Deja Vu

Finally get home after two consecutive absolutely hellacious shifts in a small community ED at holiday time.   If you've worked in an ED during flu season at holiday time, you know that equates to a nasty four-letter word: HOLD.  As in admission hold.  As in, admissions holding in the ED for 3(!) days awaiting an inpatient bed.

Night one began with the arrival of a patient who required intubation on arrival, while I'm holding the Etomidate the manager calls, opening with the normal pleasantry of "Hi, how are you?"  I reply, "Hi, I'm in the middle of an intubation right now".  In nurse-speak, "Unless your hair is on fire right now, please don't talk to me."  Apparently the nurse-speak wasn't clear, and in reply to my statement I get "There's people in the waiting room for almost 9 hours, you need to get them back."  Did I mention we're down a nurse, so I'm taking care of a couple of patients in an assignment, as well as charge headaches?  Cursing under my breath while the primary nurse is laughing at my facial expressions I nod several times, hoping maybe that will telepathically get her off the phone.  Finally hang up and mentally count to 5 so I don't throw the charge phone across the room.  I understand someone has been out there for almost 9 hours, but in those 9 hours they haven't died yet; however this person in front of me almost did.  Whatever.  Go get the obviously non-dying, not-in-distress 9 hour wait.  Seriously?? Who in the fucking world waits 9 hours in an ER.  If I wasn't dead after 2 hours I'd leave.  

The night continues at the steady pace of bullshitidness, sporadically peppered by truly sick people who cannot wait.  They buy hallway stretcher in my juggling act, and then slowly make their way over to a core bed.  I think around 5am we clear out the waiting room and the back is full.  2 hours left and all I've had is a cup of tea and 3 breathmints.  Everyone else is pretty much in the same boat.  Director calls around 6 and tells us she's stopping by to talk to us about the night, that we did great, and to listen to our concerns.  We bring her genuine issues of staffing and lack of support from other departments (lab, Nursing Supervisor, other floors), and  as we're finishing up I clearly warn her that for Night 2 we are fixing to be in very bad shape, as we are down a nurse at 7p, and will be down a total of 3 nurses at 3am.  I reiterate to her that I only have two 7p-7a nurses working, she writes it down in her book of mysteries and promises to work on it.  I go home feeling slightly accomplished.

Segue, Night Two:

Pulling down the side-street, I see my manager standing on the corner in scrubs.  As I nearly hit a telephone pole in amazement, I convince myself that my bitching and moaning this morning actually worked.  Only to have that fragile dream shattered minutes later when I walk in and see that staffing is no better than it was 12 hours ago.  Except that they've conned (read guilted and forced) the 7-3 nurses not to leave at 3am.  Both of them are happy to help me but upset with the manager for asking/making/forcing them to stay.  So much for work-life balance that the new director is pushing.  Somewhere they also dig up 2 IMC nurses to help us until 11pm.  Mind you, all rooms are full at 7pm and we have a 6 hour wait.  Manager flat out tells me "I'm not taking an assignment".  The IMC nurses take out admission holds for 4 hours while we attempt to muddle through the nonsense.  First order of business, take the drunk out of the waiting room who's been out there for 5 hours with a sustained HR of 130-140.  I call security and ask them to meet me by the hallway stretchers reserved for Mr. EtOH and Mr. Psych Eval (who has sat out there for over 2 hours).  Security starts giving me a ration of shit about how they've been out in the waiting room for so long and they haven't been a problem, so why do the have to watch them now.  I turf that fight to my manager with the simple words "They're refusing to watch him, I don't have time for this shit".  Magically, she accomplishes one task and security is watching them both in the hallway.  Surprised that he hasn't hit the DTs yet, I walk away to mix the banana bag for Mr. EtOH.  HR continues to be sinus tach, 130, despite fluids.  CO2 comes back at 13.  Fantastic.  Get orders for 2000mL NSS bolus, bed-ahead submitted for ICU admit.  Gotta love ICU admissions in the hallway.  Hey, at least I can see him.  

Time is creeping up to 1am, and the influx has not stopped.  In a 16-bed ED, we are at 14 admissions, plus my hallway admit, plus my hallway surgical transfer, plus I can easily pick 5-6 people in the waiting room that will be admitted.   All this and a bag of chips: I called in an extra nurse and she worked patients through fast-track beds for a few hours. Call the manager and director to update them of the evolving situation.  We've also run out of IV pumps, chairs in the waiting room (twice), and have only 2 portable monitors left.  Manager and director, as if they're reading from a script, in unison but 20 minutes apart on the phone: "Just do the best you can".  Again, breathe and count to 5 to stop myself from smashing the charge phone to pieces.  

5:30am rolls around and we know we have just a little over an hour left.  We are all completely exhausted.  3am nurses haven't had a break, let alone a hint of when they can leave.  We're working our way through morning labs when the lab supervisor calls screaming "Get my techs back to the lab, they are not there to draw your labs!".  *Gasp*  I thought that's EXACTLY what they were here for.  Notify the house supervisor of what transpired because I'm tired of calling my manager and director.

5:45 - BiPAP.  Enough said.  Bump most stable admission to the hallway and make room for BiPAP.  I already have a AAA transfer in the hallway, along with 2 others we're working up.  The nurse who's supposed to be in her last week of orientation has been taking care of a full assignment by herself since 11pm.  I call the supervisor, laughing manically and deliriously, to notify her that I have a Priority 1 Respiratory patient coming in.  She laughs back at me, asking (completely honestly) what a Priority 1 means.  I growly through the phone "It means they're really fucking sick!"  She laughs again, asking me where I'm going to put them.  I, literally, try to crawl underneath the nurses' desk while I growl back "I don't know, I'm working on it".

6am - 9 hour wait,  18 admissions in a 16 bed ED, plus several more in the waiting room.  Just gotta keep it together for one more hour.  Helicopter couldn't fly the transfer, so he's going by ground right after shift change.

Dayshift starts trickling in and I can see true panic in their eyes.  We are all completely exhausted and totally spent.  Turn over report.  Apparently later on they will have 24 holds in a 16 bed main ED and 6 bed fast-track  Curiouser and curiouser.

Get home around 8am, completely wiped out.  Send the director and manager an email of how unacceptable last night was.  That goes over like a wet fart in church.  Take a power nap, only to wake up and field a phone call from the grand poobah, asking me if I'm suicidal.  Not sure if she actually read my email or not, or only focused on the Facebook post some bleeding heart decided to show her:

It all sounds painfully familiar:

“He liked everything to be right and had very high standards. But he became disillusioned over the last couple of years. It became harder to reach the targets.

“He still liked his job but felt he couldn’t do his best. He wasn’t getting the support he needed or the resources.”

Stuart’s sister Mandy Hicken added: “There wasn’t enough staff. He was working long hours without proper lunch breaks.

“I remember him telling me that he worked a 12 hour shift and had only enough time to drink one cup of coffee - there was no time for food."

OR

What will it take for hospitals to realize this is not OKAY??? This is NOT SAFE. This is NOT ACCEPTABLE.  Lawsuits? Deaths? Suicides? What will it take??

Either way, this ends in a long, forced conversation, at the end of which I'm leaning much more towards violent tendencies than suicidal.  Way to make the situation all about me, when I'm trying to point out critical system problems to you.  Way to go.  And then she utters the ultimate wrong answer, telling me I can post whatever I want but I need to be very careful not to associate with the hospital in any way.  Ahh, there's the rub.  You never gave a damn about my mental health or anybody else's.  You just don't want bad publicity for the hospital.  Well then.  You won't hear from me ever again.  I'll keep my mouth shut, let the problems mount, and let the department implode, just like Hood Hospital.

This further cements my desire to get my NP ASAP and get the hell away from bedside nursing care, and move on to more advanced practice.

The only reason I stick around here is to see what happens next:

Cockpit Resource Management

After several charge shifts of utter nonsense, I stumbled upon Crisis Resource Management (originally known as Cockpit or Crew Resource Management, and developed by the airline industry).  I'll be presenting a few articles at our next monthly meeting, with the hopes that everyone can look inside themselves and develop these skills.  I'm thinking of titling the powerpoint "It's not my emergency, so don't spill my coffee".

The Promotion

So, super grumpy cat is gone and we're all mad at him and miss him very much.  What the hell.  Of course, management couldn't give two craps about it.  As he's leaving for good, he smiles a sarcastic grin and says "Hey congratulations on the promotion, Allie", which really means "Hi, here's 10lbs of shit in a 5lb bag."  He told management for months that he was leaving and that they need to start training other people for the charge spot because he knew I had not an iota of interest in it.  Lo and behold, he's gone, the other charge nurse is out on bereavement leave (which was followed by one obligatory phone call from the nursing office asking for help, because of course the manager is conveniently out of town), and they left me and charge.

One nurse down on Christmas day?  What could possibly go wrong??  In all respect, we were actually doing really well, then at 11pm a Christmas miracle happened and Jesus Nurse came in.  I love working with him.  He looks like Jesus and is as calm as a high school kid who just smoked a bunch of pot.  But he works hard and actually knows what the hell he's doing clinically.  I turn over my two flu-like sx folks to him, help a couple of other nurses and head upstairs to shift huddle.  Frantic ICU Nurse from the last chapter is there, chit chatting with the supervisor, I sit down, she gives some half-assed unit report and scurries off with the usual "Oh we're just soooooo busy up there, I have to get back".  Whatever, psycho.  So I stay, put in my two cents about our admission holds, and then out of boredom listen to the floor nurses unit reports:

When I get off the elevator I stop to pee in the clean hallway bathroom instead of going back to the ED bathroom, fix my mini-santa hat and start walking back.  Before I can even reach the door I hear a rabid banshee on the radio: "I NEED A WHEELCHAIR OR A STRETCHER TO THE WAITING ROOM NOW!"  Knowing that the owner of that voice loses her shit no matter what, I casually stop in fast-track, grab some gloves and head for the waiting room.  The banshee voice again: "I NEED A WHEELCHAIR STAT!!!!!!!!!!!" this time it's even more shrill and high pitched.  Now I'm getting pissed so I push the door open.  Waiting room is perfectly still and empty, except for a 60-something year old who blacked out while SITTING IN A CHAIR, his life partner next to him, and the 60-something year old rabid banshee triage nurse.  Having triaged the man just an hour or so ago while she was at lunch, I calmly look at him and ask what happened while she is doing some sort of ritual war dance trying to get the man to levitate to the wheelchair that the tech brought out.  He is relaxed, says he's not sure, he just went out.  Again, while sitting in chair.  She was screaming as if he passed out and fell 20' from the scaffolding, caught on fire on the way down, and landed in a puddle of gasoline surrounded by dynamite.  His life partner isn't sure whether to scream at the banshee to shut up or to cry because his spouse is sick.  The guy just has the flu, everyone, calm the fuck down.

Once he is sitting comfortably in the magical chair with wheels under it we go back to an exam room, with Rabid Banshee trailing behind us, screeching about how he should be in the trauma room.  Nope, not happening, not my only open trauma room, for a guy who's conscious & alert, just weak.  They head to room 7 while I grab an IV set up and fluids.  As I'm powering up the lab cart and taking out tubes, I hear Rabid Banshee screeching in the room, "He's going down again!"  Well, no, no ma'am he's not.  He's sitting in a chair, I'm sure he's very weak and feels like crap, but he's not going down.  I poke my head in the door and sternly but calmly grit through my teeth "Let's get him flat on the stretcher and make him comfortable."  Really??? Do I have to explain the basics of physics and orthostatic hypotension to you???  The primary nurse for the room comes over and asks me what I need, at this point I'm holding the lab tubes & IV fluids in my hands, so I look at her and whisper "I need Rabid Banshee the fuck out of that room".  Primary nurse laughs and makes me laugh too.

Why did I get stuck mitigating crazy?  For an extra $1.50 per hour?  Really??  Not worth the headache and the GI ulcer.

Interestingly enough, about four hours later, same guy has a witnessed syncope on the stretcher with a >20 second run of ASYSTOLE.

Asshole-pucker factor of 20.  Thankfully Rabid Banshee AND Upset Life Partner have gone home for the night.

Can't wait to do it all over again in 2 days.

Back in Charge... Begrudgingly

You know you work with an awesome bunch of people when you're stuck in charge two hellish nights in a row and you laugh the entire time.

Night 1:
Walk into a four hour wait, as I'm walking by the nurses' station the night-time ER doc is throwing a fit, literally screaming for security, because a drunk guy tried to take a swing at him.  Violence should never be accepted as part of the job, but nonetheless, the drunk guy is flailing around like a ferret on crack, and did I mention he weighs about as much as the doctor's left leg?  Really, doc?  Cut the drama.  Next contestant just arrived in the waiting room and is demanding to see the charge nurse.  "Yes sir, how can I help you?"  "I just waited 4.5 hours at Hood Hospital up the road, and I left because they didn't do anything, and I come here and you have an even longer wait?  This is ridiculous!!"  Thinking to myself, well if your dumb-ass didn't leave Hood Hospital you would have probably been seen up there by now.  But since you decided to give up your place in line, you go to the back of the line.  Sorry, that's the rules.  Unless you can make your heart stop on command, back of the line mister.  Happily provide him with my manager's phone number while he's berating me in-front of the packed waiting room.  Later on, chart review will reveal that he was actually removed from Hood Hospital by the police, screaming "If I was white you would have treated me already!"  Ahh yes, the infamous race card.  Well played, sir.  Unfortunately we only take Mastercard and Visa here, not the RaceCard.  Next up, the cranky and tired mother of a 7 week old who just got his first IV.  Yes, please I insist, you should hold him in a way that allows him to bend his arm and now his IV is infiltrated.  Don't be ignorant with me when I explain why the IV is coming out and why he's getting an IM dose of Rocephin.  While hold the screaming demon-spawn, receive a phone call from the director:
"ER, how can I help you?"
"Hello, this is so and so, how are you?"
"I'm holding an infant for an IV stick right now."  Thinking to myself, can't you hear the hyena-like howling in the background???
"Oh ok, I'll call you back."
Wipe demon-spawn slobber off my scrubs and retreat to the nurses' station to return director's phone call:
"So I've been watching your tracking board and I'm just calling to see how you're doing"
Momentary pause... I probably shouldn't say we're up shit's creek without a paddle.  Probably.
"We're doing okay for now."
"Oh ok, well Hood Hospital is really bad off right now, but I see you're busy too so I won't put them on divert right now."
Oh really?  Thank you for that astute observation!!  I'm glad you realize that a packed ER, no dispositions occurring within the next hour, a waiting room that has run out of chairs for the people, and a five hour wait translates to "you're busy".
But instead I just say "Great, thank you, we expect to see some movement in all this within the hour.  Thank you for checking in."
I look at the clock and it's not even eight o'clock yet.  11 more hours to go.  Sweet Jesus help me.
Cue next scene, phone call from State Police:
"Yea hi, we've just received a 911 call about a 17 year old run over by a vehicle, they may be heading your way, they decided not to wait for the ambulance."
Fan-fucking-tastic.  Trauma Alert with unknown ETA or injuries.  While we mull around the idea of activating the Trauma team with an unknown ETA the State Trooper walks through the door and we chat for a bit.  Kid's still nowhere to be found, should have arrived to the ED by now, so we stand down.  Only to get the EMS radio patch a few minutes later:  "Trooper 2 landing in the Walmart parking lot, I found him."  My hair stands up on the back of my neck.  A couple minutes later the EMS radio chirps: "2 minute ETA, awake & alert, no obvious injuries, Trooper 2 is on board."  Page the Trauma Alert.  Cut to 3am, waiting room is finally empty of patients but every single chair (20-25) is taken up by a family or a friend of the 17 year old, who only has a few superficial scratches.  At least it's not Hispanic Hysteria.
The rest of the night is a faint blur, until 6:30am, when the next wave arrives.  As we're leaving at 7:30, there is one open bed available.  Not a good harbinger for those of us returning in less than 12 hours.


Intermission.


Night 2
Upside: awesome attending doc.  Downside: short one nurse.  Oh well.  Another drunk guy is being belligerent in front of the nurses's station.  At least the dayshift doctor believes in the healing powers of Ativan.  Admission hold from last night is still here.  Beds are very tight.  An elderly, demented, pretzel of a man is curled up in front of my desk on a stretcher.  Fx femur.  Fabulous.  He will wind up spending the rest of the night with me until he gets a bed.  Play musical chairs for the next 5 hours, bringing people from the waiting room to hallway beds to start exams and then slinging them into the next open bed.  My old friend gets a bed assigned shortly after 11 and off we go.  Three floors and a winding hallway later we are met by a nasty floor nurse who says "We're not taking him, you can go back down stairs, I'm on the phone with my boss now."  Practically flying through the hallways I parallel park him and get on the phone with the supervisor who is even more ticked that I am.  Magically 15 minutes later the floor graciously accepts him.  Make the trip back up-stairs, this time taking along my tech and saying to him "If I go off on a murderous rage I need you to be my witness that it was justified."  He laughs, uncomfortably.  Transfer the patient into the bed, nurse is nowhere to be found.  Settle the patient into the bed and remove the extra linen, nurse still nowhere to be found.  Discover her at the desk sitting on her lazy ass at the computer.  Slam the chart down and tell her that I would have given her report at the bedside but she decided not to come in.  Hateful bitch.  Give report and listen to 15 minutes of groveling and back-pedaling about why they didn't accept the patient the first time.
Back downstairs.  The seizure that was coming in when I left to go up is still seizing.  The short doc is power-walking past me "Oh hi, you're back, we're intubating."  Oh good, I came back just in time.  Just barely get him intubated when EMS radio goes off with a 5 minute ETA for 70-something year old conscious V-Tach, cardioverted to A-Fib.  Clear out the other trauma room, the  previous patient looks a little bewildered as we usher him onto the transport stretcher for his ride to Georgetown University Hospital, the ER stretcher is instantly stripped, cleaned, & made just in time for the cardioversion to roll through the doors.  House supervisor sends an ICU nurse to help.  ICU nurse is pissed "because I have patients upstairs too you know".  Cardioversion is in a steady, rate-controlled A-Fib.  Ask ICU nurse politely for EKG machine & Amiodarone drip.  ICU nurse is completely flustered by this request, adjusts her glasses and in a shrill panicked voice asks what I need.  I turn around and slowly and calmly repeat myself.  She disappears, only to reappear saying that the patient's name isn't in the Accu-Dose.  Okay, no big deal, it sometimes takes registration a little bit of time.  Again, I calmly and slowly ask if she knows how to do an Emergency Admit on the Accu-Dose.  This is where it really gets good.  Ready?  She starts doing calming breaths, with the hand motions and everything!

Total meltdown imminent.  And here it comes.  Still standing there, she flips out on me "No I don't know how to do that!  Just give me a plan and tell me what to do!! If there's nothing else here I have to go back upstairs!"  At this point I can't keep a straight face any more and I bust out laughing, shaking my head and telling her she can go if she needs to.  I don't have time do deal with this shit.  She's more worked up than the elderly patient who just got zapped!  I instantly reconsider my decision of ever working in the ICU here as a nurse.

Back to Saturday night at the zoo.  Primary nurse is done with the Georgetown transfer and he steps into the room, just in time for me to catch an EMS crew rolling in with a young man with an obviously dislocated shoulder.  He goes to my last open bed, to the same nurse who had just gotten an ambulance with a 74 year old who drank rubbing alcohol.  After that patient is seen I grab the doc, asking for pain meds.  Dislocated Shoulder Man is very nice, stoic, and trying his hardest to be as polite as possible through the excruciating pain.  I quickly pick up on the Russian accent and make a point to tell him hello once his arm is back in the anatomically correct position.  Unfortunately the doc is still tied up trying to manage the seizure, and Dislocated Shoulder Man has to wait a bit.  I get orders for a second dose of pain meds and turn him over to his primary nurse.  Stepping out to go check on the Seizure Man and Cardioversion Lady, Seizure Man's nurse pulls me into the med room with an exhausted and trembling voice.  There's a large puddle of Propofol all over the floor and shards of the 100mL glass vial.  Now I'm laughing uncontrollably, pretty much deliriously.  Not so much at the poor primary nurse who had to fight with a poorly designed AccuDose and almost got clocked in the head by the bottle but at the entire picture of the night.  We are absolutely up shit's creek without a paddle, and we just lost the entire canoe.  I mop up the spill with paper towels, contemplating if I can lick it up off the floor or if I should use a straw.  After my shift it will dawn on me that I should have used a straw with a filter needle on the end.
I have been back downstairs for barely an hour and the place is absolutely exploding.  Hello Shit Magnet status.  Obviously the moon and stars are not aligned tonight.  Seizure Man has been seizing for almost two hours now, refractory to all medications.  Cardioversion Lady is doing as well as expected, awaiting her ICU bed with the ultra-frazzled ICU nurses.  Dislocated Shoulder Man is still dislocated, we're paging the Orthopod for a last-ditch favor.  He calmly tells the ER doc to stop the seizure and reduce the shoulder later.  Wow.  Thank you for your expert medical opinion doctor asshat.  Hood Hospital with Neuro ICU is refusing to accept Seizure Man because they won't be able to do a STAT EEG, Neurologist is refusing to come see the patient unless he is at Hood Hospital; recommend transfer to Trauma Magic North.  After trying to coordinate this nonsense for four hours (oh and by the way, he's still seizing) we have a 20 minute ETA on flight.  In the midst of which the attending politely but firmly tells the fiancee over the phone that there is no way in hell that the patient can be transferred to rinky dink hospital down south at her desire.  Flight arrives and packages up the patient, they are friendly, efficient, and thankfully know what the hell they're doing.  At the same time Cardioversion Lady gets the ICU bed assigned, and Dislocated Shoulder Man is reduced by the PA with 15lbs of sandbags.  It's after 5am and we all finally take a breath.