July, 2006 Archive

July 23, 2006, 10:10 pm

Growing Pains


Okay, since I’m sending this post to Radiology Grand Rounds, I thought I’d give some props to those hard-working X-RAY techs.

You know who I mean.

Those hard running folks we expect to be in four places at once and have our CT results STAT even if the computer is down.

The ones who are eternally patient with us when we send our patients down to x-ray for a chest film wearing enough bling bling to buy Trump Towers.

The ones who have the power to clear a room just by yelling “X-RAY!”

The ones who can soothe a patient during a CT scan just by the sound of their voice over the speaker.

Just so you know, we in the ER appreciate you.

We just need to tell you more often.


I never thought I ‘d have anything to say about radiology.

In fact there is an old joke. I know it’s old because I made it up 28 years ago.

It goes: If I can see something wrong on your x-ray, you are very sick.

For you see, I cannot read films. I can find lungs.


I can see your hip, but unless the your femur is totally in two, with one of those pieces on the other side of the room, I may not see your fracture.

You get the picture, no pun intended.


Now this may be old hat to all you radiology-inclined folks, but we have a fantastic new system that has done away with the old x-ray film.

X-rays are now viewed at a central station where the doctor sits via a computer screen.

No more waiting for films to be developed and if the patient needs a copy of the x-ray, it can be placed on a CD that can be read on any computer.

This is good for two reasons:

  • Nurses have more access to the x-ray – we can look at it right along with the doctor at the station.
    • Often, the films were down off the viewer before the nurse had a chance to see them. I once worked at a teaching facility for ten weeks and I never saw an x-ray the entire time, as the viewers were out of sight of the nursing areas, and the nurses too busy to get in on the teaching being done.
    • Now nurses are not often required to read films, but we are able to order them in the ER. You can never have too much knowledge and familiarity with x-ray views can be an asset when assessing a patient, expecially with an extremity injury.
    • Increased exposure to the x-rays gives teaching opportunities that nurses did not have before. I had an opportunity to view an x-ray where the fracture went through the entire growth plate with dislocation. Amazing.
  • The images can be enhanced.
    • Think there might be a fracture, but not sure?
    • You can blow the area in question up as large as you need to to see it more clearly.

They say familiarity breeds contempt, but not where this nurse and x-rays are concerned.

I can now say with certainty that if I can see a problem on your x-ray, it means you have a problem on your x-ray and NOT that you are VERY sick.

That’s a good feeling.

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6:08 pm

I Got Dem ol’ Triage Blues


Frankly, I think three apple martinis in 2 hours are quite good for the “collywobbles”.

No, actually, I think three apple martinis in 2 hours cause the “collywobbles”.

Not that I would know, of course

But I’ll be darned if Pepto Bismol would be my hangover drug of choice.

The pills maybe, but not that pink bismuth sludge. Blech!

I used to think that Pepto Bismol never worked.

Then I realized I only saw the people it didn’t work on.

I thought of this ad last night when one of my little patients told me his stomach had the ooogly-googlies!

I get the oogly-googlies when I use Google, but I don’t think it’s the same thing.


Sitting at my local (air conditioned) Starbucks and Simple Minds are singing “Don’t You Forget About Me”. Ah, doesn’t get any better than this.

I am so preoccupied with 1985….

Hope my husband doesn’t forget about me, I spend so much time here. It gets my creative juices flowing.

Hmmm….technically I am still boycotting Borders, but when does the boycott become a moot issue because you now like Starbucks better?

Just wait until the new one gets wireless this week. Every seat is plush and there are outlets on the wall every three feet. I may have to move in…..

And now for our feature attraction.


I pulled two twelve hour shifts in a row, and I was the charge nurse both days.

Now in the old days, that meant being the triage nurse and sitting in the triage room coming out in-between triages to help the staff RNs and checking the status of the department. My ER basically runs itself, the staff has been there for decades.



A few posts back, I described immediate/rapid bedding where you place the patient in an available room instead of making them go through triage and registration before seeing the doctor.

It’s supposed to decrease the door-to-doctor times and increase patient satisfaction.

I said it was quite efficient.

I take it back.


While I am all for patient satisfaction, I do not believe this immediate bedding and registration is really all that efficient.

The old system of being triaged, going to registration and having a completed chart when you are roomed was developed for a reason.

  • It worked.
  • Orders were able to be put in immediately.
  • It was a systematic way of controlling the patient flow.
  • The triage/charge nurse had a full overview of the department at all times and knew all the patients and which rooms they were in.
    • The charge nurse could decide which patients went where and could spread the wealth, so to speak.
    • The staff nurses could also room the patients when they had an opening.
    • If you were emergent, you went in immediately anyway.
    • This worked so well for us that we had the reputation of being the fastest ER in the area even before we started immediate bedding.
  • There was some control of how quickly patients were seen and the nurses had some control over their patient load at any given time.
    • Yes, there were nurses that would abuse the system by dragging their feet on discharges or not rooming when they had a spot open and patients were waiting.
    • After all, if you didn’t have an open bed, you didn’t get a new patient.
    • It was up to the charge nurse to recognize and “assist” these nurses with their bedding.

Now here is what is happening with this new “rapid/immediate bedding system”:

  • The charge/triage nurse is triaging at the bedside
    • often getting “stuck” there if the patient is urgent/emergent because
    • the assigned nurse is busy with the two other patients who were just “immediately bedded” in her/his assignment.
    • And the triage nurse must do the now required medication reconciliation form, and if the patient has a two single spaced typed pages of medications (and they do) this can take time.
  • The charge/triage nurse has to remember to let registration know the patient is there so they can run to the bedside with their portable registration computer.
    • Technically, we are supposed to circle the bed number on the board but,
    • The registration clerks are in another room from the board!
  • While you are triaging one patient, two or three others come in.
    • Now these get turfed to the waiting room because the triage/charge nurse is busy triaging in a room.
    • Or, they are put in a bed and then the triage/charge is told they are there.
  • Once the triage is done, the chart is placed in the “to be seen” file for the doc/PA.
    • Which means the only orders that can be carried out are resp tx or med orders because no tests/labs can be ordered without the registration number.
    • The secretary gets a back-up of charts awaiting orders to be placed.
    • The chart “guts” get separated from the main chart.
    • Orders get missed.
    • The nurses can draw bloods but must wait before getting the labels to place on the tubes, increasing the risk of mis-labeling.
    • The registration clerk can only be one place at a time, so the numbers either come one at a time or all at once, depending on how fast they are.
  • In the meantime, the triage/charge nurse has to triage those who are turfed to the waiting room.
    • They can do this in the triage room, then, if a bed is open, they get roomed immediately after and the registration clerk is off and running.
    • Yes, a relative can register the patient but,
    • you get half the registrations waiting for the clerk to get back to the desk while they are still running to get the immediately bedded patients.
    • It can’t be half-and-half. It’s worse that way. Either registration is done only at the bedside or it isn’t.

Now I have been a nurse long enough to know that the world does not fall apart if I don’t get to see the patient first, but add to all of the above that the patient may be roomed by the MD or PA or any other nurse and you can see where confusion may reign.

Now, let me tell you right off that my ER is staffed by on-the-run, movin’ MDs, PAs and RNs who know their stuff and could function in their sleep.

Which is why I love my job so much and it means the door-to-doctor time has been drastically cut (I’ll have to ask to see the stats).

The patients love us even more than before because they percieve it as NO wait time.

It’s just that the waiting is going on behind the scenes and I see it as a potential minefield of confusion and missed orders, especially when it was as busy as it was the last two days.

In an environment where control is a luxury, immediate bedding decreases the amount of control nurses have although I have to admit, it works better for the physicians.

I think the old system was safer for the patients because things were done methodically, but this one makes the patients happier and it’s all about those satisfaction scores.

The door-to-doctor time decrease is definitely positive.

Immediate bedding is here to stay, but I think it’s time to re-evaluate how we can make it less confusing for the staff and safer for the patients.


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4:07 pm

Wake Me UP, Before I Go-Go


“Gee Mom, I just fell off a swing, did you have to come dressed in mourning clothes?”

Do people even use handkerchiefs anymore?

This must have come from the “assess the patient fully draped with hands on hips before you let them in” era of ER medicine.

With a security guard checking for pelvic fractures through a blanket!

Ah, they don’t make ’em like that anymore!

Oh, and notice how they blurred the edges of the car to give the impression of speed?

Look at the front wheels of the gurney. They are going in opposite directions.

That gurney is stationary.

Nothin’ gets past me!


“Change of Shift” goes up on Thursday, so get your nursing-related posts to me by Wednesday. A very ecclectic group of posts has already been assembled but we need yours to make it complete! And while you are at it, make sure you have sent your post into Grand Rounds for Tuesday.

What? You don’t blog often enough to submit to both?

Well you obviously have a life!

But for the benefit of those of us whose love for blogging makes Rhett Butler’s love for Scarlett O’Hara look like a high school crush, pull a good one from your archives and send it to moi!


Okay, it’s like a bazillion degrees here in the City (Area) by the Bay, and my boycott of Borders is in full swing here at my local Starbucks. Peter Gabriel on the satellite radio.

I can dig it.

Everyone has droopy hair, make up that looks like a Salvador Dali painting and (as the B52s put it in “Love Shack”:) wearin’ next to nothin’ cause it’s hot as an oven!

Except for me, because if I was wearin’ next to nothin’, I’d be arrested as a public nuisance.

You know, Herb Cain used to call San Francisco “Baghdad by the Bay”.

I think the only thing we have in common this week is the heat….

Lets put it this way.

It is so hot here that a twelve-pack of diet Pepsi that was in my car exploded.

Most people try to fry an egg on the street, I explode diet Pepsi.

I didn’t know Pepsi could boil…..


They got me.

Work calls me at home.

I’m asleep.

Daughter hands me the phone.

Still asleep, “Hello?”

“Hi Kim, this is Designated Charge Nurse. Esteemed co-worker needs surgery and is “out for the count”. We need someone for Thursday (4 hours) and for 12 hours on Saturday.”

Still half dreaming, “Okay, let me look for my schedule.”

I then beging to stumble about the house looking for a purse I cannot find probably because my eyes are closed.

I groggily reply: “Designated Charge Nurse, I cannot find my purse. But I’ll do it.”

After which I fell upon the couch and relapsed into a deep comatic sleep.

Only to wake up to find I had committed myself to sixteen extra hours.

New Rule in House: Do NOT Wake Me up If Work Calls. Take message instead and I will call back.

I am not responsible for things said when semi-comatose.

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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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