July 21, 2009, 11:30 am

Started Out Clean, But I’m Jaded

didnothearcallDoctor Ratched: “Nurse! I’m appalled! This woman has waited five minutes for her ice chips!”

Nurse: “Oh my, how could I be so irresponsible! I should have predicted her dry tongue, left my seizing pediatric patient and run to meet her need for moisture!”

Doctor Ratched: “Well there goes our Press-Ganey scores for the entire month. I hope you are satisfied, Nurse!”

Nurse: “I’m so ashamed!”


But hey! Don’t let this happen to you!

With the Edwards Nurses Call System you know when a patient needs ice chips!

And look….one hand!

What will they think of next…answering call lights through a speaker in the wall?


Last call for submissions for this week’s Change of Shift to be hosted at Nurse in Australia. Ross is awaiting your submissions at “admin at nurseinaustralia dot com”.

Shhhh! Something is afoot over at Doc Gurley’s blog where Grand Rounds is surrounded by mystery, intrigue, foggy London nights, Peter Lorre running through the posts…..okay, not that last one, but if you are up for a good suspense-filled read, this is where you need to be!


You showed up to the ER.

You presented your case.

You got your narcs.

Good ones, too. Nice, big, fat dosage for the 50/10 pain you calmly reported.

I served it up with a smile next to a side of compassion.

After all, pain is what you say it is and we are there to meet your needs.

Patient satisfaction – we are all over it!


Wait a minute……


You don’t have someone who can come and pick you up?  How did you get here? Oh, your Aunt dropped you off? Why don’t you….oh, she doesn’t carry a cell phone? Huh. That does pose a problem!

No, I’m sorry, I can’t have you walking out of here in the dead of night to the bus station after an injection of that magnitude. It isn’t safe. Why, look! Your sister’s number is right on the chart and she lives right here in this area! Oh…she isn’t picking up the phone at this hour?

Let me go try and see if I can get through for you.

(How odd, as I am walking to the nursing station to make that call, I hear the dialing of the room phone and I hear you say something in a very low voice. I walk back in to see if you had reached someone. No, no, no one is picking up at Auntie’s place. It just rings and rings, you say.)

Funny, when I try the number it’s a solid busy signal. For ten minutes. At three am.


Gosh, I’m really confused!

You see, the ER security tape shows you walking up to the ER alone all the way from the street! Ah, I see that you reply with a shoulder shrug. Interesting. I’m sorry, we don’t have taxi vouchers in the ER. Oh, you have money at your Aunt’s house? Uncle George will have it, you are sure of it? And you want us to call a taxi for you? Well, that’s fine then!

Happy to make that call for you!


Wow – never stiff a taxi driver who has traveled thirty miles to pick you up.  Jumping out of the taxi as they round the building really makes them mad!  And they want us to know that you said you had no intention of paying anything and that you had your car down on the street.

Holy cow! That means you will be driving under the influence of a narcotic! We try to find you, after all, your safety is our responsibility! You made it off the premises so fast you were long gone before we made it to the end of the driveway!


That’s it.

No more.

I can’t play anymore.

I am nothing but a legal pusher of narcotics to addicts who know we know that they know we know….it never ends.

Emergency departments hand it out like candy. We invite this behavior. We abet this behavior. We will give you what you want, when you want it and how you want it even when we know it is bogus!

Why? Because it gets the addict out of the department faster? It’s less hassle to give them what they want? No one wants to confront and say “sorry, but this behavior looks like drug seeking to us”?

It does no good to confront after the fact. The narcotic is given, the fix is in, yadda, yadda, yadda. They scored again.

And they will be back, believe it or not. Even when we confront them with previous alterations in prescriptions, tell them we have personally witnessed them driving away in their vehicles, let them know that taxi drivers will rat them out every time…it makes no difference. And soon it is known all around the area that if you want it, you will get it at Hospital Hotel.

And before I’m accused of being elitist, not knowing the “true face” of addiction, having no compassion, riding my high horse or being a bitch, let me assure you that addicts come in all shapes, sizes, colors, genders, occupations, income levels, hair colors and ages.  None of that matters. They will lie, manipulate and ingratiate to get what they want.

So, please tell me.

When will somebody grow a pair and stop this insanity?


Narcotics in the ER is a hot topic that always engenders a hot debate. I have to give a hat tip to girlvet at Madness: Tales of an Emergency Room Nurse for the idea for this post.

Speaking of hot debates, please keep your comments passionate but polite. Thanks.


  • Candy

    July 21, 2009 at 2:36 pm

    Oh, my. You give me so much food for thought. You are correct on many levels. When did it become our responsibility to offer drugs of this magnitude for pain? Why can’t tylenol do? If these people are in so much pain, for whatever reason, maybe they should be referred to someone who can treat the CAUSE. OK, I’ll be nice now. Thank you, Kim…

  • JustCallMeJo

    July 21, 2009 at 9:15 pm

    It is tiring.

    When I observe clinical signs that show a deepening level of sedation, I document patient’s HR, BP, RR and GCS…I fractionate the narcs. I have never had an MD take issue with me on this (probably helped by my thorough documentation). I feel no guilt whatsoever in telling a drug-seeking patient ‘No More.’ To hell with Press-Ganey.

    When the patient demands more, even if they’re positively vile to me, I don’t get upset anymore. I ask them if they’d like a tube jammed down their throat with that? They won’t care. They won’t like me. But they weren’t going to give ANY nurse that took care of them that day a good Press-Ganey score, were they?

    I am keeping the patient alive and breathing. I often believe a lot of them that they’re having so much pain that even conscious sedation doesn’t touch it. But even the ones who aren’t advanced metastatic CA or post-op spinal surgeries or whatever…some people are in that much psychological pain that they cannot abide dealing with reality. I do believe some people live in so much pain that death is the only way out.

    But I can’t and don’t help people die. On any given day, I can confidently say I am simply too busy to call a code and intubate my patients, so I would rather they just not stop breathing. It doesn’t hurt my feelings if a patient doesn’t like that. So, no, it’s not my job to deny that they’re having pain. It’s my job to keep them safe first. (Or simply to do no further harm.)

  • Jen

    July 22, 2009 at 2:43 pm

    “In The Realm of Hungry Ghosts” by Gabor Mate, MD is a must-read. He agrees with you on every point AND manages to offer (possible) solutions.

  • […] On the back end of a frustrating shift, Kim from emergiblog brings us Started Out Clean, But I’m Jaded. […]

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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