October 21, 2005, 4:45 pm
….Now I’m pretty thrilled when I find gas at less than $2.85 a gallon, and I’ve heard of nurses getting excited that their post-op patients are passing gas, but I think this is WAY over the top, don’t you? For the life of me, I can’t figure this one out. There is nothing about nursing in the text. Nada…
(…something just occurred to me after I posted this….this may not be a nurse, could it be a woman with a white scarf on her head? Shhhhh……keep it between you and me…)
…I usually keep my politics to myself, but some might call me “conservative”. As in: compared to me the fine citizens of Mayberry would be flaming liberals. So it came as quite a shock when I glanced at the local news the other day only to see none other than Warren Beatty addressing the California Nurses Association at their bi-annual convention. With Sean Penn in the audience.
The sound that nearly woke you out of a sound sleep was the sound of my jaw hitting the floor. The next day, I was studiously reading over the Propositions for the special election in November when I noticed the name of a CNA bigwig at the bottom of a letter against parental notification laws for abortions. EEEEE…nough! I pay CNA almost $1000 a year in dues. They are a wonderful bargaining agency and I have great pay and benefits (and wonderful staffing ratios) because of their involvement in collective bargaining. But…I don’t want my money funding issues that I do not agree with. But, I am required to be a member and I do want to support CNA itself. So I emailed membership. I received a phone call from staff who told me that my dues can be designated to go to the “general fund” and not to any political action committees. I was impressed by the fact that (1)they called instead of just emailing and (2) relieved that I was not tied into funding issues that I do not agree with. I feel much better now….
…Oh man, I’m a Crawly Amphibian in the TTLB ecosphere again. Yesterday I was up to Slithering Reptile. Was it something I said?…
…Speaking of gas, I’ve noticed an increase in the number of post-op and post-partum patients we are seeing in the ED presenting with abdominal distension and pain. In ancient times, when Jimmy Carter was President and the Bee Gees ruled the world, patients were not discharged after surgery or delivery until they had produced the sacred Bowel Movement. The nurses would assess, many times a day, whether The Bowel Movement arrived. In fact you were stuck on clear liquids until the arrival of Flatus, the precursor to The Bowel Movement. Patients were not discharged until production of The Bowel Movement was verified and subsequently described in minute detail in the nurses’ notes, having been observed in excruciatingly fine detail by the RN. This was a required course of study in med/surg nursing. I studied adjectives to describe feces in my classes on post-op patient care. So why on earth am I seeing patients who are a week or more past surgery or delivery who still have not produced The Bowel Movement? Are they getting sprung from the hospital before production these days??? Or to put it in nurse speak, are they being discharged with their “elimination, alteration in” diagnosis unaddressed? Med/surg nurses of the world, where are you? Fight for your patient’s right to eliminate before discharge! It’s tradition!…
…You know you’ve been blogging for a long time when you can’t remember if you already wrote about a topic or not. Stop me if you’ve heard this one already. One of the ED docs I know is a whiz kid on just about anything mechanical. So before our last JACHO visit, he made a flashing sound monitor. If the noise at the nurses station gets above a certain decible level, the light bulb goes off. It’s really effective because the noise level drops dramatically post-flash. Except….I have this propensity for setting it off. A lot. Now, I was a cheerleader in my younger days but it’s not like I’m leading a rousing yell from the sidelines, ya know? I reach up and touch my ear; it goes off.
I put the chart on the desk; it goes off. I say hi to someone in the cafeteria two floors below; it goes off. Oh come on! (it’s making me vewwy self- conscious)….
(BTW: Herb Caen was a columnist for the San Francisco Chronicle for fifty years. He wrote about the San Francisco scene….the people, the places. He would write using what I’ve heard termed “three dot journalism”…. back in the ’80s I attended an opening of the San Francisco Symphony at Davies Symphony Hall. Post- symphony parties were held inside with the orchestra and outside in a tent with a rock (I believe the group was “Pride and Joy”) band. Of course I’m out with the rock band and who do I see dancing next to me? Herb Caen! The man had to be in his 70s but he was out there rockin’ to the Motown beat. He passed away a few years back and San Francisco still isn’t the same….)
October 19, 2005, 4:48 pm
The only person NOT unhappy in this old Parke-Davis ad is the nurse! The kid looks upset, the mother looks hostile and the doctor looks like he is watching to make sure the nurse doesn’t mainline the immunization. This pretty much sums up nursing: scared patients, hostile families and grumpy old doctors who can’t let a nurse swab an injection site without ordering it done in a clockwise direction.
Humility is a noble trait. My humility gene got a kick in the pants this week. Here’s the scenario:
Female patient, 36 hours post forearm-injury secondary to a sport. No swelling. No deformity. No decrease in range of motion. No bruising. No point tenderness (and I was all over that arm like white-on-rice, looking for point tenderness). Was able to continue playing after injury. Chief complaint: it began hurting again after initial improvement. Nurse-With-Overarching-Pride-In-Assessment-Skills (aka: me) tells ED MD that it just sounds like a contusion. ED MD evaluates patient and orders x-ray. “What???” I say incredulously. “You have got to be kidding!” ED-MD-With-Patience-Of-Saint assures me he is not joking, that (1) patient requested an x-ray and (2) there is an area of point tenderness where ball met forearm (an area I had palpated rather thoroughly). To make a long story short:
The patient had a fracture. There it was. In all three views.
I had a red face.
No freakin’ way!!! Uh….yes freakin’ way!! I picked up my jaw and returned my humbled self to the triage room.
So what did I learn?
- Fractures are one of the most commonly missed diagnoses in the ED.
- DOH! Before smooshing around looking for point tenderness, ask the patient where it hurts the worst and work your way around from there. It’s amazing what you discover when you actually listen to the patient.
- Doctors are doctors for a reason. I am not a doctor, although I will occasionally play one in my mind.
- Nobody’s perfect (sniff)!
I have always felt that we learn more from our mistakes than we ever do from success, and I know I’ll be much less inclined to dismiss a potential diagnosis because it doesn’t meet “by-the-book” criteria in the future.
You can never be too old or too experienced.
Live and learn.
October 17, 2005, 4:12 pm
And the EmergiAward is presented for:
Fastest Relief From a Pain Shot Award: 5 minutes. Patient is writhing, moaning with tearful sobs, nauseated, photosensitive, holding the sides of their sunglasses as they rock their head from from side to side. Injected with Dilaudid and Phenergan. After five minutes, sitting painfree on the side of the bed and very appreciative.
Worst. Luck. Ever. Award: Patient gets hypodermic needle through sandal while walking in a park.
Worst ED Set Up Award: Goes to a local university teaching hospital, world renown for just about everything else except the lay out of the ED. While the rest of the facility is state-of-the-art, the ED is a 1960s time warp. The metal detector you have to go through to enter the ED is modern, though. The staff is great, the care (both medical and nursing) is competent, but the unit itself is small, cramped and swarming with nurses, interns, residents, attendings and, oh yes, patients. Even the trauma room is small. Which leads us to the….
Worst Assignment Ever Award: while employed by the above university teaching hospital, I was given the “Hell Hole” assignment. This meant that I was responsible for six monitored patients in a small, windowless room AND the psych isolation room right across the hall that required q 15 minute observations/documentation on the patient locked inside. One RN. No LVN. No tech. Just me. And, oh I almost forgot….. about a gazillion interns/residents/attendings/ all wanting to know where the labs were and why Patient X was still in the ER. Or informing me that Patient X wasn’t getting admitted yet because twenty other Medical Services had to see them and it HAD to happen in the ED. Or sitting at my desk hogging my charts (except the interns….I let them use my desk, they were cool). Funny, the administration was shocked, shocked that I resigned after 10 weeks. I’ve heard through the grapevine that the unit is now staffed more appropriately. I don’t mind working hard, but I will never tolerate working stupid.
Most Ridiculous MD Order Award: Conscious sedation. Patient: child with a laceration. In the middle of the night. On a major holiday. In a full ED and with 8-9 patients in the waiting room. With only two RNs, one of whom would be tied up with this patient for a full ninety minutes. Let me put it succinctly: No way, dude. No freakin’ way.
You Can Run, But You Can’t Hide Award: Patient on west coast recognized by a nurse who just moved from the east coast as one of the known drug seekers in her old east coast hospital. Busted!
Oddest Response To a Negative X-ray Award: Look of absolute devastation when told extremity not fractured. Poor guy, don’t you just hate it when dreams of an insurance settlement slip through your fingers? Patient giddy with delight over crutches, however, so positive patient feedback expected….
Most Patients Presenting In a Single Family At One Time For Triage Award: Six (ages 6,5,4,3,2,1)! They all had colds.
Sweetest Man In the Entire World Award: Patient is elderly, frail delusional female who presents with the belief that her eyes are falling out. ED MD tells her that not only are her eyes not falling out, but that they are beautiful.
Unclear On The 911 Concept Award: Patient with multiple, penetrating thoracic trauma picks up spouse at home before stumbling into ED, pale, diaphoretic and near syncopal.
Just Plain Stupid Award: ER staff allows 35-year-old female with acute abdominal pain and bleeding to fill bladder by drinking two liters of water before pelvic ultrasound, only to then say, “Gosh, you are going to surgery! Here is an NG tube….” and I can give the details of this one because I was the recipient of the NG-induced epistaxis! I will never, ever consent to an NG tube again as long as I live unless I put it in myself. At least I know how to DO it!
Best Straight Shooter Award: Intoxicated, combative, restrained patient needs to urinate immediately. Patient turns to the left side, inches gown up and proceeds to shoot a stream of urine TWELVE FEET away from the gurney. Standing ovation received from all male staff in a thirteen-foot radius.
Who’s The Parent Here? Award: Parent offers liquid antibiotic to Toddler, who says NO!
Parent turns sheepishly to ED RN stating, “Oh dear, he doesn’t want it”. Five seconds later, the medication is traveling down the toddler’s esophagus via a syringe wielded by said RN. RN advises parent to remember that parent is (1) older (2) bigger (3) in charge and (4) it doesn’t matter a rat’s tutu what Toddler wants or doesn’t want; some things are NOT negotiable. Parent marvels as though hit by an epiphany.
And so there you have it. The first group of EmergiAward recipients. Unless stated otherwise, the above situations have all been sanitized for patient protection and are composites of many, many patients, nurses and doctors I have worked with over the years. ; )