Saturday, 29 September 2007

One For the Emergency Nurses

This is a fantastic article. Well written and funny too. I have never done A&E myself but I have a few friends and relatives that do. It sounds pretty hellish even on a good day.

I've ceased with the pre-shift ritual of meditating in my parked truck along with a soothing piece of music. No more prayers to God en route to work asking for more patience, more humanity, more understanding. I have accepted the fact that it will be no different than any other night in the Emergency Department, no matter if I blare Yanni's rancid piano etudes or make a promise to God to pass out my own body parts to the discharged patients as they leave. Nothing will change. I use to look forward to making a difference in someone’s life, helping a poor soul whose body has given out. Those moments are few and far between now. Instead, I resign myself to the fact that the next 12 hours will be spent pasting a fake smile on a tired body, going through the motions of caring, repeating ready-made lines of false concern and giving out medical advice that fall on deaf ears. I use to feel important in my role as Charge Nurse at a major ER of an inner-city charity hospital. Now, as I sit in my truck at 6:45 in the evening, gangster rap blaring, I send out a quick impromptu message to God..... "Please God, allow me the opportunity to be gainfully employed 12 hours from now."

7:02 PM-

I receive a quick report of the clingons and leftovers who haven't made it out of the department by change of shift and to no surprise to myself and the night crew, a few names are all too familiar and the reports of their latest "illness" easily recitable from memory. The usual apologies from the day crew for not getting them out before we arrived go unnoticed. A shrill screech from one of the psych beds startles no one. We all just look up from within the "safe" confines of the nursing station, confirm that our overweight security force is camped out beside the room, shake our heads briefly and go on about our business. We go through the ritual of taking our own baseline vital signs, popping a few Xanax and removing sharp objects from our pockets. Patient safety is important and we wouldn't want to accidentally stab one of them repeatedly in the chest.

7:17 PM-

My primary job aside from direct patient care is triage. Initial interview, vital signs, brief medical history, current medical problem, current medications, height, weight etc etc. My first of 35 or so fits the typical profile of this or any other ER in the country. 40 year old, female, morbidly obese, diabetic, hypertensive, multiple psych meds, very little English, less common sense, no means to pay. She complains of the usual nausea, vomiting, diarrhea and generalized abdominal pain. She's already spent thousands of dollars of other people’s money last week for the same complaint. She didn't fill her scripts, didn't follow up with her Gastroenterologist as requested and by no means was this 300 + lb, truffle hunting leech going to alter her diet one iota in order to prevent another attack of diverticulitis. Her idea of a "Clear Liquid Diet" was a bucket of chicken and bowl of menudo an hour prior to her arrival. So here she is, totally oblivious as to why she is still sick. Non-compliant with her meds, non-compliant with the discharge instructions, follow up or diet instructions, which included a bland, low-fat, liquid diet for a few days until she was able to tolerate semi-solid/or solid food.

She bitches profusely when she is not brought straight back and put into a bed, instead she is sent back out to the waiting area for a lengthy wait. We are full and busy with the truly "emergent" patients but she can't seem to fathom this. She barrels through the exit door, into the waiting area calling me every name in the book (in Spanish) and swearing to never come back again. "PENDEJO!", she mutters. Oh, she'll be back.


7:31 PM-

My 3rd patient is a 23-year-old mother of 3, the oldest being 10. She has somehow mistaken our "EMERGENCY DEPARTMENT" for a pediatric clinic and wants her brood "checked out" because they feel "hot." No temperature ever taken at home, no Tylenol or Motrin given before the decision was made to spend $1500.00 of other people's money and to waste our time babysitting 3 snot-nosed, unkempt ankle-biters who are no more sicker than the man in the moon. I usher them one at a time onto a scale for weights and am not surprised that each is twice the size they should be at their particular ages. One, I have to pry finger foods and a "Big Gulp" from their obstinate little mitts prior to the weight so as not to inadvertently add 5 lbs to his already triple digit reading. The electronic scale beeps incessantly and reads, "ONE AT A TIME, PLEASE."(Ok, not really) With all their vitals being normal they are ushered out into the waiting area where they eagerly pounce on the furniture and run around like the defensive line for the Attention Deficits.

I am verbally attacked by my obese belly pain lady, who has "been waiting for hours" (uh, how about 20 minutes). I instantly notice the "positive Cheetos sign" on her fingers and around her lips and remind her that the sickest are seen first and to have a seat. She tosses me a "Pincha Pendejo" and rumbles back to her seat. I sneak in a quick call to God asking that he makes sure she looks before she plops back down in her chair(s). I can hear the intercom announcer now, "CODE BLUE TRAUMA, ER WAITING ROOM." I mentally picture the scenario of the code team spending the next hour removing baby Julio from the rectum of a 300-lb verbally abusive Hispanic woman. "NEXT"!!

9:21 PM-

I've survived the dinner crowd with my job intact and make my way back to the treatment area to assist the rest of my team in the treatment of the patients who were lucky enough to make it back ahead of the non-emergent riff-raff. I make my way to the EMS radio station when I hear....."Unit 842 code 2 patient report"....we have a 102 year old nursing home patient,....found unresponsive on the IV....she's now awake, combative, confused, covered in stool, incontinent of urine, blah, blah, blah..." The report from the nursing home prior to her EMS transport reveals that this patient had a tendency to "dig out stool from her rectum when constipated." "Oh, that's just friggin lovely"

9:25 PM-

The waiting room intercom a buzz......"I beeen waiting for 10 hours, you piece of...." Click!

9:33 PM

Our lovely elderly finger painter arrives, covered in poop from head to toe. EMS personnel smirk as they wheel her by, updating us as to any changes en route. Nope, no changes, except that now she's given up the fight and is again unresponsive and her breathing more shallow. In an instant her breathing stops and is immediately rushed to trauma 1 where CPR is initiated. "CODE BLUE ER-1, CODE BLUE ER-1."

9:57 PM-

"Time of death, 9:55" is belted out by the code team leader. "She never stood a chance." "It was her time." "She had a long and good life." Blah Blah Blah Blah. She had a horrendous death. Born covered in amniotic fluid, but certainly a proud moment for her parents one can be sure. She died, however, covered in shit, piss and bedsores. The nursing home where she spent her remaining days in agony and perpetual loneliness should be burned to the ground. No family, no attention, nowhere near as prominent and proud as she once was. Left to waste while the understaffed workers at Our Lady of the Perpetual Petri Dish took their extended breaks and pillaged through her personal belongings. A courtesy call to the nursing home is placed telling them that Mrs. Mullins will not be coming back and has been transferred to the ECU (Eternal Care Unit). I hear, "Whew, thank God.....CLICK."

10:22 PM-

Our usually bevy of drug-seeking, bipolar, depressed, suicidal, Xanax, Vicodin, Demerol hounds arrive as scheduled with multiple and varied complaints of, migraine headaches, chronic back pain, stress, anxiety, fibromyalgia, blah, blah, blah....! They are easy to spot, almost always familiar, with the same ole' story. Most we know on a first name basis. They are all, coincidentally, allergic to the same medications; Tylenol, Motrin, Vistaril, Toradol, Aspirin or any other non narcotic or harmless placebo we've attempted to quell their "pain" with in the past. The only thing that works is "Demerol" and they must have a large supply of Vicodin in the form of a prescription when they leave. (Vicodin has Tylenol in it but apparently doesn't cause a severe allergic reaction when mixed with euphoria,....go figure!)

Security is usually called, for to tell them "no drugs tonight" is just asking for a fight. $1000.00 later of other peoples money and they usually leave with their buzz on and their script for Vicodin. But usually not before asking for a "shot for the road" or additional scripts for anxiety (preferably Xanax) or sleep aids. 30 pills are often the number of pills given, depending on the frequency of the prescribed dose. This usually last a few days for the typical drug seeker and then they'll usually return with more "pain" and a hungry monkey.

In the age when Doctors are sued for both under treating pain OR for prescribing too many narcotics and "getting them addicted", we medical personal are caught up in the proverbial "catch 22". More often than not I have been written up and on several occasions was at a point where my job was in jeopardy because I challenged their pathetic lies whenever these low-life drug addicts invaded our ER's. Now I just shut up, shake my head and pray for an overdose.

11:12 PM

Waiting Room intercom is ringing off the wall. " long will I.......can you tell me where I am on the list......Donde esta su Doctor.......I can't find my child........the dingo ate my baby.....PINCHE PEDEJO, I BEEN HEER FER TWO DAYS AND MY ASS FEELS LIKE SOMEONE POURED SALSA RIGHT UP

Midnight in the garden of good (for nothings) and the evil (doers)-

After a flurry of non emergent triages, (sore toe, "the shakes", anal abscess, foreign bodies in the nose, ears and stomach of a 2 year old, blah blah, blah) I call in an astute, well dressed, middle aged white male, who is walking quite gingerly and refusing to sit. Differential diagnoses race through my head, back pain, abdominal pain, rectal abscess,. or!....NO!......NOOOOOOOOOOO!


The story goes (and it is a common one) that he and the Mrs. were "experimenting" in bed (against his wishes, no doubt) when a vibrator was jammed in his keester and is now painfully out of reach. Given the nature of the "injury" he is whisked back to a private room, placed on his side, lubed up like a 57 Chevy, and a valiant effort is made to retrieve the 12 inch "perpetrator with ribs" from his large bowel. All to no avail. At one point we had a hold of the foreign body (actually, it was made in the US) but the colon wouldn't let go of it's new found cylindrical friend. We tugged, twisted, yanked, pulled, all efforts proving futile. Finally the physician stopped, exhausted from the tug-o-war match, with the forceps, commonly used to removed big headed babies, protruding from the prominent lawyers butt, he made the decision to call in the surgical team. All efforts to remain professional, however, fell by the wayside when, during a moment of silence, a low buzz was detected in the room. Had the blood pressure cuff inflated? Were the incandescent lights buzzing? Was the TV on?

No, no and no. We looked at the forceps and noticed they were vibrating uncontrollably, instantly realizing at that point that this thing was STILL ON. A mad rush by the scant crew to the exit door of the private room was attempted as to not embarrass this local professional with our boisterous laughter. No dice.

We will all eventually be written up and apologies made for our "unprofessionalism and disregard for the patient’s privacy and mental well being". That's ok. We needed that to preserve our own mental well being. Still proving that laughter is still the best medicine.

1:02 AM

Ten triages later and its dinner time for this mentally worn crew. We retrieve our food, locate it to the middle of the nursing station and we eat. Not all at once, mind you but usually a bite at a time. Eat a French fry, go wipe an ass in ER-1, a bite of a Big Mac, go clean up cherry cool-aid flavored vomit in ER-4, a sip of Dr Pepper, then physically restrain a combative Scitzo-effective patient. By 2:15 we have polished off the last bite of a hardened burger, ate our last stale French fry and sucked down the last gulp of our watered-down soda. A soda that is now as warm as fresh urine and food that is as cold as Mrs. Mullins in ER13.

2:30 AM-

Ahhh, my favorite time during the entire shift is upon us. The "Last Call at the local bar crowd" (LCLBC) start to pour in to the front entrance, while EMS brings the ones who got the shit kicked out of them through the back ambulance entrance. "Santa Rosa, this is unit 842....we are coming code 2 trauma with a 19 year old male.....closed head insurance.....blah, blah,blah.

The same ole song and dance spews from this patients bloodied spout as he is wheeled into Trauma-2......"I was just minding my own business"......"I only had two beers"....."I don't do drugs"..... "Can I get something to eat?" "RAALLLLLLPHHH!" "Housekeeping to ER Trauma-2, Housekeeping...."

2:31 AM-

"Dear Lord, If ANYONE can make time travel possible, it's you, God." "Pleeeese, send me forward to 7 AM.

3:03 AM-

Patient waiting room intercom is screaming..........."CLICK"......."BANG, BANG, BANG".

3:15 AM-

I am ushered into the staff break room for a "time out" and reminded by the night supervisor that the cost of the intercom will be deducted from my paycheck.

4:18 AM-

Our portly female beast of a woman is finally ushered back to a room but not before mumbling under her breath as she brushes past me, "Pendejo"! A major "abdominal work-up" is ordered. 40 lab tests, urine tests, stool cultures, abdominal x-rays, Cat Scans, blah, blah, blah......She's placed in a gown that looks like curtains stolen from the Grand Ole Opry, and given the reminder "Opening to the back, please," tossed in for good measure. ("Lord, give me the strength to...........Oh forget it, never mind")

She's given a URINE cup as she bounces her way to the bathroom. She fills it with STOOL. "Housekeeping to ER, STAT."

Can't find a blood pressure cuff large enough so we must take a chance at an erroneous reading by placing it around her calf or forearm. The hydraulic bed grunts and groans with ever twitch and shift from this woman of substances. She continues to bitch and moan and will eventually file a complaint with (in) human resources, I am sure. Multiple attempts at IV access finally yields a vein that hasn't been choked off by the mass of arm fat and IV fluids are initiated. After a quick assessment by the ER physician she is off to radiology, with a little 120 lb tech pushing 600 lbs of patient and bed up to the 3rd floor for a series of $3000.00 radiologic exams. X-rays that were done just last week and that she has no intention or means to pay for. It would have been easier (and cheaper) had she driven to Sea World instead. Certainly more accommodating for a woman of her stature.

5:57 AM-

Multiple early morning stragglers are triaged and sent to wait. The foul odor of urine, poop, BO, booze, vomit, etc, permeates the air. "One Hour Left", I thought. We get all the results of the voluptuous Ms. Hinojosa's tests back and surprise, surprise...."Diverticulitis." Perhaps this time she will be compliant with her meds, compliant with her diet, compliant with her follow up, compliant with life. "Fat chance,"I thought. (Pun intended).

Her IV is removed and a half gallon of fat globules ooze from the harpoon hole. She is hoisted off the bed with the help of several departments within the hospital; half of who will call in sick tomorrow with severe back spasms. The battered stretcher which now resembles a low-rider after a major accident is towed to the back for repair. Ms Hinojosa is discharged but not before requesting a breakfast tray. Request denied.

Off she goes to the local "Taco Cabana" for a flurry of assorted breakfast tacos and a bowl of menudo. "She you in a few days, Ms Hinojosa."

"Pinche Pendejo!"

6:47 AM-

The dismal faces of the morning crew are evident as they reluctantly make there way in, some still in mid-prayer, the newer nurses with walkman's on, listening to ocean waves or cricket noises saturated with Muzac. A quick report is given to the mentally exhausted night crew and apologies made for the missing bed in ER 3 and the dead body in ER-12.

7:07 AM-

Each member of the night crew, each with a phone in hand, are awaiting the instant the clock strikes 7:08 where, with lightning speed, a flurry of buttons will be punched to clock out, ending another horrendous but typical night in the ER.

7:47 AM-

I pull up to my apartment and sit quietly in my truck. I recall the night’s events and wonder if I had made any critical errors in care or judgment. I mentally prepare for the answers to the complaints made the night before by this unique ER culture of ignorant, non-compliant, abusive, poor, helpless, drugged-up, psychotic, dregs of society.

I say a prayer for Mrs. Mullins and her family and curse all those who've abused the system in the last 12 hours, spending thousands upon thousands of dollars of other people’s money but contributing nothing to society what-so-ever. Once I deem that I will have a job come 6:45 that evening, I ease my tired body and shattered mind out of my vehicle, meander up to my apartment and into bed, hungry, frustrated, angry. Where I will fight the demons for an hour or so until I am able to fall asleep. I don't. I am woken by a dream whereby the ER staff are all patients in the waiting room on a busy night. I am called into the back where a 500-lb female nurse is ripping my clothes off with one hand and swinging a 6 foot rectal scope in the other like a pair of numchucks in a Bruce Lee movie. The alarm clock sounds and I immediately spring up and grab my ass, praying that a 6-foot proctoscope isn't dangling precariously from it. It's not. I breathe a sigh of relief and make my way to the shower and into another fateful night of chaos and mayhem.

6:43 PM-

I pull up to the ER, park my truck and sit. I clip on my name badge, giggle as I read our "Mission statement" tattooed on the back. "To extend the healing ministry of Christ," it reads, and I take a minute to ponder that statement. I smile, acknowledge it's powerful and profound meaning and bow my head to pray. "Lord, today, give me your divine power to accept my responsibilities within this ministry. I pray that..."

Just then a beat up delta 88 rolls by on two wheels, with a definite lean to one side. I watch as they take up two parking spaces in the "staff" lot and out pops Ms Hinojosa. I cringe. She leaves a trail of urped-up fajita and menudo through the patient parking lot, into the physicians parking area, towards the ER entrance. Anger churns inside me and I hang my head, looking down at my badge and the mission statement on the back. I try desperately to find the peace and pride I felt just 2 minutes earlier and I resume my prayer......"Lord,....I just.......If you could only find it in your heart to............OH FORGET IT!!!!!....... NEVER MIND."

Michael Brown is a Registered ER Nurse from Texas. He is currently taking no medications at this time.

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the A&E Charge Nurse said...

Never worked in A&E,'s never too late you know ;o)

Many of the problems identified by the ER nurse, such as inadequate self-management of chronic disease, childhood obseity, litigation, consumerism, etc, etc do not seem to have been resolved despite huge health expenditure in the States [16% of GPD I'm told].

Well it's often said that health trends in the US are soon followed in the UK - but aren't we closing down A&Es and opening a few gimmicky "polyclinics".

Gulp, maybe it'll be me looking for a job elsewhere.

Nurse Anne said...

Emergency departments in the USA ar pretty rough. A particular Emergency department may be a regional trauma centre with the medi chopper landing constantly bringing in trauma patients.

Same ED is also full of people with very minor problems who demand to be seen NOW. These people may not have insurance, and therefore are unable to see a GP to sort out routine stuff so they use the ED as a clinic. I have heard of people waiting ten hours to be seen over there. The waiting room is full of uninsured people who want bloody antibiotics for a cold, and repeat scripts for pain meds meanwhile the place is getting slammed with trauma cases and choppers are trying to land.

Our Night sister was telling me that we had a patient come in by ambulance for a hangnail once though here in the UK.

I thought the author was a bit mean to make all of those "fat jokes" about that patient and that made me cringe a bit but I can see how he is burned out.

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