Archive for November, 2009
So my dilemma, in which you will notice I am being even more circumspect and misdirecting than usual, because I am certainly paranoid of my real nursey identity being discovered and picked over.
A certain low-level managerial type resigned unexpectedly and I’m debating whether to leave the safe and comfortable role of crusty-and-cynical-yet-caring (somewhat, under favourable circumstances) Emergency Nurse to do something new and for which I am actually qualified, and also to put my money where my mouth is as far as management and managers go — and God knows, they are a constant source of mockery and derision.
So the Pro:
- a chance to actually improve the lives of my colleagues
- increased money
- a modicum of prestige
- no more shift work
- am being strenuously urged to apply by several of my peers and even some managers
- drinking the blue management Kool-Aid
- being transformed into a dink, by increments
- dealing with the pit of snakes that is low-level management at Acme Regional (and trust me, it truly is a pit)
- having presently one of the coolest jobs around
- having generally a poor, incorrect attitude (at least towards managers)
- having a big, opinionated mouth and being unable to govern it accordingly
Also I am thinking that yesterday, I helped save a life. And I helped save a life on Friday. It doesn’t get better than that.
So I am leaning towards . . . nah.
Sometimes patients surprise you. Sometimes you really need to talk to them about their expectations, desires, wishes, and hopes. Sometimes their assumptions don’t quite match up with your own. And sometimes this has unexpected consequences. Today the surprise is in the Resus Room. Here, there are five beds, two nurses. It’s where the sickest come, CTAS 1 and 2, and this morning is no different.
Contestant 1 is a 74-year old male, right-sided failure, no blood pressure to speak of, junctional bradycardia, a medical history that’s a tale of woe, full code, and Altzheimer’s, so he calls out and tries to climb out of bed. Contestant 2 is a 54-year old male, in acute renal failure, who’s blown his only good kidney, anuric, taching along at 140, BP in his boots, maxed on Levophed, whacked out chemistry, including a creatinine of 868; he’s pale to the point of waxiness, and diaphoretic. He’s been sick for a long time, and he has the wary eyes of someone who knows the jig is up.
He needs dialysis now, therein being the problem: Acme Regional doesn’t have facilities for dialysis. Renal patients are supposed to be sent to Superior Hills Health down the road, which is our regional dialysis centre — except getting SHH to accept transfers is at all times problematic. It’s always some damn thing: no beds, no staff, can’t be bothered, whatever.
But there is a light. The patient, JK, has actually been accepted by the hospitalist and the nephrologist at Superior Hills. It’s just a matter of making the arrangements and sending him off. Maria, my partner for the day, flip a coin — I get JK. I do my initial assessment, which confirms my first thought eyeballing the patient from the nurse’s desk: this guy is circling, and what’s worse, knows it. Fear is clearly in his black eyes, peering out from under knots of unkempt hair, but he says little. And there is little I can offer him, except comfort and a fast transfer out.
But he has some imminent problems: he’s third-spacing all the fluid he can’t pee out, his lungs are filling up like a bathtub, and his respirations are starting to get a little laboured. I’m having a psychic vision of an intubation in my near future, which giving this patient’s condition is clearly a bad plan.
I finish charting and start on the usual telephone trek to get this patient transferred. I page both the hospitalist and the nephrologist who accepted the patient. Neither is on-call, and Locating at Superior won’t get them either. I call the floor at Superior Hills where’s he’s supposed to be going. Nope, haven’t heard of him. I call the Patient Flow Management at SHH. Same answer — and the bed manager there is a little concerned my patient is obviously an ICU patient, and neither the hospitalist nor the nephrologist have ICU admitting privileges. Finally, after an hour of telephone hide-and-seek it becomes apparent that neither accepting doc has bothered to tell anyone at Superior Hills about this patient.
I sigh, and glance over at JK. Let the games begin. This patient, as critically ill as he is, is going nowhere.
I page the internist, and together we plot a two-pronged strategy: I will continue to hound Superior Hills for a renal bed, while he’ll try to Criticall the patient out. The phone calls continue. Vast amounts of time are wasted, as the patient continues to circle, trying to find a bed somewhere, anywhere, that can do dialysis. The internist speaks to docs in hospitals between between Windsor and Ottawa, looking for a bed. A moment of humour: a nasty phone call from the bed manager at Superior Hills. Criticall called her, looking for a bed. She isn’t impressed. Oops. Finally, at last, we manage to contrive a bed at Holy Somolians Hospital downtown, where he will finally get his much needed dialysis.
At 1700, ten hours after start of shift, the ORNGE team finally collects JK and flies off to Holy Somolians. Good luck, I breathe, so long, and have a good life. Despite hours and hours of bullshit and nearly insurmountable institutional and systemic barriers, you’re going to live.
Next morning. I’m exhausted. I can deal with a sick patient, and I can deal with health care stupid, but doing both at once leaves me wiped. Diane’s in charge. She takes off her funky pink reading glasses and peers at me over the Desk. “That patient of yours, JK, the one transferred downtown? He died.”
“He got there and refused dialysis. Said he never wanted it. Then up and died.”
Dr. Contentious is not known for his love of talkative patients or his bedside manner.
He hates the former and has none of the latter.
Quoth he: “If I wanted to fucking talk to people, I would’ve become a goddamn priest.”
He’s the guy, though, I want when I’m brought in with a multisystem trauma, or a dissecting aneurysm.
The Human Hip Geyser.
Buddy comes in the other day with a draining abscess the size of a grapefruit over his right hip, all indurated, erythemous and nasty looking. Touching the thing meant jumping back three feet to avoid the exudate jetting out. Too bad if you were in the line of fire.
“Oh yeah,” says buddy. “Was squirting people at work with it.”
So my ancient clunky Chevy finally died — it owed me nothing whatsoever, I might add — so Mister Man and me went out car shopping. I hate this, dealing with car salesmen (yes, men — if there any women in car sales, I have yet to see ‘em) and their condescension and pushiness. It’s aggravation that I don’t need.
We went to one used car place, that has a good reputation in my neighbourhood, and we’re poking around this car and that one, looking for something decent, and thinking about which ones we might want to test drive. The salesman comes out, slick and unnaturally tanned, and Mister Man talks to him about this and that. And then buddy says, “Well, I can’t stand here all day and wait for you to test drive every vehicle in the lot — I’m not the test drive guy. Just pick one, and when you’re back we’ll make a deal.”
I see Mister Man’s jaw just tighten a bit, and I know this jerk is not getting any of our business. I thank the salesman, say we’ll think about it, and we leave.
In the car, Mister Man says, “If I’m going to give fifteen or twenty thousand to that jackass, I’ll drive every goddamn car on the lot buck-naked if it pleases me.”
So we went to another dealership, just down the road from our house, and were treated very seriously and respectfully, and we test drove several cars, and finally bought something brand-new, for just a few thousand more than the used because of factory and dealer rebates.
Well, I thought, buddy at the used car place really screwed himself out of a commission. But then I thought, used car salesmen aren’t idiots, and obviously it’s a line that’s worked before — “I’m too busy to talk to you.” I wonder how many people have fallen for it?
Quite a few, I’m thinking.
Every department has a Joan.* Joan is a very bad nurse. I don’t mean bad, as in is rude to the patients, or leaves full commode chairs for oncoming staff. (Though she does that too.) I mean bad as in I-just-killed-the-patient bad. Everybody has a Joan story. She is that incompetent. She’s the nurse who inflates the catheter balloon when it’s still in the urethra. She’s the one who hung D5W with the blood transfusion — and pushed Ancef at the lower port while the blood was running. She’s the one who who ran the insulin drip by gravity. And piggybacked a KCl bolus (when we still did those) by gravity. She’s the one who thought there was no real issue with the rectal bleed with a pressure of 54/p. And that the Seroquel od didn’t need a cardiac monitor. Or that the obtunded HBD was okay laying flat on his back.
Joan frightens me badly. I am frightened to work with her. I am frightened to follow her at shift change. I am frightened for her patients most of all.
We have tried remonstration. We have tried using each of these as colleague-to-colleague teachable moments. We have documented. We have complained to the manager. We done have everything short of calling the College of Nurses of Ontario.** Joan just carries on, oblivious and immovable.
*Of course not her real name, and actually a composite of several “Joan’s” I have known over the years.
**Our fear and loathing of the CNO is obviously greater than our fear and loathing of Joan. Sad, but true.
She wasn’t right.
In Observation the other night where we, well, observe patients: holds and the frequently admitted and such. Then EMS offloads a 68 year-old woman into Room 4, acutely SOB, restless, history of COPD and a long, long cardiac history, nonSTEMIs and stents and whatnot: so not surprising. Chest actually sounds okay, no peripheral edema. No chest pain now or earlier.
But she isn’t right. I mean her vitals are stable, and she’s much less SOB with O2. She’s obese and getting her comfortable on the emerg stretcher is a challenge but she even settles into an uneasy sleep. Yet something is wrong. Nothing I can put my finger on. The only other abnormal finding, apart from her shortness of breath, is her cold periphery: hands and feet are ice.
The virtue of being an old emergency nurse is that when you think you need to move a patient into the Resus Room, the charge tends to listen to you. So we moved her. There’s moaning and kvetching from the two Resus Room nurses who were patient-free, happily bored and watching Nurse Jackie on the Net. Why did you move her in here? She’s stable, isn’t she?
I think: I love you both dearly, but you’re being lazy as all hell.
But I say: “She’s not right.”
My colleagues shake their head. WTF, they’re thinking. I don’t care. I give report then go to break, hoping to doze off for a few while listening to endless gabble on CP 24. I drift off, dreaming I think, of a warm beach and the sound of water . . . then a rude awakening.
“Code Blue, Code Blue, Emergency. Code Blue, Code Blue, Emergency.”
Shit. I know it’s her.
I run into the Resus Room. Compressions have started. What happened?
“She went into an idioventricular, then PEA.”
Compressions halt for moment for a pulse check. No pulse. We all stare at the monitor. Slow idioventricular, then nothing. Asystole. Compressions again, another round of drugs, then it’s all over.
Trop comes back at 64.8.
She wasn’t right.
Buddy is 22 years-old, and buddy has had too much of the Molson’s. Or so his girlfriend says. Buddy is semi-conscious, moaning and holding his stomach.
“Do something,” the girlfirend yells. “He’s sick!”
No, he’s drunk. There’s a difference. But still, we do the usual I-drank-to-much routine: IV fluids, bloodwork, in bed, in the recovery position.
Ethanol level comes back.
12, is what, half a beer? Buddy could’ve driven home. The legal limit is 17.
Buddy goes home, miraculously cured. Girlfriend is chastened, and maybe even a little disgusted.
It was Brad who summarized the situation.
“Buddy,” he said, “needs to turn in his man card.”
A friend of mine said to me the other day: “I have empathy for the 43 year-old with two teenage girls dying of ovarian cancer, and the contracted 83 year-old guy with Alzheimer’s who’s breaking the heart of his wife, but for this” — she waved her arms towards the usual waiting room crowd of three month abdo pain and r/o H1n1 —-”today, I have no empathy. None, nada, rien. I’ve run out altogether.”
She paused to consider a minute, and adjusted her Littman slung over one blue-scrubbed shoulder, her lips pursed thoughtfully. “No wait,” she said. “I have fake empathy for those people. I save the real empathy for people who need it.”
I looked her in the eye and nodded with understanding. After weeks of H1N1 hell I could empathize. With real empathy, not the ersatz stuff.
Patient A.B. has a bed on 5 South, a med floor notorious for NOT taking patients. Patient A.B. is a pleasant — as in nice-as-pie-pleasant — 45 year old woman with a very remote history of substance abuse as well as HIV infection related to, and well-controlled with antiretrovirals. She is here for recurrent fevers and myalgias that may or may not be related to her HIV infection; she is presently well, afebrile and basically waiting to see Infectious Diseases, who ironically has an infectious disease himself and can’t come till the next day. She is easily the best patient — and did I mention nicest? — I have today.
5 South has gotten wind of this patient from Bed Management, and all sorts of alarm bells are going off mostly, I am very sad to report, because of this patient’s HIV and/or substance abuse history. (In 2009!) I spend an hour trying to get this patient up to 5 South and into a decent bed — and just get flak from the floor. She’s too fat, I’m told. Seriously, and not that it should make any difference — but they can’t tell the difference between kilograms and lbs, apparently. She had loose stools five days prior to admission — Sweet Jesus, she has C.diff! She’ll disturb the patient in the next bed, who needs her rest. And so on. Finally they tell the charge to pick another patient, ’cause she ain’t coming, no way no how. A.B., it seems, has “too many issues.”
Is this a hospital, or what? Since when does the floor get to pick and choose patients? Apparently, this is what Acme Regional Health does.
In my exasperation, I call the 5 South charge nurse and suggest to her that she needs to come down and explain to my patient what issue in particular prevents her admission to 5 South.
This goes over, um, poorly.
Meanwhile (and against my better judgment) I complain, loudly, to my manager about the shoddy treatment my patient has received at the hands of the hospital.
Nothing, of course, is done. A small fuss is made. A lot of stonewalling from the 5 South manager, with a dash of equivocation. Accountability counts for squat.
Another day in the emerg.