January, 2006 Archive

January 8, 2006, 8:05 pm

When Your Patient Gets A “Two-For-One” Deal

One thing?

I can think of a million things I would have like to have said to a few doctors over the years but I was too young and intimidated. Now that I am of a certain age and incapable of intimidation, I realize it just isn’t worth the effort.

Doctors just don’t seem to yell as much anymore.

One, the working relationship between doctors and nurses has changed into more of a collegial partnership.

And two, I was dancing to the Bee Gees when they were still in diapers. Perhaps they are respecting the elders.

Anyway, this nurse in the ad feels confident that she can tell her doctor about acoustic ceiling tiles without stepping on any toes.

Was noise pollution an issue back then?


Many, many years ago I learned that things are not always what they seem to be. Especially in emergency medicine. Here’s an old story of a case that taught me never to assume anything.

Patients will often come into the ER self-diagnosed. Often they are right. The asthma exacerbation. The recurrent migraine. They’ve been there, done that and gotten everything but the T-shirt.

So, when a patient anxiously enters the department and with muffled voice says they are having an allergic reaction and their throat is closing off, it gets your attention. This is the definition of “immediate bedding”.

Family reports that two weeks before, this middle-aged patient had significant facial puffiness following ingestion of an OTC (over-the-counter) medication. Patient self-medicated with Benadryl and no medical attention was sought. (Patient had no other medical problems and denied tobacco or alcohol consumption. They didn’t have a primary physician, having not needed one before).

Not believing that the reaction was caused by the OTC med, the patient took it again that day. Within minutes the throat sensation was noted. Again, Benadryl was taken (twice the recommended dosage on the bottle) but when it did not work, they presented to the ER for treatment.

To say the patient was anxious was an understatement. They lay upon the gurney as stiff as a board. I’ve seen rigor mortis that wasn’t that tight. No stridor, no wheezing, no tripod position, no facial swelling, just a thick, muffled-sounding voice that seemed difficult to produce and a look that could almost be described as panic.

The patient did note that in spite of the fact they were still uncomfortable, the throat was somewhat better. Perhaps the Benadryl was working. The ER doctor was at the bedside and the patient was diagnosed as having an allergic response and was treated appropriately.

I explained the medications calmly, reassured the patient that they would be feeling better in just a few minutes, perhaps a bit shaky from the medication, but certainly improved. The family was at the bedside. I left the call bell within reach and because I was covering the cardiac beds that shift, I went to check on my other patients.

I was summoned to the bedside of my patient with the allergic response within five minutes.

“Should I be having chest pains?” my patient asked. “My throat feels better”. The monitor showed mild sinus tachycardia. I asked the patient to describe what they were feeling. Sharp, intermittent and mid-sternal with radiation to the left shoulder. No nausea, no diaphoresis, no SOB. I went to the ER doc thinking that what this patient needed was some Vitamin “A” (aka Ativan, given for anxiety). An EKG was requested. Of course it would be – I was embarrassed that I didn’t just do it myself, but I was fixated on “allergic reaction”.

Occasionally there is a moment when an EKG shows up on the screen that produces an “uh-oh” response from the technician – something isn’t right. Well, I happened to be the technician doing that EKG and my response as it printed off the machine was “Oh s***!” It was BAD.

Twenty minutes later the patient was having a cardiac cath and three stents put in his coronary arteries, one of which was 100% occluded.

Was the patient really having an allergic reaction? Was the closing throat a symptom of the MI? What about the angioedema two weeks previously, seemingly related to the same medication taken by the patient that day? Was it just a fortunate circumstance that this essentially healthy individual happened to have his MI right in the ER?

I never learned the answer to those questions. I do know the patient did wonderfully and was discharged without complications.

But I still get a twinge of anxiety just thinking about that EKG!

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January 5, 2006, 1:23 am

It’s A Tough Job, But Somebody (Else) Has To Do It

The voting is still going on over at Medgadget for the Medical Blog Awards of 2005. If you haven’t voted already, please consider visiting the site and giving “Emergiblog” your vote for Best New Medical Weblog and Best Clinical Weblog. I believe the voting is going on until January 15th. Thank you!


This poor man is trying to get in to see his wife. But no, the doctor has said the patient is to have no visitors.

Not even her husband?

He’s even brought his wife flowers, grown in her very own greenhouse.

Why, that’s wonderful, opines Nurse Sentry! They just might make her feel less depressed!

Umm…..maybe if she could have visitors she might be less depressed?

And so ends another chapter in the history of the nurse-in-advertising. This ad is actually for portable greenhouses! Go figure!

Do you even see nurses in ads anymore?

And how do you know they are nurses if they are there?

I miss my cap…..


My philosophy of emergency medicine is very simple.

If there is a patient in the waiting room and an empty gurney in the department, I believe that the patient’s butt should be on that gurney. Period.

The minute the gurney is clean the next patient is getting tucked in.

Not all emergency nurses share this view and some will go out of their way to, shall we say, divert the patient care to their department colleagues.

Here are a few behaviors I have witnessed over the years:

  • Selective Vision – there are five charts in the “orders to be done” rack, but they are not seen because the nurse is too busy reading about Brad and Angelina in an old People magazine.
  • Selective Selection – the nurse approaches the rack, assessess the work to be done and leaves the NG tubes and enemas to the next nurse. They are, however happy to adminster the ibuprofen and put a band-aid on the skinned knee.
  • Cleanliness Is Next To Godliness – the nurse develops an acute onset of obsessive-compulsive disorder as he/she is too busy to take another patient because the IV tray contents must line up perfectly. In every room. And if she doesn’t do it, who will?
  • The Waiting Game – everyone sees the chart for the patient in the waiting room, but no one makes a move, waiting to see if another nurse will grab it first.
  • Ambulance-induced Abdominal Discomfort – it begins with the ring-down and reaches its apex when the rig pulls up to the door. Immediate residence in the staff restroom is required. Spontaneous relief occurs as the patient is settled into the gurney and report has been taken, as demonstrated by the sound of a flushing toilet.
  • Tech Support – run your ER tech to the point of exhaustion, doing things you can actually do yourself, but why bother?
  • Helpless Hattie – oh dear, she just can’t seem to get that darned IV in, would you please help? At which point you immediately insert a line into a vein the size of a fire hose.
  • The Charter – the nurse sits at the corner desk, hunched over a chart and furiously writing. As she is known for her compulsive charting, no one questions her motivation.

In reality, she is making a list of topics for her next blog entry.

Hey…I never said I was perfect!

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January 4, 2006, 1:12 am

The Polls are Open!!

The polls are open for the 2005 Medical Weblog Awards! I went to vote and was surprised to find that Emergiblog was nominated in two categories: Best New Medical Weblog of 2005 and Best Clinical Weblog! Holy cow! So hop on over to Medgadget , check out the nominees and select your favorites.

I would be honored to receive your vote for “Emergiblog”!

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About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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