Showing posts with label ER. Show all posts
Showing posts with label ER. Show all posts

The Shoe

Sunday

Fresh out of ER orientation and really wanting to prove myself to be a competent nurse. An unconscious petite young woman was brought in by DFD* ambulance.

She had a high fever and had experienced a seizure PTA*. She stood about 5 feet tall and may have weighed 100 lbs. As a team, we stabilized her condition and were preparing to send her to the ICU when a resident announced that he had to perform a spinal tap first.

Well hell.

The spirit of the ER was to “Treat & Street” meaning…“Stabilize them and get them out of the ER”. Our rationale was (since you never know what will come through the ER doors at any time) a bed must be available for the care of the next patient. It made sense to me and was a priority of the ER nurse to facilitate transfer to another area of the hospital as quickly as possible.

So, I (reluctantly) set up an LP* Tray for the resident and left him and three other residents to their own devices while I took care of other patients – this was my first mistake. About a half hour later, I couldn’t help but notice that they hadn’t finished the LP yet – the procedure usually just takes a few minutes. So, I poked my head in the door and saw that all four of them were still inside. “What’s up?” I asked. The senior resident replied, “Dr Surly (a pseudonym) is coming down do it.”  Another delay.

On a good day, Dr Surly, a tall, imposing doc was grumpy. Today, he was grumpier. Being summoned to ‘the pit’ because no one on his service was successful in performing a simple L.P. put him in ‘a mood’ to be sure. He walked into my patient’s room, and without saying a word, rolled up his sleeves and began the procedure. The tension in the room was palpable. Everyone, including myself remained in the room, silent.

I took this opportunity to quietly create a written inventory of my patient’s belongings - a hospital requirement prior to transfer – and (as I was told) one of the signs of a good ER nurse. I found her bag and began my list…
  • 1 pair of shorts
  • 1 pair of socks
  • 1 towel
  • 1 bottle of unmarked blue pills - “I should mention this later – after the tap is done”
  • 1 bottle of unmarked white pills - “Wow. This is critical information, but it can wait until after he’s finished” thinking to myself. 
Despite 4 Residents, 1 Staff Doc, myself and a sick lady, the only sound heard in the room was the ticking of the clock. Back to my list...
  • 1 set of keys
It was then I made my second mistake.

Reaching into my patient’s bag, I removed a HUGE tennis shoe. It must have been a size 13. Unable to stifle myself, I held the shoe high in the air and blurted out, “Holy Cow! Would you look at the size of her feet!” With that exclamation, everyone looked at our petite patient's feet. Without missing a beat, Dr Surly (with the spinal needle still in the patient’s back) said, “May I ask just what you are doing in my gym bag?”

One by one, the residents filed out of the room. We could hear them howling with laughter in the hallway. Then, Dr Surly’s eyes met mine - I burst out laughing, tears streaming down from my eyes. Dr Surly, ever the professional - successfully completed the LP. All the while, his shoulders quivering and biting his lip. As he was leaving, I handed his bag back to him and without a word, he walked out of the room.

I wonder if he got a kick out of finding the completed "Patient Valuables Record" I had left inside.

#TheIsolationJournals - Glorious Awkwardness

*DFD - Dallas Fire Dept
*PTA - Prior to arrival
*LP - Lumbar Puncture (Spinal Tap)




2020. The Year of the Nurse. As if...

Thursday

A glimpse of the camaraderie, professionalism and science of Nursing
My inspiration for this post is not to praise my colleagues, although they deserve praise...
but rather to put the call out there for backup. 

I'm talking to the kind, organized, intelligent and compassionate people out there 
 to be the next generation of Nursing.

I'm talking to you.

So, here I am making masks for my friends who are on the front-lines of care during this COVID19 pandemic. 

Nurses in the ER, ICU and Screening Centers. I think of them. And how cool they are. How smart they are. How 'science-based' they are. I've been retired for a few years now and anticipate that there may be a high probability I will get back into the fray - should it be necessary.

The 'calm before the storm' in Dallas has got my head back into 'Nursing Mode' and my training to never quit and to anticipate worst-case scenarios has been revived.

Hence, the masks


Recently, our current Lieutenant-Governor of Texas, Dan Patrick implied that I would gladly give up my life for the US Economy... but I say- hold up there, Dan - not so fast. 
 I take good care of myself and I still have a little life left in me. 

Believing in science and knowing how expert Nurses, Doctors, Techs, Respiratory Therapists and all those in concert, encompassing a wide variety of healthcare disciplines, I'm confident that this virus will be managed safely and effectively with all hands on deck. 

That includes you, Dan. You are in a position that can help move mountains in this crisis. 
Be a Nurse, Dan. Don't be a Dick.
Anticipate worst-case scenarios and work your ass off to prevent them.

Awright... back to Nurse Recruitment...

Who knew that Nurses were not all about bed-baths and pill passing?

Beginning my Nursing career in Toronto, Canada and I became a 'Dialysis Nurse' at age 19. To say that I was scared shit-less would be an understatement. That year in Dialysis was one of great introspection and self-assessment. Not counted as one of the best Nurses in my unit, I had some growing to do but I realized that what I brought to the Nursing table was a passion for learning, and a profound degree of compassion and love for others.
Just a kid, really.
Nursing provided me an opportunity to travel. I made it to the USA from Canada and found myself  'Jones-ing' on 'Cardiac Medicine'. It was a 'Telemetry Unit' where I got a crash course in Organizational Skills, EKG Interpretation and Cardiac Resuscitation. Loved it!

Being young. I had a restless heart. The ER strangely soothed that restlessness. Hard to explain but there ya go.

Advised to be an ER Nurse by a Doc I had met while working in Cardiac Medicine, I loved it. It was exhausting, and difficult, and life-altering and taught me more than I can ever know about the fragility of life.  

Later in life, I anticipated (Hey, Dan) that the pace of ER Nursing might be a little much on my 50 year old body and decided to learn how to be an ICU Nurse. 

Back in the day, our CT scanner was a 0.5 mile trip each way from the ER. Multiple trips to/from CT included running all the way while pushing a stretcher loaded with a sick patient, monitors, defibrillators, IV pumps etc. Good News... since then, I hear things have improved as most ER's have their own CT Scanner in the department now! Yay you!

Although ICU Nursing was no picnic, it was physically hard work as well but you generally had a chance to get a cup of coffee before you took report from the off-going Nurse.
In the ER - this was not always an option as many times CPR/Traumas/Hemmorhagic Emergencies/Crazy/Stoned/Drunk People (the list goes on) required that you immediately step up.
ICU Nurses, et al
ER vs. ICU:
It seemed to me that in ER you relied on your super-keen observation skills & spidey-sense to anticipate if a patient was going to 'crump'. In the ICU? Everybody looks like they are about to 'crump' to begin with - so you have to rely on the numbers to help you prevent 'crumping'. Numbers? That's where it gets really interesting. ICU Nurses use high tech monitors to identify specific values of pressure, rate, volume etc. simultaneously in real time while administering care to their patients. But that's yet another post. Oh, and I was surprised at how 'thankful' families were in the ICU - the 'emergency' was now over and they had time to process what had happened to their loved one. Gifts of cookies, flowers, pizza abounded ...Sorry ER.

In Nursing...you have an instant 'peer-group': The friendships are real and lasting and many times profound. So many memories of the fun (and not-so-fun) times with my Nurse-friends. I could write another post on Nursing-friendships alone...but you get the idea.

At one point, I gave Nurse Management a whirl - it was not well suited to my personality - but is definitely the way to go for some great Nurses out there - I'm talking to you, Susan Rossow RN, Jody Phillips RN, Jessica Wilson RN, Jane Norris RN & Lillie Crain, RN ...to name just a few. I wish I could name them all but after 42 years... it's a lengthy list.

And I kid you not... I was an 'underachiever' in Nursing.

Nurses that I have been honored to work along-side throughout the years, are now...
  • Infection Control Nurses
  • Cardiac Rehabilitation Nurses
  • Nurse Practitioners: Some of their specialties include Emergency, Pediatrics, Psychiatry, Trauma, Critical Care, Family Practice, Gerontology
  • CRNA's : Certified Registered Nurse Anesthetists 
  • Clinical Nurse Specialists: Critical Care, Pediatrics, Nursing Education
  • Professors of Nursing
  • Case Managers: They assist patients, families, and the Health Care Team with determining future needs of the patient, prevention of 'issues' and identifying potential barriers to their progress.
  • School Nurses
  • SANE Nurses: Sexual Assault Nurse Examiners
  • Flight Nurses
  • OR and Recovery Room Nurses
  • Day Surgery Nurses
  • Plastic Surgery Nurses
  • Home Health Nurses
  • Nursing Entrepreneurs
  • Neonatal Nurses
  • Hospice Nurses
  • Palliative Care Nurses
  • Oncology Nurses
     So I'm writing this in anticipation that one day soon, we will need you. I will need you. 
ER Nurses, et al
Granted, Nursing is not for everyone. 

A good attitude about dealing with shit that you really don't want to do is necessary for Nursing. But Nursing as a career choice was the best choice for me and I'm here to say... if you think you might have what it takes... do it. If you already have a degree, it will take you about 2 more years (give or take) but that would be 2 years well spent. At the risk of sounding crass, the pay is good - starting around $65,000 in Texas for a new grad. (depending on your area) with health care benefits for you and your family, flexibility in hours and shifts, tons of specialties, incredible job-security and a lifetime of unbelievable experiences.


Any Questions? I'm here for you. 


And for my Nurse-Colleagues, the Techs, RT's, Docs, Unit Clerks out there... I know this is a scary time for you and your families. Please know that I love you, miss you, pray for your safety and thank you. But I also know that you are all over this and will help see us through this difficult time. 

2020. The Year of the Nurse. As if Flo planned it this way.





Have You Hugged Your ER Nurse Today?

Sunday

A few years ago I packed up my trauma shears, kelly clamps and community acquired antibodies to leave ER Nursing behind me. The separation was quick and clean and one of the toughest career decisions that I have ever made but knew it was healthiest for me to quit while I was still on top of my game and while I remained patient, competent and caring.

To me, the intrinsic beauty of ER Nursing was in the capacity to choose to be someone’s hero every day but believe me when I say that ER Nursing can suck the life out of you. If you let it.

So there you have it. A love/hate relationship if ever there was one.

During my twenty-odd years in ER Nursing I recall the token gifts of appreciation that were given to us by our nurse managers during Emergency Nurses Week…
  • an “ER Nurse’s Call The Shots” t-shirt
  • a  tote bag with matching pen
  • a battery-operated alarm clock 
Although I was thankful for the gesture, I couldn’t help but think that Emergency Nurses Week always fell a little flat.

Why? I think I get it now.

How do you thank someone for…
  • Allowing themselves to be exposed to God-knows-what-kind of viruses, bacteria, air-borne and blood-borne pathogens on a daily basis?
  • Caring enough to incorporate extraordinary measures - just to make sure a patient can get a ride home?
  • Working for several hours without so much as a drink of water?
  • Bathing a homeless person - just because they needed it – all the while hoping you are adequately protected from the transmission of scabies and/or lice?
  • Participating in the life-saving efforts of a critically ill child..immediately followed by de-escalating someone who is angry because they "are waiting too long to be seen" by the doctor for their rash?
  • Reaching into their own pocket to help a patient or family member down on their luck?
  • Choosing to "rise above" and continue to care for someone who just verbally, physically and/or emotionally assaulted you?
  • Risking personal injury by having to restrain someone who may hurt him or herself?
  • Rarely receiving a simple thank-you?
I could go on forever, but now I understand why the tote bag didn't cut it.
In my opinion, ER Nurses are not motivated by gratitude or money...but simply to the service of caring for human beings ...at their worst.

Emergency Nursing. It's a thank-less job - but somebody has to do it. And I'm proud to say that I've been fortunate enough to have worked along-side some of the best.

What can I say?

Keep your chin up, your eyes open and know that you are 'in the trenches' for a reason.

You are there not only for your patients and family members. You are there for the docs, cops, firemen and co-workers that need you to be.

So, for all you intelligent, skilled, compassionate and funny ER Nurses out there…Thank You. And know that you are sincerely appreciated.

If only by an ex-ER Nurse.

PS: I miss you.

UAB "ER Rap"...




Munchausen's Syndrome

Tuesday


Baron von Munchausen
I was first introduced to the psychiatric malady known as 'Munchausen's Syndrome' back in the late 80's. I understand it's name comes from Baron von Munchausen, a widely travelled adventurer who would regale those who would listen of his fantastical experiences...
_____________________________________

Munchausen's Syndrome: "A chronic factitious disorder with physical symptoms.", "A plausible presentation of factitious physical symptomatology of such a degree that he is able to obtain and sustain multiple hospitalizations. The frequency of hospitalizations will be so extensive that the individual spends the majority of his days either seeking or maintaining hospitalization". 1.
_______________________________________

A dishevelled young man, I'll call 'Joshua', approached the E.R. triage desk with a complaint of moderate abdominal pain subsequent to an approximate 15ft  fall from the roof of a house. He was carrying a bag and a down-filled coat. It was August. In Texas. My inner "Bullshit Detector Alarm" sounded. Loudly.
But, having a high index of suspicion of possible internal injuries, our patient was efficiently triaged. During the primary assessment, he began to complain of sudden, excrutiating diffuse abdominal pain. Drawing up his legs and guarding his abdomen from further examination, his level of acuity was immediately cranked up a notch or two and our walk-in-fall-injury became a high level trauma patient with all the necessary bells and whistles... Trauma Team activated.
  • Oxygen 100% via non-rebreather mask
  • C Collar/Backboard
  • 2 large bore IV's w/NS
  • Multiple diagnostic labs including Type and Cross for 4 units of blood on hold.
  • Heavy duty narcotics
  • Stat CT Scan - abdomen & pelvis.
  • Nasogastric tube (NGT) to low suction.
  • Foley catheter.
Your basic Trauma Team
Before I go on, for those of you not in the health care biz, there are two tubes most people really don't like....
  1. Nasogastric tubes (NGT)
  2. Foley catheters
Why?
  1. NGT are long tubes that are inserted into your nostril and advanced until they reach your stomach.
  2. Foley catheters are placed into your urethra and are advanced until they reach your bladder.
'nuff said.

'Joshua' was a champ. Submitting to the barrage of tubes and needles coming his way simultaneously, he sucked it up and "took it like a man", so to speak. I was impressed. Even our drugged and/or drunken patients have a hard time with the NGT. He was stoic.

Now stable, vital signs within normal limits, Joshua and I went to CT.

It was upon his exit from the CT Scanner that he had the first of his many "seizures".

I had been an ER Nurse for about 10 years at this point and had seen my share of seizure activity. And although this was by far the best seizure performance I had ever witnessed, my "Bullshit Detector" alarmed yet again.


I shared my skeptism with the ER doc.

He shrugged.

Little known fact: Many nurses beat themselves up for thinking bad thoughts about people. I was no different. The poor guy was traumatized physically and emotionally. Here I was thinking it was all B.S. What kind a a nurse was I anyway? Had I become jaded? One of those crusty, old, acerbic ER nurses who could care less about you or the horse you rode in on?

All of Joshua's lab and radiology reports came back within normal limits. He was being kept in the hospital for further observation as his level of consciousness was deteriorating. At the change of shift I began reporting off to the oncoming night shift nurse..."This is Joshua X, patient of Dr. Y's, chief complaint; fall injury...." she interrupted me. "That's not Joshua X, that's Tony B. - I took care of him last month after he fell off of an escalator."; "He's faking".  Suddenly, upon hearing our report, and as if by divine intervention, 'Tony', my 'semi-conscious' trauma patient sat up, pulled out his NGT and demanded to be discharged.
___________________________________________

"Features associated with this disorder, as described by Sussman and Hyler include pathological
lying, extensive knowledge of medical terminology and hospital routines, demanding and disruptive behavior, substance abuse, shifting complaints and symptoms, equanimity regarding invasive procedures and operations, wandering, discharge against medical advice, deception regarding identity, evidence of prior treatment, and intermittent time in jail or psychiatric hospitals." 2.
_____________________________________________

A few months later our ER doc recieved a call from another hospital's ER asking if we knew a "Tony B." Apparently, he had been 'found down' after reportedly falling down a staircase at the mall. He was unsconscious but had a card in his wallet from our ER...
______________________________________________

"Although the precise motivation for Munchausen's syndrome is unknown, several explanations
have been offered, such as underlying organic problem, substance abuse, resentment of physicians,
childhood deprivation and rejection, subintentional death wishes, castration fantasies, relief of aggression and guilt through operations, and seeing the physician as a father figure. It is currently
believed that different motives operate in different patients and even in the same patients on
separate occasions." 3.
 _____________________________________________

Reflecting back on Joshua/Tony, I wonder where he might be today? I guess it would be a safe bet to think (unless he has had extensive psychiatric treatment), he's occupying an ER stretcher somewhere, messing with the minds of his health care team.
 ______________________________________________

References;

1. Committee on Statistics and Nomenclature. Diagnostic and Statistical Manual of Mental Disorders,  3rd   ed.American Psychiatric Association, Washington, DC, 1980.
 
2. Sussman N, Hyler SE. Factitious Disorders. In: Comprehensive Textbook of Psychiatry, 3rd ed. Kaplan H,Freedman A, Sadock B, eds. Baltimore: Williams & Wilkins,1980.
 
3. Howe, G.L. Munchausen's Syndrome or Chronic Factitious Illness: A Review and Case Presentation. Journal of The National Medical Association, Vol. 75, No. 2, 1983.