day I prepared a pseudo specimen of water colored with Betadine to bring to the committee meeting. True to form there were a few drops in the bag that escaped the cup. I placed the cup in front of me on the conference table and said nothing. The head of purchasing looked aghast and said "is that a real specimen?" I smiled inscrutably and said "It sure looks like one". Before long we changed to cups that didn't leak.

The little alcohol pads used to wipe the skin for an injection have gotten smaller and less moist. One nurse said to me "you have to suck on 2 or 3 to get a good buzz now". She was kidding. I think.

Demonstration of use of the eme-bag.

We recently got rid of all our large plastic basins. We lost the traditional kidney shaped "emesis basin" a while ago. Now if a patient has to vomit the only receptacle is the "eme-bag". They come in a handy wall dispenser. They do leave a smaller "carbon footprint" because they use biodegradable plastic. I suppose that's why they are green. I don't really want a container with body fluids to break down too quickly though. The bag is demonstrated here by a nurse and you can see that a certain amount of precision is required to aim correctly. Not everyone is that careful about vomiting. I handed one to a nauseated patient the other day and he said "WOW! Now that's a big condom!". Some people just have their minds on one thing all the time.

For a short while the meal trays for patients in our behavioral care area were little more than bread and water. They were given a simple sandwich, a small bottle of water and some marginal dessert. These austerity meals did nothing to improve the ambiance of the department. Patients protested the "jail food" and regular meal trays were brought back.

We face a constant battle for our health care dollars. Its all about reimbursement. Hospitals get paid set fees based on a patient's diagnoses from insurance companies or medicare. If the hospital brings costs under what they will be reimbursed they get to keep the difference. There really isn't ever a surplus, because money is reinvested in upgrading equipment or buildings. Truthfully I prefer scrimping on toilet paper rather than something more critical, say for instance, defibrillators.

Revenge in the Mountains

2012-07-25T20:51:00.002-07:00

I worked for a time in an ER in Utah. The intermountain west has a completely different lifestyle from the suburban NY environment where I grew up. Never was this more evident than during deer season. The opening day of deer season is a state holiday. Schools and banks are closed. Mothers send their children and pets out to play wearing day-glo orange for safety.

Stores in town have "deer widow" sales although a fair amount of women hunters join in the gunfest. Hunters stream en masse from nearby states. It gets a little crazy especially when excess alcohol is involved. (Yes, there are people who drink in Utah.) The deer hunt always brought us an influx of casualties.

The start of the general hunt is always in late October. Much of the country has crisp fall weather and sometimes warmer "Indian Summer" days at this time of year. (Are we supposed to say "Native American" summer now?) In the Wasatch Mountains of Utah, October brings wintry weather. Hunters coming from California can be surprised at the temperature and may be under-prepared. We'd always get some people needing treatment for hypothermia or frostbite.

In addition, city "desk-jockeys" were often not fit enough to traipse around snowy mountains at 8000 ft above sea level. The thinner air brought on extra stress to the cardiovascular systems of these mountain man wannabees. We'd get a fair amount of heart attacks from this group.

Because of the sheer numbers of gun-toting yahoos out there a hunter needs to take extra precautions to avoid injuries. It is vitally important not to carry a deer in your arms nor place it on the back of a horse or pack mule after it is killed. If a trigger-happy idiot sees moving antlers he'll shoot even though the deer might not be walking on its own. We even heard of cows or large dogs being mistaken for deer.

One hunter was proudly dragging his trophy down the mountain in the snow. The slope was pretty steep and the carcass picked up some speed. Soon the hunter was running down the hill trying to keep ahead of his prize. Before long the deer caught up with him and gored him in the testicles with an antler.

The man walked painfully into the ER where we fixed him up. His hunting buddies were having a glorious time embellishing the story with ribald commentary. His gait was still pretty awkward even after the doctor had finished suturing. I'm sure he was in a lot of pain for a good while. Even worse must have been the humiliation from the comments he would surely hear during the next few days. The hunters in Utah take deer season very seriously.
So do the deer.

Drama, Life and Lies in the ER

2012-07-23T12:32:00.001-07:00

Once in while the ER is full of drama just like on TV. Adrenalin is pumping and sometimes a miracle takes place. Other times melodrama takes over.

More often than I care to count I've had a patient burst in the door with a bloody towel over his hand or arm saying he'd cut off his finger or hand only to find that his injury was nowhere near as major as the performance. Sometimes when the blood is washed off the actual wound is hard to find. Usually the exaggerated behavior is due to panic but other times it is strictly for attention. One man threw himself on the floor in "agony" when he heard he'd have to wait for the doctor to see him before he got any pain medication. He refused to let me help him up because he didn't want anyone as mean as me to touch him.

We had a frequent patient who was often brought in by ambulance after having a seizure. When she regained her normal mental status she'd always want to leave quickly because her children were left home alone. EMS unfailingly found full bottles of her seizure medication at her house. She swore she took the capsules as directed but said she had a gastric absorption problem so they didn't work. This same scenario recurred on a regular basis with us discharging her as quickly as possible to get her back to her waiting family.

One ER doctor insisted on doing a complete medical evaluation in spite of her protests. We started off by doing orthostatic vital signs. (Taking blood pressure and pulse both standing and lying down to determine if the patient is dehydrated). When we had her standing up she started swaying. She stated "I'm fainting" and jumped up onto the stretcher, collapsing into a tragic pose.

Another "seizure" patient was from my days as an EMT. I was a volunteer for an ambulance service in a small city. My usual shift was from 6 PM till Midnight on Friday. One older man must have gotten lonely during the weekend because he often needed to go to the ER on Friday night. One night he tried shooting himself in the head with a BB gun. He had just a small dent in the side of his forehead which didn't even need a bandaid. Another night he was having seizures. He was thrashing about violently when we arrived. The shaking continued far longer than the usual seizure although he was breathing adequately and did not appear in any real distress. Once in the ambulance he settled down until one of the crew said "look, he's not seizing anymore". The patient promptly started convulsing actively and kept it up till we arrived at the hospital.

I used to work with one ER doctor who had a unique approach to waking up a male faker pretending to be unconscious. The doctor got right down next to the man's ear and softly said "now hold very still while we cut off your penis". The patient immediately sat bolt upright protesting loudly to any impending surgery.

It is not always clear what motivates a dramatic performance. Sometimes it is obvious like when we get a defendant from the courthouse with an attack of chest pain just as the judge is about pass down a sentence. There are times though when the event truly is a head-spinning, heart-pounding experience.

Military Anti Shock Trousers (MAST)

One night we got a call from the paramedics that they were bringing in a victim of a stabbing. CPR was in progress. Apparently the man was stabbed in his chest on the street. He was able to stumble into a nearby bar where someone promptly called 911. Paramedics arrived rapidly, placed him in MAST trousers and transported to us. At the time (early 1980's) inflatable anti-shock trousers were the standard treatment for a serious trauma. The theory was that compression from the trousers decreased the need for blood in the lower extremities preserving the diminishing blood volume for the brain and vital organs. I'd never seen it work all that well up till that point although it usually helped the patient's veins engorge enough for the medics to access them more easily.

Pericardial Tamponade

When he arrived at the ER he had no discernible vital signs in spite of the anti-shock garment. Our trauma surgeon used the electric sternal saw and rapidly opened the man's chest. The pericardium was full of blood causing a tamponade which prevented the heart from beating. We suctioned away the blood using an auto-transfuser which enabled us to give the blood right back to the patient. With the tamponade relieved the heart started beating again although there was a hole in the wall of the heart. The thoracic resident plugged up the hole with his finger to slow the leakage from the ventricle. Meanwhile two nurses kept busy hanging bag after bag of blood from the blood bank.

We ran with the patient to the waiting surgical suite. Doctors, nurses, respiratory therapist and ER technicians all racing down the hall and crowded into the elevator. The resident kept his finger in the hole kneeling on the stretcher next to the patient. Upon arriving at the OR he was rapidly prepped for surgical repair of his heart. I glanced down after hanging yet another transfusion and saw an OR nurse speaking in the patient's ear. At first I didn't understand what he was doing until I saw that the patient had awakened. His chest was splayed wide open, the beating heart, inflation and deflation of his lungs visible to all. He could not speak because of the breathing tube in his throat but his eyes were open and his fingers were crossed. I could hardly believe what I was seeing.

We turned over the patient to the surgical team and went back to the ER shaking our heads in disbelief. None of us had ever witnessed anything so profoundly miraculous. How the chain of events had worked in this man's favor! What if the bar had been closed? What if the medics didn't get there in time? Now, thirty years later, the anti-shock trousers have all but been abandoned due to their lack of success. That night they were part of the miracle.

About ten days later I had a patient in the ER for a minor medical problem. When I saw his name I looked up at his face. It was the man who'd been stabbed. He was discharged from the hospital the day before and had a problem unrelated to the injury. I asked him if he realized how lucky he was. He nodded and said "I sure do".

Years later I saw a similar case dramatized on the TV series ER. It did make good viewing but it didn't come close to the night when I saw it all unfold in front of me.

Newsworthy?

2012-07-19T19:41:00.001-07:00

We love our news. We complain about all the bad things we hear but if they focused on good news would we watch? Sometimes they go overboard with the blood and guts but only because people want to see more of it. If the racing cars never crashed once in a while wouldn't watching NASCAR get boring? Look at space travel. Before the Challenger explosion we were pretty blase about watching a launch on TV. It was televised live that fateful day only because it was to be the first shuttle voyage for a teacher. We sure watched the film of the explosion. Disasters get a lot of air time.

Fortunately earth-shattering news doesn't happen every day. In fact, news often requires some creativity. When you work in a field which makes it on the news once in a while a couple of things become abundantly clear.

1. Reporters exaggerate to make things more exciting.

2. Sometimes the newshounds get desperate for something to happen.

3. Don't believe everything they say.

Sometimes the truth isn't as terrible as they'd like you to believe. Reporters like to state that someone intoxicated is at twice or three times the legal limit. I'm not disputing the hazards of driving while impaired by alcohol or drugs. It's just that its pretty easy to get to three times the legal limit. We see these numbers in the ER all the time. In fact I've seen chronic drinkers happy and singing at six times the legal limit! Some of them start having withdrawal symptoms ( DT's ) at twice the legal limit.

One time, after hearing the blood alcohol level of one of our regular patients, a security guard asked me about it. He remembered learning in driver's education that a level of .400 should put someone in a coma. I explained that those numbers were for amateur drinkers. The patient overheard our conversation and laughed. "That's right", he said. "I'm a PROFESSIONAL".

Rabies is a deadly disease. A few years ago an article in a local newspaper about rabid bats brought in a surge of patients with bat encounters to the ER for rabies shots. So many people showed up that we actually ran short of the vaccine. In addition, the media loves to use the phrase "the series of painful rabies shots" to describe the immunizations. Many years ago the rabies antiserum was incubated in duck eggs. They required fourteen separate injections which were administered in the abdomen over a period of thirty days. This vaccine caused the bad reputation but was discontinued by the manufacturer in 1981. A vaccine produced in human cells is now used and is no more painful than a flu shot. The first visit includes an injection of rabies immunoglobulin given in the gluteous (rear-end) and one injection in the arm. A total of three more injections in the arm are required over two weeks. If an individual is immuno-compromised, one more is given two weeks later. It's a hassle but not as dramatic as the news makes it sound.

We received a flurry of incoming phone calls one day after a news item on The Today Show reported a child died because some hospital ER didn't have the proper pediatric equipment. The ensuing scenario, which I'm sure, was replicated across the nation, was that panicked parents needed to make sure their local ER's had enough child-sized resuscitation apparatus.

Big cities have enough newsworthy events to make an editors job only deciding which of all the crime, mayhem and corruption will bring about the best circulation or most viewers. Smaller communities require more labor to find that type of sensationalism. This became evident one night in the ER. A taxi pulled up and out limped an scruffy-looking injured man. He looked a little like later-life images of Howard Hughes. His story was that he'd been in a plane crash. He said he'd flown in a small plane from Wyoming to Salt Lake City. The pilot reportedly had overshot the runway and ran into a fence. The patient said he walked to the nearby road, flagged down the cab and came to us. The driver didn't know anything other than the man had just been walking along the road.

Artist impression of Hughes in his final years,

based on eyewitness descriptions.

This story sounded a bit far-fetched but we had to decide whether or not he had potential for serious injury or was just crazy. If he really was in a crash, did he walk off and leave the pilot in a heap of wreckage? We called up the local airport to check this out. They hadn't heard about anything like this but wondered if something occurred at a smaller nearby airport that was only open in the daytime. They thought maybe the pilot had planned to land there, forgot it was closed and didn't have enough fuel to continue. Nobody was there at night so they would have the police department send someone over to check it out.

Not five minutes after this phone conversation had passed we got a call from a local TV station wanting a statement for the press regarding victims of the plane crash. Apparently some reporter hunched over a police scanner had heard the squad car being dispatched to check out the closed airport. The guy probably wet his pants with excitement at the prospect of his big scoop! We hated to burst his bubble. We told him that we weren't sure what happened but there certainly was no huge disaster. No downed plane was ever found so we decided the patient was just confused and went on from there.

Another night, as I was working in the ICU, I was taking care of a patient who'd been the victim of major trauma. The man was critically injured and unconscious but still alive. The TV in his cubicle was on and his accident was the lead story on the late news. The anchorman grimly proclaimed that my patient had already been pronounced dead at the hospital. This was rather surprising since he looked alive to me. I remember hoping that none of the man's family had been watching the broadcast.

The Simpson's Kent Brockman

The news gets it wrong a lot of the time. Part of the reason for this is that the people who actually know what really happened are bound by privacy laws to keep things confidential. An administrator speaks for the hospital but usually hasn't had any direct contact with a victim. The closest a newscaster can hope to get is in the parking lot or possibly an auditorium. Certainly medical news can't be the only area where there is a gap between the news and the truth. Keep that in mind during the stories about politics, sports, wars, crime, religion, celebrities, industry, science...

Your Drug of Choice Sir/or Madam?

2012-07-17T21:04:00.002-07:00

Every ER is a target for people who are dependent on drugs. When a private physician doesn't meet all the patient's expectations we're sought out to fill in the gaps. When you work in the only hospital in town you get to know some of the"frequent flyers" pretty well. We see some of them so often that they almost seem like family albeit not necessarily our favorite auntie or uncle. I've changed the names to protect the innocent and my liability.

Vern, a middle aged insomniac, would stop by in the wee hours for some Thorazine and a cup of coffee. He wandered in at night because he didn't sleep but not because he was lonely. His girlfriend, Lisette would sometimes come in with him but usually she wanted something more potent and was very loud when she didn't get what she wanted.

Unlike Lisette, Brenda was an excessively cheerful, blonde, pony-tailed drug seeker. She had the kind of perkiness that Suzanne Somer's character Chrissy had on the sitcom Three's Company. Her unlikely life story was that she'd once been a dancer with the Radio City Rockettes. A back injury ended her dancing career and started her downward spiral. She later became a surgical technician which is where she first had easy access to needles and narcotics. By the time we met she had massive scarring on her arms from IV drug abuse. She had frequent infections from using dirty needles and when she needed an IV for antibiotics it was very difficult to access her veins. She came in often to score pain pills but unlike most addicts she was always happy and talkative.

One day she let us know that she was working on a new career. She was going to mortuary school to learn embalming. I offered her my best wishes but secretly I wondered how she would fit in with the funeral industry. Every funeral home employee I've ever seen was dignified and serious. I just couldn't imagine her bubbly personality in that somber environment.

Would you buy a casket from this woman?

At one point she developed an illness that needed treatment with frequent IV medications. Since she'd already exhausted the veins in her arms the next step was a portacath. Embedded in her chest was now a nice, handy port through which she supplemented her prescribed medications with pain pills she purchased on the street. She crushed the tablets, dissolved them in water and injected them into her port. Naturally this caused more infection and clogged up the tubing. Brenda ultimately overdosed on something and passed away before she could complete her morticians training.

Kaye was bipolar and would show up often when she was manic. Prone to dramatics and self-medication she was rather unpredictable. Some people with bipolar disorder tend to have times when they feel they don't need their prescribed medications. That is usually when their behavior becomes the most bizarre. This state combined with recreational drugs or alcohol you never know what will happen.

I first met Kaye when she was brought in as a suspected drug overdose. Not knowing what she'd taken the doctor ordered a urine toxicology screen. She was much too wobbly to walk to the bathroom and aim into a plastic cup so I placed her on a bedpan. A security guard was outside the door. I gave her a few minutes of privacy since not everyone can pee with an audience. After a suitable interval I peeked in to find her towering over my head, standing on the stretcher, stark naked with the bedpan between her feet.

Kaye's frequent visits were prior to the widespread use of computers. Our charts had the demographic information typed by hand and the medical information was written in longhand. It escaped my notice for a long while that Kaye was sometimes identified as Kathleen. I assumed Kaye was a nickname. We had lots of patients who used more than one name. I didn't give this much thought until the day I thought I was seeing double when they came in together. Identical twins both with bipolar disorder, drug habits and very difficult to manage.

The sisters would keep us guessing as to which one we were seeing until one day Kaye was brought in in full cardiac arrest after an overdose. It was the weirdest "code" I've ever had.

She arrived via ambulance with basic CPR in progress. If not intubated during resuscitation the stomach can become filled with air from the rescue breathing. Kaye had so much air in her stomach that she looked nine months pregnant. We placed a tube into her trachea and also placed a nasogastric tube to decompress the stomach with limited success. The patient care technician was doing great CPR but with every compression there was extremely loud flatulence. That's right. A prolonged, sonorous fart accompanied every stroke. As if all the noise wasn't bad enough the room was soon permeated with an odor so incredibly foul that it was all we could do not to gag or throw up. It was difficult to maintain professional decorum in this environment. We worked the code for a long time because of Kaye's young age but we were unable to save her. It was oddly fitting that someone who had been so troubled in life should have a death that was so freakish.

Strangely enough, I was present for Kathleen's demise also. A few years later she too was brought in unconscious after an overdose. Extremely unstable when she arrived, her condition continued to deteriorate and ultimately she arrested. Unlike her sister we were able to get her heart going again. She hung on for a while but died later that day in intensive care. Kathleen's death was more conventional than her twin's but I marveled that I had been the last ER nurse for both of them.

Pain sucks whether it is emotional or physical. Throughout human existence we've found a lot of chemicals that can comfort us for a little while. In my time in the ER I've seen many unhappy patients because they don't think we cared about their suffering. Often times they storm out after making a big, sympathy-seeking scene. The medical professions are all about wanting to ease suffering and helping people to be healthy. Some individuals can't have both. What makes them feel good sometimes kills them. We try to stop that from happening but if they don't get the drugs from us they'll find them somewhere else.