Thursday, March 15, 2018

Annual "I haven't blogged in months, but I'm still alive!" post

Oh hai guys! Lookit that, it's been yet another multi-month stretch where I haven't blogged. Sorry about that. Every year, I somehow get surprised by the fact that over the dark cold months of November-February I withdraw into myself (and my couch) and then suddenly rediscover joy and socialization and friends once the sun comes out and warms everything up for more than two consecutive days. It's like haven't gone through this before...except I have, every year, for the past fifteen years. One day, I'll buy one of those happy lights or just take a vacation to Mexico in January.

ANYWAY. Blog. Here we go!


I had a patient a while back who died.

She was one of those patients who, by all rights, should have died before she got to the hospital. I triaged her in from the ambulance after she had a sudden syncopal episode while driving and thought, since she was also diaphoretic and complaining of chest pain, that she was having a massive heart attack.  I was wrong - I got an EKG on her before doing literally anything else, but it was normal. So I proceeded to get her undressed, on the monitor, get vitals, and start a line. I did all this within five minutes. Her pressure was in the 80's, and all of a sudden she told me her lower back had just started to hurt.

Fuuuuuuuuck. After announcing to the ER MDs that I thought she might have a ruptured AAA, one of them went into the room and promptly confirmed my suspicion via bedside sono.

I did everything right for this lady - from ER arrival to OR arrival was around 80 minutes. It would have been sooner, but the cardiovascular team was already operating and had to close before they could take my patient. We were short staffed, and somehow by myself I still managed to get this elderly patient undressed and triaged, on the monitor, obtain an EKG, start two big IVs, send down all the labs including a type and cross (which at our facility is a step that takes an extra minute or two), get a doctor in quickly, find the sono machine, order blood products, keep this sweet and totally oriented patient and her family from panicking, move her to the critical care side of the ER, give report to vascular when they did arrive, keep the patient alive, AND chart all that shit. I did a fanfuckingtastic job, all by myself. This was one of those situations where everything went perfectly, and I felt like a complete badass for correctly diagnosing a critically ill patient and giving her the best possible shot at making it though alive.

She died the minute they moved her onto the operating table.

It was emotionally devastating, and I was fortunate enough to find the family and spend some time with them to express my sadness and cry with them. I've thought about this patient for months, but always was comforted by the fact I really did give her an amazing chance at surviving - and that the family saw how much work I did to help her.


I found out this week that the patient's case was reviewed by the hospital for a possible delay in care, and I'm furious. It just goes to show that even when everything is stacked against me and I still manage my patient perfectly, instead of a congratulations for a job well done I get told it's still not enough.

Monday, November 27, 2017


You know what's really gross? What I could go without seeing again? The inside of someones knee. That's real disturbing, especially when it's attached to a leg that is flailing about but also sadly lacking in skin or kneecap or ligament and is also flinging blood everyone. I thought the only time the femoral condyles should be visible were during a sterile and well planned knee replacement surgery, but I guess 23:00 in the ER trauma room is a great time too.

PSA: Don't get piss drunk and do a lot of drugs, then drive >100 mph on the freeway and get ejected from your car where you'll skid facedown across all four lanes. You'll leave your knee on the road, as well as most of your face and toes.

Wednesday, November 22, 2017


I think the only thing that surprises me anymore about ER ridiculousness is that I'm still surprised by it. Like, seriously. I've been doing this for NINE years! HOW am I still shocked that people are so ridiculous?

Case in point, last week:

Young Dude, with a mild viral illness: I don't have anything for fever. Can I get a prescription for tylenol so I don't have to pay for it?

Me: No, tylenol doesn't require a prescription. If you get the store brand acetaminophen, it's like two or three dollars a bottle.

YD: How the fuck do you know if I can pay for that or not?

Me: Uh, you have an iPhone X in your hand?

YD: Fuck you, lady, I'm outta here. If I get a fever again, I'll just come back here for more tylenol.

End scene.

Tuesday, September 12, 2017


So remember that time I was orienting back up in the trauma area, and was feeling super bummed because I felt like I had forgotten a lot of old skills and was generally being a shitty nurse?

I finished my orientation, got a couple of solo shifts done, and I'm happy to report that it's coming back. There haven't been any really hectic dumpster fires yet, but so far so good. I signed up to take a critical care refresher course in a couple of weeks as well, so that's good too.

Thanks to you guys for the support and encouragement from a few posts back. It's a good feeling to know that I don't, as initially feared, fail as a nurse.

Wednesday, August 16, 2017


Last night I walked into the docs area to let him know that the gyn exam was all set up. Instead of being a normal human being and saying, "hey doc, the gyn exam is all set up," I just walked in and bellowed "ARE. YOU. READY...TO PELLLLLVVVVVIIICCCCCC???????" and walked back out. 

I don't know what's wrong with me.

Thursday, August 3, 2017

Beans, beans

YOU GUYS. I did a hilariously bad thing and got away with it. Just before getting into the elevator to take a patient and family upstairs, I farted. It was unavoidable; I had to let it out. Honestly I thought it was going to be a little poof of air and nothing more, because that's what my toots had been all day. Naturally, I was spectacularly wrong.

Don't you judge me. I know you've all had those same farts, the ones where you let out a little squeaker and somehow the stench of death and shame follows you across the house. A constant reminder of the evil you've loosed upon the world. Don't even play like you're better than that.

Anyway, I let it out while we were walking down the hallway towards the elevator. I thought the speed of my transport pace and the fact the family was up just ahead of the stretcher would save me. The doors opened and we all got in. As soon as the door closed, I realized that the aforementioned stench of shame and death was somehow clinging to my scrubs and slowly filling the elevator. Of course we were headed to the 7th floor, so it was going to be a bit before anyone could escape.

And then...miracle of miracles! THE PATIENT APOLOGIZED! For a fart that wasn't his! It was a true case of you smelt it you dealt it, because he sure did go "oh man sorry guys, I guess I let one go when I shouldn't have!" I was saved by his admission, and can only wonder if he genuinely thought he ripped one or if he knew it was me and was covering.

I'll be eternally grateful, and my shame and I will survive another day.

Thursday, July 6, 2017


I loved travel nursing. So, so much. It was everything I always wanted - fun, adventure, shiny new places, mountains and lakes and friends and road trips and sunshine and spontaneity. The single downside to that job was the lack of working trauma - in the smaller non-designation hospitals, we of course saw some walk in stuff; in the larger ones I was inevitably assigned to the non-trauma sections due to being temporary staff.

As such, I've lost a good amount of trauma skill.

Or to be more precise, I've lost a good amount of confidence in my trauma skills.

Recently I started orienting back into the trauma section of my current hospital, and it's been a rough start. I know what to do, I know how to do it, but it seems like the ability to adapt to the new protocols and new ways of doing things is a steeper curve than I expected and it's been a huge drag on my outward confidence.

I started my career in an absolutely fabulous trauma hospital. I was regularly assigned to the most critical of critical-care rooms, because I was great at it. I honestly don't mean to sound self absorbed, but I was truly good at managing those type of patients.

And now that I've been out of that constant trauma game for five (!) years, it's a different beast. The specific protocols, the phone numbers to call blood bank with, the organization of crucial trays and supplies within the's all different. I'm having trouble letting go of the old ways - why is it that I can remember the phone number to the CT read room of my home hospital, but can't retain the number to the page operator? Why can I remember the location of O2 Christmas trees and the precip tray and the luer locks in the supply room of a hospital I last worked in four years ago, but can't find things in the stock pyxis without using the lookup function? Why do I still recall the phone number of the local ambulance company but can't remember the damn zip code of my own current hospital? Why could I handle the grumpy surgeons at home hospital, but still feel on edge with the ones here? If I were dropped back into patient care at my old place I'd be running the show in five minutes flat, just like before I left.

I know how to take care of a trauma. It's all that routine, hospital-specific stuff that is killing me. And I inevitably feel like I'm a shitty critical care nurse when I can't quickly locate things or numbers or policies, and thus my confidence in the patient care side of it falters.

It's frustrating as hell.

I think I'm being harder on myself than I need to be, but I'm used to being the best and it's disheartening to not be that right now.

Wednesday, July 5, 2017

Eye can't handle this...

Forewarning: don't read this if you're grossed out by eyes. Or blood. Or blood clots. Eegh.


After very little thought, I've decided that this new thing I've seen has taken the top spot in the list of GROSSEST STUFF EVER.

I've seriously never been this squeamish before, not even holding traction on crunchy bones or dealing with avulsed fingernails.

The offending thing? Canthotomy. Or more specifically, a lateral canthotomy and cantholysis with both superior and inferior canthal tendons cut for emergency decompression after a retrobulbar hemorrhage during anaesthesia.

Let me put that into basic words, for any non-medical people out there: during the numbing of the nerves behind the eye for cataract surgery, something starts bleeding. That sudden influx of large amounts of blood behind the eye builds up and tries to squeeze the eyeball out of its socket, but pesky anatomy like eyelids and tendons are keeping it in place. The pressure inside the eyeball shoots up to 90 mmHg (normal is 10-21), so an emergency procedure called a canthotomy is done. This procedure consists of cutting the lower eyelid enough to see the tendon holding the eyeball in place, and THEN CUTTING THAT TENDON. If all that doesn't fix the pressure in the eyeball, then you cut the upper lid and tendon too.

Obviously this whole process is a bad outcome for supposedly minor eye surgery but as if that's not enough the patient will uncontrollably bleed because they're on blood thinners too, so they come on in to my ER. Where the doctor will have me take down the dressing to see what's up and I will gently remove said dressing until I reach the eyelid, in which case I'll have to stop because I'm not sure if what's attached to the dressing is clot or eyelid or eyeball and oh god it was so gross I'm getting squeamish just writing this.

I made the doc take over because NOPE. And also because I don't want to be responsible for accidentally pulling someones eye out of their skull. When she got all the dressing and clot out of the way, all you could see was tendon ends, floppy lid, and what theoretically was still an eyeball but pretty much just looked like a handful of red mush.

I'll be fine if I never see (heh) that again, thanks. Once was enough to place this very solidly in the top spot of grossest stuff ever.

Tuesday, June 20, 2017


Me, to the doc who just saw my 45 year old patient presenting for two days of constipation: "Hey man, you want me to go ahead and call the fire department, or would you like to?"

Doc: "Uh, why exactly would we call for the FD?"

Me: Oh, well, you ordered an enema. I figured his butthole must be on fire, and I wanted to make sure that was taken care of by the appropriate people.

Doc: "Not funny."

Me: "Incorrect. That is hilarious. But the sentiment stands; I'm not doing a soap suds enema on this patient. You can change it to literally anything else, but unless I see flames I'm not going anywhere near him with that SSE."

I told the doc later that while I was in fact trying to be funny, I didn't want them to think I was blatantly ignoring their orders for the sake of being rude. I did, however, want them to recognize that ordering an enema as a first line constipation treatment on a completely healthy patient was ridiculous.

Seriously though, dude hadn't even taken a colace before coming in. He sure did get discharged with a bottle of mag citrate though, and NO ENEMA.

Monday, June 19, 2017

Gravity always wins

My feeling when, two minutes before my orientee and I get to clock out, our fall risk score of zero patient decides to faceplant off the end of the bed and I realize we now have another full hour of care/documentation to do:

*for the record, he was totally fine

Thursday, June 15, 2017


It's easy to write about the times I felt good as a nurse, or did things easily, or was smart and caught some little detail that helped me better care for a patient. It's much more difficult to write about my failures.

This wasn't even a big mistake, just an offhanded comment that I've been ruminating over for weeks now.

Recently I had a kiddo with appendicitis who was being transferred to the pediatric hospital down the road. It was a ridiculously straightforward case: kid with zero medical history had no appetite for a day and then started with nausea and classic RLQ pain, parents brought him in for a workup, CT showed an appy and we started antibiotics and the transfer process. He was a typical young kid - old enough to know what was happening, but young enough to be terrified by it. About twenty minutes before transfer, he started to cry a bit.

What I should have done was sat down next to the kid and told him it was okay to be scared, that it was okay to cry. I should have validated his feelings and told him that yes, surgery is scary and doctors in masks can be scary and that this whole thing is scary - even me, trying to be comforting, can be scary.

I didn't.

Instead, I told him that it's okay, he doesn't need to be scared, that we're going to take great care of him and everything would be fine.

I can't make that promise - what if everything is not fine? I'll take care of him to the best of my ability, but he might still hurt. I'm not scared by hospitals, but he damn sure was. I told him the classic caregiver lie - with the best intentions and hopefully true, but not at all what a nine year old needs to hear.

I messed up.

Monday, June 12, 2017


I went in to discharge a patient last night, and since she had been there a little over two hours I needed to check a set of discharge vitals. I opened a new cuff and p-ox and let them run while I was going over the paperwork, then wrote down the vitals and waved her off to the exit. Back at my computer to chart all the discharge paperwork, I noticed that the blood pressure and heart rate I had just taken were the exact same as the triage set. Does anyone else ever get that weird feeling when this happens that if your chart gets audited, whoever is reading over it will scoff and be like "chyeah, obviously they didn't check discharge vitals! No one has a repeat BP of 143/68 and HR of 71! I'm definitely going to call them in for a meeting."

I then had a moment of questioning if I should change it by just a single number, to 142/68 or something, just enough to make it different and clearly a new set of vitals. Or even to chart the correct identical BP/HR, but free text a note that yes, they are in fact a new set. Which then led to me feeling horribly guilty for even thinking about falsifying data, but also wondering if I'm just a crazy person simply for having this series of thoughts.

Paranoia over chart auditing is such a weird thing.

And then I remembered that everyone, everywhere, always charts 16 as the RR (edit: in the stable, non-respiratory or neuro patients. I'm not that shitty of a nurse; geeze, guys!) and then I felt better about myself.

photo credit

Wednesday, June 7, 2017

Personal Best

So guys I hit my personal all time-best record of AMA discharges yesterday. I had, count em', one two three FOUR against medical advice discharges! Four! And two of those came literally at the same time, with adjacent rooms both signing out (no, they weren't there together). I did my part in legitimately trying to get the one guy who needed to stay refrain from signing out, but no dice. The other three I practically tripped over myself to get the paperwork ready so I could hold the door open for them.

I very nearly had a fifth AMA, but the admit doctor swooped in at the last second and convinced her to stay. Le sigh. Coulda had the championship thumb ring, but at least tonight is another chance!

Thursday, May 25, 2017


So the bosses at work, in all their infinite wisdom, apparently decided that I'd be a good fit for training a new grad into the ER. I guess that means I haven't screwed up too badly there yet? Adapting to a new hospital is always hard, and that makes the feeling of "am I actually good at this, or just good at faking?" a little harder to shake. Even after eight years of nursing and multiple rounds of precepting (mostly travelers and other experienced nurses, but a couple of new grads too), there's always a little voice in the back of my mind telling me that I've still got a long ways to go before I don't suck at nursing.

I went through a pretty intense year or two of impostor syndrome back when I was a relatively new nurse. Most days I came home and felt that any good thing I had done at work was owed to the abilities of my charge nurses, coworkers, or just good luck. Gradually, I felt more comfortable with most things but that little nagging feeling has never completely gone away. People tell me that it's a good feeling to have, because it means that I still care about the profession and that I'm not allowing myself to become complacent. I can understand that, but I wonder if other people still feel this way even after so long?

So tell me, do any of you feel this way too?

Tuesday, May 23, 2017

Me-owch (I'm pretty pleased with this blog post title)

One of my favorite doctors at work is apparently very naive when it comes to standard vagina-slang. Case in point:

After the doctor and I saw a patient presenting with vaginal burning and urinary frequency, I asked if he wanted me to put in for a veterinarian consult. I was met with a confused look from him with immediate snickering from the other docs and scribes around.

Doc: "Uhhhhhhh..."

Me: "You know, for her kitty cat problems?"

Swear to you guys, this patient referred to her vagina as her "kitty cat" at least three times during the doc's exam. It seems that in all his years of doctoring he's somehow never heard this term, which I'm totally okay with because it makes for these little moments of hilarity. And let's be real, it's these moments which make working in the flaming dumpster fire that is today's healthcare system even a bit tolerable.