Enantiomer

The brain is still kicking!  Called in at midnight for a case, finally got the patient at almost 2am, wheezy and tachy, so I call the anesthesiologist for orders and ask DuoNeb, Albuterol, or Xopenex, and she says "Xopenex, because that’s the one that doesn’t cause tachycardia right?"  I said "yes because it’s Lev-albuterol, it’s an Enantiomer of the regular albuterol", and she goes "wow! I'm impressed!", I just chuckle and reply "Yep, big words and everything at 2am!".  Oddly enough I feel like an Enantiomer of myself from 2 years ago: a stereoisomer that is a non-superimposable mirror image – I'm still me, the nerdy critical care nurse who is passionate about animals, coffee, good music, dry humor and fall weather, but I am not the person I saw in the mirror 2 years ago – I'm not grouchy, tired all the time, arguing with my husband, depressed, and sleepy. Albeit being buried up to my eyeballs in schoolwork, I manage to sneak in some fun in my free time, spending quality time with friend and family, I do crafts, I bake, I go outside. I feel appreciated at work, I feel like I contribute to quality patient care, I feel like I actually matter and make a difference. I can definitely handle 11 more months of school until I graduate with my AG-ACNP. Hard to believe it's almost been 2 years of school already; I am not only smarter academically, but also smarter as a healthcare provider, smarter as an adult, more mature, knowing a little bit more about which fights to pick and which to ignore.

Peaceful PACU

I haven't written a hateful blog post since I left the ED.  I actually haven't written any posts here because I've been too busy with school.  In fact, I rarely even get worked up at work anymore.  It's like the calming anesthesia gases permeate our little hamster cage and we all walk around and just chill.  The clinical coordinator is cool as shit, funny, educated, no drama.  The docs trust me.  The nurses ask me questions and look up to me.  I have friends I sit with and gossip about FERN ("Former ER Nurse" on the verge of retirement).  I re-read a few of my posts tonight, and I am in a tranquil state of inner peace.  The ER made me who I am, but I got out before it broke me and turned me into a miserable person.  It made me go back to school, and for that hard push I am eternally grateful to my former incompetent manager, director, and lazy-ass co-workers.  "You haters is what gave me this strength".  15.5 months left of school, clinical rotation starts in 6 weeks.  Lab coat fits awesome, and I look damn sexy in ceil blue scrubs.  Trauma NP or ICU NP?  Or maybe Cardiothoracic surg?  Or Cardiology in general?  The sky's the limit.

Transition

What happens when you take a 6+ year night-shift creature and switch to day-shift?  Zombies happen.  Waking up in your own bed to a 5am alarm, absolutely clueless and disoriented happens.  Blatantly running a stop sign on the way to work happens.  Spilling coffee on yourself happens.  I consider it a good day when I leave the house and have all my clothes on.  Not feeling utter disdain for humanity happens.  No longer checking ER wait times happens.  Not looking at every ambulance as the harbinger of utmost evil things happens.
Enjoying the job so far, not expecting too much, not getting over-the-top excited, firmly believing that it's just a job, nothing more, nothing less.  My life outside of work is much more important.

Leaving a job is like breaking up with a boyfriend

Three weeks ago I turned in my resignation to the ER.  I've been an ER nurse for 5.5 years, and have been in an ER/EMS setting for the last 11 years.  It's like we're practically married.  The ER has been my home and my comfort zone for the last decade.  I don't think I've done anything else for that long.  The ER has been a place of solace and a place of frustration.  A place of knowledge and a place of "holy shit I don't know anything but these people trust me to take care of them".  A place where I could go home triumphant that my coworkers and I kicked some major ass and snatched back a few people from the clutches of death, disease and pestilence; a place that makes you think like you got hit by a train, over and over again for 12 hours; and a place that makes you question how some idiots tie their shoes.

The ER is a unique specialty, and a very coveted specialty among nurses.  If I had to pick a single nurse to be stuck on a deserted island with or in outer space, you bet your ass I'd pick the ER nurse.  We are resourceful, passionate, highly skilled individuals who are innovative, creative, kind, fierce and have a wicked sense of humor.

The ER nurse must be flexible (physically, mentally, and emotionally), must be able to roll with the punches (physical and literal), and must be ready for absolutely anything that walks, runs, crawls, flies, or drives through the doors.  It is this very quality that is an ER nurses undeniable strength, but also her downfall.  "What's that, the unit is full so we have to board the two vented patients down here all night while our waiting room cup runneth over?  Suuuuure.  Bring it on; while you're at it, can you maybe find me a couple of traumas, and a couple more unstable patients to really spice things up?  We're down two nurses tonight, so we could really use some excitement."  The ER has always been society's safety net; unfortunately now it's also the hospital's safety net.  No room for that transfer?  Board them in the ER.  The floors are full?  Board the admit for three days and then discharge from the ER.  Have a rapid response the ICU can't /won't go to?  Get the ER nurses to respond to it.  Have an elective transfer leaving, pre-scheduled days ago that needs a nurse?  Pull from the ER.  Step-down full, but inpatient rehab needs to transfer a patient?  Send them to the ER for admission, and, you guessed it, board the patient in the ER.

I have approximately three weeks left until I transfer out, and here is the ever-growing list of reasons why I don't want to be an ER nurse anymore:

- Understaffed.  While this affects every specialty out there, the ER is a unique setting with a constantly varying census.  Although not at all unpredictable, patient census can go from 10 one moment, to 30-60 patients an hour later, depending on average volumes.  And then there's always that freak accident involving the bus full of nuns on Coumadin.

- Solving EVERYONE's problems, with very limited resources and limited authority over the situations.  The ER is absolutely a jack-of-all-trades.  We are expected to figure out problems of how to get someone's family member into a nursing home, how to perform inpatient care, how to manage transfers that are being boarded awaiting destination, how to deliver textbook perfect patient care  abiding by policy while missing equipment, medications, resources, and staff, how to collect evidence for a DUI, how to admit a patient whose PCP hasn't called back in 8 hours after multiple pages.  By the very nature of the job, we cannot say "sorry, that's not my job" or "not my problem".

- Drug seekers.  While addiction is a recognized medical condition with a complex etiology, it is not a life-threatening emergency, and the emergency room is not a place to manage detox nor a place to come get your fix.  No, we will not give you any drugs, regardless of how hysterical, violent, agitated, cantankerous, histrionic, or abusive you become.  And yes, I'm well aware of the fact that you will either get a satisfaction survey in the mail or a follow-up phone call.  I couldn't given a rat's ass.  I'm not getting you a damn turkey sandwich and blanket after you spit at me and tried to hit me.  I think surveys shouldn't count from people who are abusive to the staff.  

- The Bob's

Imagine having to answer to these people several times each shift.  Having to explain over and over again the rationale for your decisions and requests.  Having to justify your existence when it comes time for annual evaluations by tallying up points of how well you can practice scripted, checkbox medicine.
- The generally ignorant and abusive patients, regardless of what they want (pain meds, work note, footies).  The ER is one of the very few rare places where it's perfectly normally to be cursed out, spit on, and have something thrown at you by a patient or family member, and then they complain that we did not get them a blanket fast enough.  This type of behavior ANYWHERE else would not be tolerated for a split second, and the local police would haul them outside.  Yet in the ER, we are obligated by law to examine you and stabilize you, regardless of how much of an asshole you are.  Repeated exposure reaffirms staff beliefs that Nothing Changes, Nobody Cares.

It's simply time to leave.  I've fought this idea for a long, long time.  Kept telling myself maybe it will change, maybe it will get better, maybe I'll love it again.  The only thing that is still growing is this list and my disdain for the human race as a whole.  ER is not all it's cracked up to be and there are many other sandboxes to play in before walking away from the park all together.

Every single time I've left an ED job I had the same feeling: it was very similar to leaving a bad relationship: (1) once the idea to leave sets it, nothing can change your mind, you only prolong misery by staying; (2) once you actually leave, you feel an immense sense of freedom and inner peace, thinking "I should have done this months ago!".

A Leap of Faith

Time has come for me to bid adieu to my ER family.  I've accepted a job offer back up at Hood Hospital in the PACU.  All the joys of critical care, none of the headaches of long term care.  Essentially, a short-stay ICU unit, with no weekends, no overnights, and no holidays (only on-call).  2:1 ratio, 1:1 for ICU patients until stable, wide open department with full visibility and staff jumping in to help each other, average of 30-60 minute patient stay, then it's off to an inpatient bed or back to day surgery bed for discharge, occasionally an admission hold (not nearly as often as the ER).  Limited family interactions, and even those are always pleasant and grateful that someone is taking good care of their loved one.  Patient satisfaction surveys encompass all outpatient, so, while PACU certainly plays a role, many factors are out of control of the entire department.  Metrics are fairly simple: Beta blockers, Foley, Antibiotics, and DVT.  You know it's going to be a good place to work when the manager asks how you feel about downtime and will you be bored if it's slow.  I'm hoping that the switch to days will be a blessing in disguise, but since it is a fairly behind-the-scenes kind of place, I don't expect much administration to walk around, and as long as I'm off their radar I'll be happy.  Low turnover, one employee graduated as an NP, another one switched to the late evenings position, so day shift has 2 openings.  Staggered shifts four days per week for 9 hours.  Can get crazy hectic but not nearly as draining as the ER.  I will still pick up OT in the ER, simply because it's only a ten-minute drive, so I will have to still play nice nice, but I am glad to be making a switch.  I will miss my friends in the ER but it's simply a toxic place to work full-time, the staff is burning out and leaving, both Hood Hospital and Tiny Hospital.  The new director has her head in the sand and is completely oblivious to the department's problems, no matter how many times you bring them up or throw them in her face.  The Hood Hospital manager sounds like an evil sea witch, and the Tiny Hospital manager is quick to back pedal and protect herself whenever problems are mentioned.  I'm trying not to leave unhappy or disgruntled, but it's hard to see any positives anymore.

$20

Gotta love the feeling of having the attending offer you $20 if you insert an IV under ultrasound into a chronic seeker.

Ironically, that's also the amount that it would cost me per day to change jobs to Big Bob's Trauma Emporium PACU or NICU.  Applications submitted, fingers crossed for new opportunities.

Death and Molasses

Cue another busy Saturday night in the ED.  Steady stream of nonsense interrupted with acutely-ill people.  Down two staff members.  Oh well.   As always, we persevere and overcome.  I'm eager to get the night over with and get home to finish editing my final paper for my first grad school class.  Apparently the great cosmic universe had other plans:

06:38 - day shift is slowly trickling in as I let my r/o ACS patient up to the bathroom.
06:45 - said patient diaphoretic in the bathroom
06:52 - coding said patient in the trauma room
08:39 - TOD

In the few minutes that it took us to get the patient out of the bathroom and onto a stretcher felt like agonizing hours.  Like watching molasses drip out.  Already feeling completely defeated after no break and no food all night, this was enough to push my limits.  Emptied 2 code carts, central line kit, art line, every drug you could think of, and all of my emotional reserves.  It's been a very long time since I've cried over a patient, but this morning it came in stifled sobs, snotty sniffles, shaky voices, and trembling hands.  I sat in the corner of the trauma room, feeling completely drained, lost, and confused.  After most codes I try to keep busy, cleaning up trash and straightening up the room for family to come in.  This was the first morning where I didn't have the strength to do that.  I felt like a part of me left with her, and what remained behind was broken and scared and lost and confused.

Photo Credit: Brandon Plyler (Haynes Ambulance of Elmore County, Wetumpka, AL)

Coworkers said plenty of gentle words to try and comfort without much avail.  Two hours later I finished charting and went home.  I got to go home and she didn't.  And she never will.  For days, the what ifs will haunt me and keep me up at night.  As always, forever will I be haunted by the agonizing screams of a family that lost a loved one.  And I pray that the only thing the family remembers is that I treated her with kindness and respect, bringing her footies and warm blankets, calmly explaining everything.  Her granddaughter spent the night in the ED and I arranged a hospital bed AND an ER stretcher in the same room so they could sleep together.  I pray that's the last memory she keeps.  Not the one where she's standing in the hallway, watching us wrestle her grandmother off the toilet onto a backboard.

The good thing about all the tears is that I know I'm not as dead inside as I seem sometimes.  The cynical, gruff, tough ER nurse has a heart.  It's hidden far away, behind walls built up to keep the evil out, the evil of having witnessed too many codes, too many near-codes, too many traumas, too much violence, too much sadness, too much circumstances of life.  Occasionally some stories find a way under your skin, through the walls and into your heart.  Those will stay with you forever.

Photo Credit: Katie Duke

A photo by another ER nurse (who was fired from her ER job for this photo) sums up so much in one image.  You can almost smell the sweat and tears of the staff present in a resuscitation.  You can hear the equipment in the background.  You can feel the ribs cracking under your hands.  You can feel the hair stand up on the back of your neck.  You can feel your own heartbeat thumping in your temples as you search for a pulse during a rhythm check.  You can feel your heart sink to the lowest pit of your stomach when you know it's over.

My hands shake as I lower her eyelids over bloodshot eyes.  She trusted me and I can't help but feel like I failed.

Best ER Nurse Phone Call

A "nurse call" is typically a phone call from a member of the public calling for medical advice.  Sometimes it's a simple question of "how much Motrin do I give my baby?" but often it turns into complicated and bizarre stories, that get more and more convoluted every time you tell them "Ma'am I cannot give you advice over the phone, you can come in and be seen by our doctor."

Case in point:

2am on a Friday:

- Um hi, do you do lead testing?

- No, we typically don't.  This is the emergency room.

- Well I understand that, and I've already been to Hood Hospital and they wouldn't do it...

Me, thinking, well shit Sherlock!  We're not going to do it either then!

... but I keep having these neurological symptoms.

- Okay, I cannot give you advice on the phone.  If you'd like to be seen you can come in.

- Well will you test for lead if I come in.

- That's not up to me ma'am, that's up to the doctor who sees you.  And he cannot give you advice on the phone either.

- So you can't tell me if you'll test me for lead?  I have these metallic hair extensions and I think they're giving me lead poisoning!

Attempting to stifle my laughter, turning purple, while the charge nurse is sitting next to me laughing at my expressions.

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.

Eeeeeeebooooooooooooola

So yesterday we had an Ebola information session conference call with God knows who, because half of us arrived late because we were given the wrong room assignment.  Aaanyway, we definitely didn't miss much, because it went something like this:

 Pretty much everyone is shouting it from the rooftops right now.  Even more so than throughput and patient satisfaction.  Wow, never thought I'd see the day when we didn't have to hear about patient satisfaction for once.  Can't wait to see the complaints rolling in: "And they made me wait for 5 hours because they said they were busy taking care of someone with Ebola".

In all seriousness though, I can't wait for wintertime & flu season, when EVERYONE will have fever, vomiting & diarrhea.  Good timing, Ebola, good timing.

I also can't wait to be taking care of these idiots dressed like this:

When I should be dressed like this:

But it looks so cute & innocent!

I'm also getting rather tired of various posts out there that point out that TB, HIV, Meningitis, and other infectious disease have killed and daily kill more people than Ebola.  That's great.  None of them are as virulent, unpredictable, or unfamiliar to US healthcare workers, and frankly any healthcare workers outside Africa.  So stop trying to downplay how serious it is.  If you think it's such a walk in the park, please come work with me in the ER.

Keep your head on a swivel folks, know what to look for, what to do, and who to call.

But of course I gotta have a little bit of fun:

When your patient done DID.

The McKesson disposition for "Dead in the Department" (as opposed to DOA, which is Dead on Arrival) always made me chuckle a little bit, because it would mark the dispo column "DID".  Patient did what?  "He done did die!"  I've always wanted to say.  Please take a few minutes to take this ENA survey about end-of-life-care in the Emergency Department.  Definitely something we don't spend much time discussing but face a lot of time dealing with.  And we can and must do better.

Horses not Zebras

A great read about (+) D-Dimers and their consequences.  Not every elevated D-Dimer needs a CTA chest.  Please understand that and argue for that.

Donkey Portions

I would like to get this in a velcro patch or perhaps a bumper sticker that I can forcefully apply to coworkers to drive my point home:

If I wanted the work to be done half-assed I would have asked ________ (insert name of your least favorite co-worker here).

I'm not saying we all need to be perfectionists and stars at what we do.  But we do have to be competent.   I don't think "competent" is too much to ask for when a 61 y/o male tells you he has back pain, hurts all over, sharp chest pain, and you note wheezing, I don't think it's too much to ask for to order a chest pain protocol and at least 1 DuoNeb.   No, telling me that "he's not in distress" isn't good enough.  No, telling me that you've ordered a chest XRay because of the wheezing isn't good enough; last time I checked, radiation doesn't fix wheezing.  But a DuoNeb just might.  And I'm sure that in the 90 minutes that patient has sat in the ED core you could have figured that one out.  This isn't rocket science.   But obviously this was not happening inside your skull:

No, no, it's alright.  I'll totally work-up the 61 y/o with hx of angina for his chest pain & back pain.  And yes I'll totally admit him for groundglass infiltrates PNA.  And I'll even draw the blood cultures prior to his ABX even though the doc forgot to order them.

So, please, today, when the doctor that I wouldn't trust with my dead goldfish is working, please, take your fucking head out of the goddamn bubblegum factory and for once in your fucking life THINK like an ER NURSE.  Which sometimes means, yes, you have to think like a DOCTOR.  It doesn't really matter to me what you call it, I just call it CRITICAL THINKING.  And in a busy ED, it is CRITICAL.  Otherwise please expect a thorough ass chewing from me.  I hope you taste good with Nutella.

They forgot my birthday!

This may seem trivial, and I probably shouldn't let it bother me so much but I can't help it: it's day 3 (I guess, business day 2) of Emergency Nurses Week and so far we've received ONE half-hearted e-mail with cheesy stock photos from the Nurse Educator (read Non-Clinical Nurse Nazi)...  Not a word from our director, our manager, the administration of the hospital, other departments, or the other EDs in the health system.  Again, I probably shouldn't let it bother me so, but it still sucks.  I hear from 10 different people when I fail to submit my TPS reports, but I can't get a goddamn sincere "Thank You" one fucking time in a year?!  This is a nationwide week of recognition, and quite frankly I'm not accepting any excuses.  Tonight I'm going to work & I'm going to keep my head up high and proud, like the expert emergency medicine professional that I am.

Never mind the fact that I just spent 3 hours looking for other jobs.

Light duty

I absolutely object to direct-care nurses coming to work on "light duty" and "attempting" to do clinical work.  I say attempting because light duty in the hospital means you're on the schedule as a full nurse but in reality you can't do certain crucial aspects of your job.  This scheduling gimmick is often used by managers, but hurts the fully-functioning direct care nurses (image a nurse that only works triage and refuses to work another assignment, or a tech who only works the desk as a secretary despite the fact that the job description is Tech-Secretary).  You either do your job 100% or don't show up at all.  However, I think there should be a light duty option for clinical nurses (staff education, unit administrative work, patient call-backs) to come back & earn a living while recovering.  Perhaps at a reduced wage (as arranged through proper legal channels), but still working and earning money and earning PTO time.  Over the last few years I personally knew (and donated money/time to) several nurses and paramedics that suffered a tragic accident or a debilitating illness and couldn't return to work due to new limitations or trivial documentation that makes them seem unfit for duty.  All honest, hard-working, great people that would give you the coat off their back even if they had nothing of their own.  And except for some sporadic donations, we as a profession, tend to forget and ignore our friends when they need us the most.  I've had nurses tell me that all their friends abandoned them and they hardly talk to anyone at work anymore.  We must do better than this, and we can do better than this.  No matter how busy our own lives are, never forget your blessings and be humbled by the lives of your co-workers and friends who may be fighting a very hard battle.  Reach out and say a kind word, donate some time, money or services to them (could be as simple as driving them to the grocery store or running their kids to practice).

Cross your "t"s and dot your "i"s

I actually feel like my eyes are crossed now... Sent and re-sent my application for Walden University multiples times (4, 5? I've lost count), all times getting daily phone calls from the mysterious Admissions Recruiter who first told me to elaborate regarding my work experience (and this conversation required 10 days of phone tag), then told me my addendum page elaborating my work experience was unacceptable and that I have to fit it all on the application page (thank goodness for editable PDFs).  Sorry for the run-on sentence but this is extremely frustrating!  Out of frustration I looked up Walden on allnurses.com and quite a few posts question it's validity and discuss whether or it it's just a diploma mill.  Currently it's between Walden & Drexel for the AGACNP track.  Walden is 100% online, starts December 1st, but seems not very reputable.  Drexel is all online except for 3 required campus visits for "clinical lab", starts next fall, but also is a much more reputable school.  We'll see what happens, I still need to submit a potential clinical sites selection form for Walden & then I'll have an admission decision.

At the same time, my disgruntled, burned-out self is questioning if I should even pursue an NP track, or get out of nursing all-together.  My blindly hopeful & optimistic self is making plans about how I can do house-calls to retirement communities for physician groups, work in ICUs as a Critical Care NP, work as a nurse consultant (see previous post about pimping myself out), or any other healthcare career tracks.

This is the Stuff Nightmares are made of

Nurses are very stubborn creatures by nature.  We claim that we adapt to change easily and can work in the ever-changing environment, but when you tell us you're starting some non-sensical evaluation tool like HCAPS in the ED setting and then tying ED provider reimbursement to the HCAPS you bet we're gonna be angry.  I'm debating how long to stay at the bedside.  My lofty aspirations continue to draw me to Flight Nursing.  In-hospital, I'd like to do PACU or maybe OR.  Completely non-bedside I would seriously consider Legal Nurse Consultant, Clinical Toxicology Specialist, or simply Nurse Consultant.  I could pimp myself out to patients and families agreeing to visit them in the hospital and review their care with them to make sure that the care they receive is appropriate and actually indicated, not just care that the doctor wants to give or the care that the government mandates.



Below are just some of the articles that explain why those of us that work at the bedside think that patient satisfaction is a bad metric:

http://www.kevinmd.com/blog/2014/03/patient-satisfaction-hospitals-car-dealerships.html

http://archinte.jamanetwork.com/article.aspx?articleid=1108766

http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/

http://www.kevinmd.com/blog/2014/06/patient-satisfaction-surveys-riddled-problems.html

http://www.kevinmd.com/blog/2014/06/hold-patient-satisfaction-scores-done-right.html

http://www.kevinmd.com/blog/2013/06/doctor-guilty-fraud-great-patient-satisfaction-scores.html

http://archsurg.jamanetwork.com/article.aspx?articleid=1679648

http://www.kevinmd.com/blog/2012/02/patient-satisfaction-kill.html

http://www.kevinmd.com/blog/2010/04/oped-patient-satisfaction-medical-care.html