Thursday, July 3, 2014

Constipation

I'm not sure if this is practicing good medicine or not, but coworkers and I were sitting around the other night discussing the various alternatives to patient care (read: ways to avoid actually completing the order) when a doctor orders an enema on a young and otherwise healthy patient. Really, we'll do anything to get out an enema administration. They're not fun. Trust me.

In this conversation, I mentioned the best constipation remedy I've ever heard of - it was a comment from Hood Nurse, and I still laugh about it and wish I could tell my patients this:

If you are young, healthy, and just suffer from an unfortunate lack of fiber in your diet and subsequently think "should I go to the ER because I haven't pooped in four days?" then the answer is no. Go home, drink one cup of black coffee, eat one taco bell taco or burrito with hot sauce, and then go for a jog around the block. If you don't run the risk of shitting your pants before making it back to your house, then you may come to the ER and we will give you a bottle of mag citrate.

Pretty sure that's not an exact science though, so take it with a grain of salt. And don't sue me if it doesn't work, because this is the internet and contrary to popular opinion not everything on here is true.

Wednesday, July 2, 2014

Blame

There's this one doc I work with who is super slow at seeing patients and discharging them, but is otherwise a great provider. She's smart and thorough and a really nice person. The patients like her because she takes the time to explain everything to them, and is also very good about telling them exactly what to expect during their stay - things like "I'm worried you may have something wrong with your belly, so we're going to do bloodwork and I'll be ordering a CT with contrast. The contrast can't be given until your kidney function is confirmed as good, so it won't be done until your blood tests are back which will take around an hour. The CT will then probably take around 2 hours to be done and resulted, and since it's a busy day it will probably take me a little bit longer to get back in to you with the results. But Shrtstormtrooper here will keep me updated on how you're doing and if you're in too much pain, so make sure you communicate with her. Any questions? Can I get you a blanket?"

I mean, it took forever for me to just write that, let alone have her explain that to a patient. But I don't really mind the delay because communication really does (sometimes, if the patient is logical) prevent pissed-off people. Also, alliteration.

However, we use Meditech at this here hospital, and it's a piece of shit. This doc hates is so much that she frequently just bursts out in a string of curses whenever trying to do something mundane like chart or order something or review a test. Since she is not the quickest to begin with, this EMR just turns a slower pace into something exponentially more lumbering and painful.

So the other day, we had a patient who was somehow connected to the bigwigs at the hospital. He came in for a pretty minor reason, but the department was slamming busy and the primary nurse hadn't gotten back in after the initial assessment. The guy comes out to the nursing station, and sees this doc standing there. He's like "what's taking so long? I just got asked my address at least four times by two different people!"

Doc jumps on the opportunity that no one else is ballsy enough to take. She says "It's Meditech! It's a terrible, outdated system which doesn't allow anyone to communicate with each other and we have to ask the same questions a million times! I'm still trying to document from patients I had hours ago, and that's why I haven't been in to see you yet. You should definitely take this to the board and let them know that Meditech is awful and directly affects patient care. I'm not kidding..."

I am 99% sure the guy took it to heart, and I can only hope that somewhere, somehow, an HCA exec is getting ripped a new one for supporting such a terrible EMR.

Wednesday, June 25, 2014

Denver fun times

One of my favorite things about travel nursing is getting to experience cities in depth, not just from visiting the touristy places for a couple of days.

I haven't put up a lot of photos from this assignment, so let me remedy that for you now...

My first Denver beer.

Maxwell Falls

These mountains. I love them.
An early-assignment hike for which I was woefully unprepared. And also didn't finish, because OMGZ elevation is a bastard.

Stranahans Whiskey is so delish.

M-A-R-S MARS, bitches! Red Rocks! But seriously. It was SO AMAZING!

Baseball, of course.



Don't worry. I don't know that guy on the deck. But this view. I can't even.

So I've made some good friends, and I've had a lot of fun times. I didn't realize quite how soon I'll be done here - just a few more weeks and I'm out. I'll miss it here. I think I'd be singing a different tune when winter comes, but right now it's summer and it's gorgeous and I love this state.

The adventure will continue elsewhere, though!

Tuesday, June 17, 2014

Throwback

There is this doc I work with who is super badass. He's no nonsense, only-the-necessary-workup type, funny, compassionate, and intelligent. I seriously enjoy working with him because he's the best mix of all of the above, and gets shit done in a timely manner to boot. Basically, an ER nurses' dreamboat of a doc. I mean that not in a Tiger Beat weird way, but in a professional "I enjoy coming to work and seeing this doc on the schedule" kind of way because I know the patients will be well taken care of and I also won't hate my life during the shift.

He does, however, have one downside.

Every single shift sees him wearing these awful, hideous, terrible ACIDWASHED JEAN material scrubs. It's so painful. Is this the 90's? These scrubs are the equivalent of me putting a VHS tape into the VCR and the machine eating the tape. Or of hearing the devastating news that *NSYNC has broken up fo' eva. Possibly as bad as having a Lisa Frank folder that didn't fit into your trapper keeper.

All I'm saying is that this doc somehow stopped dressing himself in the 90's. And a very small part of me is amused by it, but the vast majority of me is like NOOOOOOOOOOOOOO, the horror! I wish I could help. I think, however, that he is too far gone to save.

Wednesday, June 11, 2014

Food

I've gotta hand it to the tech and nursing staff at this Denver hospital. They have these docs trained so well it's almost like watching an educational video. I'm seriously impressed.

When the 11am doc comes in she brings a tray of cookies. When the 5pm doc shows up he brings a veggie tray and a two liter. When the 9pm doc arrives he brings a bag of chips and m&m's. When the 6am doc rolls in she brings a dozen bagels.

Every. Single. Day.

I'm not exaggerating. Every single day, when the docs show up for shift they bring food. I didn't go grocery shopping this week because I'm lazy and couldn't make myself get out of bed early, but I didn't starve at work. I also didn't eat healthy but you win some and you lose some. The important matter is that I was never hungry, because the nursing staff has laid down the law and demanded food and their edicts have been followed ever since.

I've never worked anywhere else that had the providers trained this expertly. I've really enjoyed working at this hospital, and will be sad to leave when my contract is over. It's full of great people and the city is fantastic. But if for no other reason, I'll miss my daily 6am work bagel.

Friday, May 30, 2014

Science

In the ER world, gravity + beer is a very bad thing. It inevitably starts with the famous "here, hold my beer" statement and is quickly followed by a brutal demolition of both ego and intact anatomy. I'm pretty sure Newton even started formulating his equations after witnessing some drunk guy holding an apple while on a horse go, "Hey guys! Watch this!"

These unfortunate people are most always surrounded by a group of people who either gasp in horror or point fingers and laugh. Sometimes, the act of Spectacular Fail is even recorded on video for posterity. Which helps me out in the ER, when my patient comes in with a broken arm and has a perfect rebuttal for the question of "Oh my God! HOW did you DO that?!"

Fortunately, there is no shortage of beer in this world and no shortage of stupid people willing to hand over said beer to try something dumb.

Take, for example, this girl:


Close analysis of the picture reveals a few things: a hill in the background, a bike, a bike wheel at an odd angle against a piling, and a bike rider with a face accelerating towards the dock at 9.8m/s^2. Fortunately, she's wearing an alcohol helmet and flip flops. Because safety first, you guys.

I can only imagine the shame that was felt by this girl after this accident. Wait. I don't have to imagine it...

Because I'm that girl.

Science. Helping drunk people make a fool of themselves since the Neolithic Era.



Sunday, May 25, 2014

I'm done on this topic, for real. Until next time.

You see? YOU SEE?! I've posted many, many times about this. So have all the researchers. I'll post it again though.

VACCINES DON'T CAUSE AUTISM.

(Link: I Fucking Love Science: Huge Meta-Study of Vaccines Reveals No Link to Autism)


Friday, May 23, 2014

Night shift

I swear...night shift gets no love. Last week I worked a shift where we were severely understaffed - I'm talking there were TWO nurses from 3a-7a. This ER has been getting busier and busier, so of course this was a slamming night. Want to know about unsafe patient ratios? Try sixteen patients for two nurses. 8:1 ratio. That translates to 7.5 minutes of care time per patient per hour. Which is awful. Pretty much I went from triage to triage, threw in an occasional IV, and did a couple of EKGs in that time. And charted. Sort of. And because this place has no triage nurse, we can't leave people in the waiting room like a normal ER.

By the time 7a rolled around, we were drowning. I was sitting at the desk charting the three new triages and one EKG I had done in the last 10 minutes, and the dayshift charge grabbed the staffing clipboard to fill out the assignments for the day. "Oh man," she sighed, "we're so shortstaffed today! There isn't a float to cover lunches, this sucks!"

The other night nurse and I just looked at each other. Or we would have, except she was taking up her own tele admit since we didn't have any techs.

I would be pissed, but it won't do me any good. We'll continue to be dangerously short staffed on nights, because administration needs to cut costs and nights are where it comes from. We'll continue to get burnt out on nights because we do the same amount of work with a fraction of the staff. I'll continue to blog about it because I'm just a traveler who gets pulled aside to ask why I took an hour to discharge a fast-track patient instead of congratulated for making the five minute EKG time even though I did an entire nSTEMI workup myself.

On the plus side, free pizza almost every night. And free diabeetus...

Wednesday, May 14, 2014

Burnout

I love ER nursing. I really do. I love the rush I get from successfully managing really sick patients. I love the ridiculous things overheard from patients. I love being able to help someone not by giving all the meds or hanging blood or placing an IV, but by holding their hand because it's 6am and they're sad to be missing Easter dinner later today. I love the camaraderie of all the staff placing guesses on the BAL of the local college student who just came in. I love when the ER doctor I've only just met a month ago asks if I'd be willing to housesit for her, because she thinks I'm a competent and responsible person and "would trust me with the house, since I definitely trust you with patients."

There is a lot to love in the ER.

But when someone asked me the other day how I was enjoying travel nursing, I found myself not talking about all the things listed above, but how much I hated the politics of medicine and how awful satisfaction-based care reimbursement is and how resentful I am of the people who come in and get everything they want because they're entitled and know how to work the system.

I found myself saying, "I love the ER, but I kinda hate people now." And that makes me sad. I started this career as a nice person, one who loves people and helping them and was full of naivete and compassion. In return, the direction medicine has taken is slowly overtaking the compassion in me. It's still there, but it's buried beneath cynicism and bitterness.

When I get a patient who says to me, "I hurt and the only thing which works for me is dilaudid," instead of thinking she probably hurts really bad and has been through this before I immediately jump to how much of a drug seeker she must be and how it's bullshit to even be in the ER right now. When a 22 year old comes in on the ambulance for a mild asthma exacerbation, texting and wearing a brand new hat, then asks for a cab voucher home, I don't think that perhaps he is homeless and wearing the only things of value he has in the world; instead I think that he's just a typical arrogant entitled drain on society who will get that voucher because the hospital can't say no without getting a bad review. When a patient lashes out at me and calls me horrible names, instead of thinking that he is in the most stressful time of his life and have reached the crisis point where he can't cope with the stress anymore, I immediately write him off as a horrible person and provide appropriate nursing care but extend only the bare minimum of servility to him. The things about these patients may be true, but the fact that I immediately jump to them instead of giving the patients the benefit of the doubt, if only for a moment, says a lot about me.

I never wanted to be that cynical nurse from the nursing school horror stories. But here I am, waving that flag like it's going out of style. I'm sad to have found myself in this position, because I truly do love nursing and the ER. I'm hoping the system will someway somehow start to be fixed, because seriously. This can't continue.

Friday, May 2, 2014

Friends

The best part about travel nursing is the number of new friends I've made across the country. The hardest part about travel nursing? Making new friends.

You see, I went to a smallish rural high school where the people I graduated with are the same ones who pushed me down on the playground in kindergarten or who I puked on in gym class in third grade (just kidding - I actually puked in a potted plant, not gym class). All the friends I had in high school were people I had known my whole life. It was easy to be friends with them, and there were enough of them around that if you didn't like someone you just didn't hang out. When I got to college I was placed in a dorm with three hundred other people - a couple of us found ourselves living together the next year, and friendships were born. It's not hard to be friends with people when you have TV marathons at 4am and create hard copy calendars for pooping schedules and hold prank wars involving firecrackers in an underwear drawer or a Harry Potter doll set into jello. It's also not hard to make enemies when you have to fight a roommate over burnt out light bulbs or who forgot to wash a fork, but that's besides the point...

My actual point, which I've gotten kinda far from, is that in high school and college it's pretty easy to make friends. If one is super introverted it's a bit harder, but the opportunities are still there - in both schools there is a built-in group of people who one might have things in common with. Travel nursing removes that built-in group and forces me to step outside that comfort zone.

There is always the risk of rejection when meeting new people, because one doesn't have the benefit of being in a situation where you'll see them again and again for months or years and can mutually take the time to decide if a friendship should happen. Many times they don't want to invest in someone who they know will only be around for a short time. Sometimes you even hang out and discover that no, you actually don't like that person or vice versa. But you just have to put yourself out there on day one and hope that others will respond in kind.

I did just that in Austin - at one of my first post shift breakfasts I wrote my phone number on a bunch of pieces of the receipt and handed it out, saying "Guys. I don't have any friends here. I want to have friends. Call me if you're doing anything fun, okay? Here's my business card..." And it took a few weeks, but they did. And I made life long friends. So when I got to Denver and was seated in orientation next to a girl who works in a different department, we exchanged phone numbers after discovering that we didn't know anyone around. Tonight we met up for dinner, and have plans to grab drinks in another week or two. And there you have it. My first friend in Denver.

Thursday, May 1, 2014

Calendar

I had a real post all set to go. But then the interwebz happened. And when you wake up,



You're welcome.

PS, actual post to follow in a day or so, after I've stopped laughing at this.

PSS - Yes, I know the size is off on the header picture up top there. Blogger has defeated me, and I give up for the night. In other news, I'm technologically illiterate. I've become one of those old farts that I always laughed at - like when your sweet uncle fumbles with the iPhone because it only has ONE BUTTON OMGZ but it's not funny anymore because now I'm that person. Le sigh.

Tuesday, April 29, 2014

Hood Nurse: Thoughtful Answers

I'm in triage the other night when a nice younger gal checks in for some kind of strep/allergy/viral illness hybrid- not life threatening but definitely super unpleasant. I get her vitals and history and ask her the dreaded pain scale questions.
She thinks for a while, then rates her throat pain a 9 and her headache a 7. Then, she stops herself, thinks for another little while, and says,"wait, I guess like, people who get shot come here, and probably their pain really is a ten. So I guess mine isn't anything like that, so that number should be like, way lower. Sorry."
I could have hugged her. Instead I just smiled and told her I always thought that scale was really stupid anyway, and walked her back to a room in fast track. At this point in my ER journey, this sort of perspective is almost just as refreshing as taking care of someone with an actual emergency.

Friday, April 18, 2014

Hood Nurse: A Little Perspective

Verbal abuse in the ER is hardly notable, even at the much nicer job I'm at now.  I'm pretty sure there's actually a mad libs version that would fit 90% of these encounters. Feel free to play along-  get me some (noun) you little white/tattooed (noun).  I told you to (verb) you (adjective) bitch! This is my life. Not every day. I've mastered the blank stare, usually followed by "okay!" with a smile as I call security.  Sometimes, though, the rationale for the verbal abuse is so minuscule and unexpected that it manages to make me a little angry.
Such was the case the other day, when my request for a UDS on my definitely chronic homelessness/maybe acute on chronic psych patient was met with "get me some juice", and I had the audacity to reply, "sure, can you grab me a urine sample while I'm getting that?"  Yeah. So as a general rule I don't get juice for people who refer to me as a stupid bitch, regardless of how much screaming you follow it up with. SAH-CUR-ITY.
When security's stern talk about honey, vinegar, etc. was not well received, they sent the social worker in to try to clear her for discharge, who finally brought her some juice to get her to stop screaming. Crazy lady then gave me a talk about how I should be more professional and proceeded to obtain a nice cocaine metabolite filled urine sample for us.  Afterwards she made sure to tell me that I was a "scared  little white girl" for calling the po-pos on her. I was DONE.
I'm sitting charting all this foolishness being irritated as hell over and above my baseline pregnant bitchiness when the social worker came to talk to me.  What she said could not have been a more perfect antidote to my angst and frustration.  "Yeah, hood nurse, she's completely batshit crazy.  Don't take it personally.  She's absolutely out of control and awful, so there's no point on even trying to reason with her. She's not this way because of anything you're doing, or anything anyone is doing- she simply lacks the capacity to be any other way.  She's not capable of being calm, or reasonable, or nice.   And what a horrible life that must be."
Really thinking this out nearly brought me to tears. I actually did cry when I thanked her for saying this a few days later. Maybe it resonates with me more now, being crazy hormonal and more emotional than I've ever been and having the sensation that my feelings are not coming from within myself, nor do they seem at all in character with who I feel I am as a person.  I'm sure this pales in comparison to people suffering from mental illness. I can't imagine feeling things so strongly and beyond my control every day, for life, and struggling constantly to strike the right balance of medications with innumerable awful side effects to just be able to function in society.  Even worse, the people that suffer from hallucinations and delusions and who live, what for most of us, would be a bizarre nightmare- only they never wake up from it. It's no wonder so many of these people turn to drugs or alcohol.
I hope it doesn't come across that I'm excusing or justifying bad behavior.  Aggression should be dealt firmly across the board, because when it isn't, dangerous things happen.  It's just in situations like this, it's really easy for anger to be the first emotion to surface, even when it's not the one that will get us anywhere.  It's advice I'd always give to the new nurses I mentored, but that I still find hard to take myself sometimes- you can't argue with crazy.  Beyond that though, and what I'm trying to be mindful of from here on out, is that not only can we not reason on that wavelength, but we should be very, very, very grateful that we can't.  I hope I play those words back in my head every time I feel my temper rising, and my face flushing.  "What a horrible life that must be."  Indeed.

Monday, April 14, 2014

Oxygen is a privelege, not a right. Right?

I had a moment of slight alarm when I put the Sp02 monitor on my patient the other day and it read 89%. "Do you have any history of COPD, sir?" I asked. "Or maybe any other breathing problems?"

He looked at me with a blank face, so I quickly pulled a nasal cannula off the wall and started to apply it. The nurse who was precepting me was like, hey, he probably doesn't need that. I was all "yeah okay, I guess oxygen isn't all that important but whatevs" and kept putting the NC on. The guy denied feeling short of breath, tired, or anything. So I go to turn on the O2 at 2 L, and again my preceptor is telling me that he probably doesn't need it. In my head I'm thinking she's a crazy person because we all need oxygen, right?

Then she gets one of those lightbulb moment faces, and asks if this is my first job at altitude. I answer yes, and she looks all satisfied.

Three minutes later, I'm educated on the fact that apparently everyone here in Denver lives in the 89-100% range, instead of the more common 95-100% non-COPD range for everywhere else. The more you know, I guess?

I dunno. I still put the oxygen on, because I just felt more comfortable doing that. No one's gonna die from hypoxia if I have any say about it, dammit.

Saturday, April 12, 2014

Black cloud

I've had pretty good luck in my past few assignments in not being a total shit-magnet, but I've got a feeling that this one's gonna be different. It harkens back to Ye Olde Days of Home Hospital. I've already told you about the dude who dropped a deuce on the floor on day 1 off orientation, but did I also tell you about the guy I put in restraints literally the FIRST FIVE MINUTES of day one? No? Well, I'm gonna tell you now.

My first shift off orientation was a bit dodgy since I didn't have computer access yet. Being a Meditech user, the awesome high tech piece of shit this system is thought I was still in Texas even though multiple requests had been made to change my access. No luck. So I'm stuck without.

Because of that, the charge nurse put me as the float for the first two hours so I could just task and not worry about charting. I ask a coworker if there's anything I can do, and she gives me a gown and requests for me to go change a heroin/meth/pcp guy out of his street clothes. I mosey into the room with security, and the guy is sleeping on the stretcher.

"Hey man, we need to get you outta those clothes and into a gown. Hospital policy." The guy cracks one eye open, mutters a Fuck You, and goes back to sleep. I give security a look, and then shake the guy's shoulder again. "No seriously, you need to change. Get into this gown and then I'll leave you alone." He opens both eyes, and I'm not even kidding - straight up exorcist screams, throws a shoe across the room like Hillary Clinton was standing there, and lofts his blanket at the security guard. This next step was great, and points for creativity. He rips the tubing out of the saline bag hanging from the hook above him, and then power-wash style squeezes the bag and sprays every person in a ten foot radius. At this point the security guard calls for restraints and everyone piles on to apply them. I ensure they go on in a medically safe way, and then walk back out to the nursing station where I hand the gown back to the nurse and shrug my shoulders. She's like yea, I kinda expected that to happen so don't even bother apologizing...

Good to know I'm not only a shit magnet but also a sucker.