On the Eve of Resolution

I could not let this year pass without a few simple comments about health and fitness.

Like many people I know in the northern hemisphere, winter brings with it a time of weight gain and exercise laxness. Throw in back-to-back holidays characterized by rich foods, cakes, pies and candies, and excessive alcohol consumption, and many of us find ourselves relaxing our belts, dreaming of diets, and redefining flab as love handles.

What did Rene say: I eat too much; therefore, I am fat.

Having a few extra pounds in colder climates might seem like prudent insulation. But the stress of trudging through deep snow and trudging through the deep stress of Xmas and New Years can put a lot of strain on the cardiovascular system. A few extra pounds doesn't help.

And I am not pointing fingers. I include myself in the category of those who may have indulged and bugled too much whilst exercising too little. In fact, this trend didn't start with winter or the holidays. I have been slowly gaining weight since my all-time adult low weight of about two and a half years ago.

What happened?

Well, I got happy. No joke. I was at that all-time adult low weight because I was experiencing a lot stress about a family member in the midst of medical crisis. I wasn't eating well or enough, and I was exercising incessantly in an attempt to preoccupy my racing mind and reduce the negative effects of stress. Needless to say, I wheedled down.

Then almost two years ago, the crisis seemed to be (relatively) fading, the stress began to lift, and I became involved in a very happy period of my life. Needless to also say, my relaxation wasn't only mental; my waist relaxed as well.

In the year 2008, therefore, I hope to reclaim a diet and exercise ritual that is healthy, safe, and effective. By the latter I don't simply mean in terms of losing weight, but instead, feeling and being healthy. I owe it to myself, to my family, and to my community. Happiness should beget healthiness, not hedonism.

And so, bring on the New Year!

Never Put New Nurses into Old Nursing Skins

I received an e-mail from a friend today that informed me she planned to enrol in nursing school. Knowing her, I think she will enjoy the challenges and diverse employment opportunities the career of nursing presents. Knowing her, also, I'm not sure she'll enjoy nursing school. I didn't.

Needless to say, I sometimes feel guilty when friends of mine decide to go into nursing. I have encouraged at least four friends to leave their previous professions and become nurses via, of course, nursing school. (The friend who recently e-mailed is not among them.) I feel so strongly about the personal and societal benefits of more people being nurses that I don't mind recommending the career to them. However, knowing they have to go through nursing school to get there fills me with a bit of remorse.

It is not that I don't think they'll be able to succeed in nursing school--I have smart friends. It is that I know such a pursuit will aggravate, frustrate, and probably disappoint them. Oh, they'll graduate and come out as nurses, but they'll do a lot in the interim that has little to do with being a nurse. Really.

Like most other associates and bachelors degree programs and most professional-technical education programs, nursing school is very much about busy work and tedious conformity to standards that have little to do with nursing and what nurses actually do. Instead, nursing school is mostly about...well, nursing school. It is about doing the work, making the grade, and passing classes, the ultimate goal of which is to get the degree. In short, a rather underwhelming experience.

One would think nursing school is about learning the professional skills and culture of nursing. That would make sense. But there is a disconnect between what nurses do and the organizations in which they do it and the experience of the nursing student. I don't think this has always been the case, but it is prevalent now.

I went to nursing school later in life, in my 30s, after having already completed a bachelors and masters degree in an unrelated discipline, and having worked in several professional pursuits. I knew how to get through nursing school, and I had enough sense to know that working as a nursing student wasn't going to be like working as a nurse.

But many of my fellow nursing school students were in their late teens, traditional students by college standards. Some of them seemed to chose the nursing program as as just another college major, similar to accounting or English or biology. There did not seem to be anything about their lives that propelled them toward nursing or encouraged them to become nurses. They had gone to college because that is what you do after high school. It was an expectation.

Choosing nursing probably felt good to them and others probably responded to their choice with support and encouragement. But did they know what they were getting into? Did nursing school prepare them for what they would be doing as nurses?

As a nurse, I have likewise had the opportunity to precept nursing students and orient new nurses. I have had nursing students who fainted at the site of blood, got sick to their stomachs because of the smell of feces or vomit, or couldn't handle the look of a surgical site or stand poking a patient with a needle. Wouldn't they have made better accountants? How come they didn't know this?

I've also had students and sometimes new nurses who couldn't reason what amount of medicine to give a patient when the order was for 1 milligram but the medicine vial contained 2 milligrams per milliliter. Clearly they shouldn't have been nurses, or shouldn't have passed nursing school anyway.

When precepting or orienting new nurses I try to communicate a single idea: that being a good nurse is not about doing it the way they told you to do it in nursing school, but to develop your own method and rhythm and style and become the nurse you want to be, not the nurse they tried to cookie cut.

So, I am glad that my friend is going into nursing. I suppose I've written this both as encouragement to her and also a warning. Nursing school is not about being a nurse. Get through it, learn the theory, the methods, and perform the skills the way they tell you to. And then, after graduation, forget it all and become the nurse you want to be.

That's what I did.

A Chatty Post-Holiday Entry

Okay. The holiday is over. Most of mine was spent, you guessed it, in the ER taking care of every nebulous, insignificant, and ridiculous complaint that this community could throw our way.

*** A sore throat that you've had for two and a half weeks is an emergency on Christmas Day, why?

*** A 9-month old's diaper rash is an emergency at 2 a.m. Christmas Eve morning, why?

Why?

Because in this community, we were the only health care available on the Eve and Christmas Day. Doc's offices aren't open; student health isn't open; the urgent care clinics aren't open. We were it.

To be fair, some patients did have legitimate complaints. I started my stretch by being called in to work on the weekend when two head-on accidents with passenger ejections occurred at the same time. The lone ER nurse (who was that because of double sick calls) was desperate for help. I thought I'd give her an hour or so of my time; I ended up giving her 4 hours.

Her patient ate a cement embankment after being thrown from the passenger window of a pick-up (wasn't wearing a seat belt!) and was found by EMTs face down in a pool of congealed blood. Broke nearly every bone in her face except her jaw, had a transverse skull fracture, dislocated her elbow, and fractured her tibia. We stablizied her and then had to admit her because the inclimate weather didn't allow for either air or ground transport to a higher level trauma center. Last I heard, she was still alive at Harborview in Seattle. Lucky her, maybe.

My patient was a 13 year old who was thrown from the middle seat of a minivan despite the fact that he was wearing a seat belt. The sliding door had been ripped off, which allowed for his ejection. A fractured nose and fractured iliac crest of the pelvis and he had gotten off easy.

And that was it for trauma. The next three days, including Christmas Eve and Day, I heard as many clinic complaints of soar throats, tendonitis, urinary tact infections, etc., as I care to. Good thing we were here for them!

Sure happy I don't work for the New Years and its Eve. Happy, Healthy Holidays to all!

The Art of Children's Hospital

A friend of mine once surmised that hospitals are depressing because they are generally painted in browns and mauves and don't have any art on the walls. I agree with her.

But hospitals have changed. The one I am sitting in now, a Children's Hospital, is so brightly colored and has so much of all sorts of art that it is hard to tell that it is a hospital at all.

There are giraffe and zebra statues in the halls, giant fish tanks, a choo choo train on tracks in one corridor, and a huge Native American-inspired representation of an Orca, a sculpture measuring approximately 25 feet in length (life-size) and so heavy that it is suspended from the ceiling on thick metal cables. There are rocket ships and stylized balloons and an entire jungle creation in the radiology suites.

The idea, I suppose, is to help children forget they are patients in a hospital, or perhaps, help their visitors forget this. The relative success of the decor could be argued, but at least it is not a drab environment.

For me, however, Children's is a sobering and humbling experience. There is nowhere else I can spend time that makes me feel as fortunate to have the child I have, despite his relative disabilities and chronic illness. No matter how bad things have gotten for him and for us together, when we are here I do not feel as if things for us have been so bad, so depressing.

But it isn't the art or the colors that does this. It is the children in wheelchairs, the horribly disfigured children, the ones without hair, without limbs, with all manner of bodily insult, deprivation, chronic illness, life-threatening illness and injuries, and the sullen and depressed faces of their parents and visitors that helps me realize how good my son's life is and how good our life together is.

I know this is an odd observation, but who doesn't feel at least a little better when they realize they are not the worst off?

(Why Do) Things Fall Apart

In memory of my friend's brother...

Before studying nursing I wondered why people got sick, why bodies break down and fall apart. I was amazed by how capricious disease and injury seemed to be, and how the effects on the body seemed indiscriminate and sometimes unimaginable.

After studying the structure and function of the body in anatomy (with a cadaver lab) and physiology, and the dysfunction of the body in pathophysiology, I began to wonder how people maintain their health at all, why we all don't just fall down and break apart this very minute.

The complexity of the biological form and the intricacy of its functions amaze me. With all the ways in which the body could break down and with all of its susceptibility to disease and injury, the fact that it has such tenacious integrity places me in awe of it.

When a hammer doesn't work or work effectively it is usually easy to figure out why. A broken or too short handle, broken or too light head. But when a computer doesn't work, diagnosis is a little more difficult. The relative complexity of these tools determines our ability to understand the former easily and the latter with more difficulty.

The body is both and more. Physically, a mechanical, hydraulic system of levers and fulcrums, pumps and pulleys; an electrical, computer-like system of stimuli and currents, algorithms and feedback loops; a chemical system of neurotransmitters and pathways. Metaphysically, the systems and systems' components altogether are greater than simply their sum.

The human body, in health and in illness. Amazing.

Ethics and Nursing Compensation

I am happy to report that the dispute between nurses and the administration of the hospital in which I work mentioned in the previous post has been resolved.

I am doubly happy to report that the administration has decided to eliminate wage disparity among staff nurses, moving all nurses to a single wage scale regardless in which department of the organization they work.

I take a modicum of pride in this resolution because the philosophical commitment to wage equity was the position for which I argued from the beginning of the struggle. The administration has, apparently, changed its organizational mind in order to agree with me (and other nurses who felt the same).

I could be magnanimous and believe that the administration's change of position is wholly based upon its ethical commitment to wage equity, that they have done the right thing because it is right. I could believe that the administration is made up of good people in this fashion.

However, good people or not, no organization does what it does not have to do. No organization risks financial insolvency if it does not have to, not simply so that it can be said to have done the right thing. No. The administration's actions are clearly based upon the fact that financially it could produce wage equity. The money was there; the money was there all along.

So then what is the lesson to learn from this struggle?

The lesson I learned is multi-faceted but simple: Organizations do what they can do in the context of good reasons to do it. What the administration of our hospital needed in order to make the decision it did was a good and compelling reason to do it.

We, the nursing staff, provided that for the administration by demonstrating our collective will to continually advocate for a single wage scale, even if it meant taking our case to the hospital's board of directors and eventually to the public. Both of these intentions were in formulation at the time the announcement of a single and increased wage decision was made.

What the administration did was devote the financial resources it has to avoid the uncharitable position of being called upon by the board of directors to answer for a dissatisfied nursing staff, a possible "don't show up for work today" action, and the negative publicity such would generate in a small town that has the general impression that the hospital is a decent, caring organization.

The other part of the lesson I learned is never doubt yourself or the value of your endeavors when you know that you stand up for a right and good thing. There were times that we could have accepted the mediocre offers made to us, offers that were somewhat generous but did not resolve the issue of wage inequity.

Despite the fact that some of us could have benefited from these offers, we stood up for an ultimate good over immediate gain. We're nurses, after all. We like to take care of ourselves, all of ourselves.

Wage Dispute

It is somewhat funny to me that many people think that being a nurse should be in and of itself satisfying. That the generally high esteem in which the public holds us should be reason enough to do the sometimes hard, sometimes gory, sometimes horrible job we do. To be an ER nurse, like being a hospice nurse, seems to double this sentiment.

People watch too much TV.

In fact, and I know this may come as a shock to some people, nurses like to get PAID for what we do. I don't know a single nurse who would work as one unless s/he got paid to do so. Like many workers, nurses may not be paid as much as they would want--no one goes into nursing to get rich--but they work at nursing in (perhaps unrealistic) hope of being paid for their labor what it is truly worth. Given that peoples' lives are often at stake, it seems that what we do should be worth a lot.

Recently, however, the hospital in which I work that employs over a hundred nurses has chosen to give a small minority of those nurses (approximately seven) a 15% wage increase simply because they are "surgery" nurses. There really is no other way to explain it.

The nurses in question have no more education, licensure, or skills than other nurses in the organization; they do not work harder or more; they are required to have fewer skill certifications than ER nurses (1 versus 4); and they do not even do what many other nurses in the organization are required to do: float to other departments, respond to codes, start IVs (the anesthetists or same day center nurses do it) or push medications (again, anesthetists or ICU nurses do it).

The administration's rationale for this unfair compensation increase is that surgery generates a lot of revenue for the hospital and we certainly can't allow the surgery department to close down. Forget the fact that it was not in jeopardy, that surgery nurses were not threatening to leave, and the fact that you can no more run a hospital without medical surgical nurses, same day center nurses, emergency room nurses, recovery nurses, etc.

The result has been that many of the other nurses in the hospital feel as if their labor has been de-valued. They feel that the organization has told them that they are not worth as much. There is foment of unrest and talk of walk outs.

I know the public is not used to the idea that nurses could refuse to work. It seems like patient abandonment. It seems wrong. But nurses who won't work for substandard or unfair wages or nurses who will not work under the stressful conditions of unsafe patient loads are not trying to be hurtful to patients. They are trying to demonstrate to health care organizations that they shouldn't be taken for granted.

I, for one, like being a nurse. But not being a nurse for nothing.

Types of Patients VIII: Frequent Flyers

Pardon the rather long absence. Sometimes I have things to share and the time to share them, sometimes not.

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Every emergency room has it's FFs (frequent flyers). FFs are individuals who utilize emergency room services over and over again, often for the same complaint, and often for complaints that are dubious at best. FFs become familiar with the ER staff as well as to the ER staff, and their complaints are often well-known and predictable.

Some FFs have psychological problems. Bipolar and Borderline personality disorders are common, as well as various forms of psychosis and schizophrenia. Sadly, some FFs have Munchausen Syndrome, a psychotic disorder in which an individual fakes illness or injury, or intentionally injures him/herself, in order to garnish sympathy and be cared for by others.

Sadder still, some FFs have Munchausen Syndrome By Proxy. These are individuals who encourage their child (usually) or other vulnerable relatives to fake illness or injury, or may intentionally injury these people for the same reasons as above.

Some FFs are drug seekers. (See, Types of Patients III)

FFs are usually on some form of public assistance (e.g., Medicaid) but this is not a hard and fast rule. It is amazing, however, how much paying for one's own care directly or indirectly through insurance tends to discourage frequent flying.

Some FFs, however, have real complaints. Migraine headache sufferers, patients with epilepsy, and patients with chronic diseases that are prone to exacerbation (e.g., emphysema, congestive heart failure, etc.) might classify as FFs. Many of these patients actually require emergency care, and yet, it is sometimes hard to feel good about the sort of "buff and polish" we are often required to apply time after time.

FFs also present the ER staff with a potentially serious dilemma: you've seen the patient what seems like at least a million times, and they always come in with the same complaint, and their complaint today is no different...what do you do?

I would like to say that what you do is the sort of comprehensive physical assessment and medical history as well as examination of the chief complaint like you were seeing this person for the very first time. I'd like to say that these patients' complaints are always taken at face value. I'd like to say that the ER staff takes no shortcuts when it comes to FFs.

There are so many things I'd like to say, if only they were all entirely true.

FF status invites shortcuts. It invites seeing the same thing time and time again simply because nothing new is looked for, and consequently, treating FFs in the same way they have always been treated.

Worse yet, FF status discourages the willing suspension of disbelief. If something novel should come up in the cursory exam and assessment, it is all too easy to ignore it. This is potentially dangerous for the FF and a tremendous liability for the ER staff. Unusual symptoms are unexamined; potentially dangerous problems are ignored because they are not found.

There is no easy answer to these problems other than vigilance. The onus of this solution, however, is almost completely placed on the ER staff's shoulders.

Some of us bear the weight better than others.

The Abyss

The television and film industries heavily influence popular conceptions of events in the medical and nursing worlds. Unfortunately, misconceptions are predominant (see, Zen and the Art of IV Maintenance).

Many TV shows and movies have "medical advisors" whose job it is to create realistic re-enactments of medical and nursing processes. However, to a trained nurse (or doctor) even shows like "ER" fall short. Often, it seems, realism suffers, taking a backseat to drama.

To wit, I recently saw the movie The Abyss. However much the viewer must willingly suspend his or her disbelief in order to make the movie enjoyable, a resuscitation scene near the end of the movie is just so incredibly wrong concerning the reasons for and effects of defibrillation that I wondered whether or not the director even made an attempt to present a more accurate depiction.

The scene reiterates the common misconception that when a person's heart stops, it can be jump-started with a defibrillator.

Briefly, the movie is about deep-water divers in crisis due to an accident. The resuscitation scene occurs after a diver brings an apparently "drowned" and severely hypothermic individual (his wife) up into an underwater work chamber. The patient is unresponsive, not breathing, and has no pulse. CPR is initiated and the first other thing the rescuers do is "shock" the patient. After three shocks and no response, the rescuers stop their efforts. Everyone is sad.

The husband, however, refuses to give up, and after slapping the corpse around a bit, resumes CPR and shouts "Shock her again, dammit!" After this fourth shock, she spontaneously revives. Cue the dramatic music! Love, hugs, and kisses all around! Everyone crying in joy!

Why is this a problematic misconception?

One problem we experience in the ER is that family and friends of patients who come in dead don't seem to understand why the patient usually leaves dead. People seem to think that we can re-start hearts, mostly they seem to think we can do this with a defibrillator. Why do they think this? Well, they see it on TV and in movies like The Abyss.

Your heart is not a car battery. We can not hook it up to jumper cables and shock it into working again. Defibrillation is used to augment and hopefully correct lethal cardiac rhythms, not create electrical and muscle activity that isn't already there. If you come to the ER without a heartbeat, a.k.a. in "asystole" (i.e., without cardiac activity), we initiate CPR and administer heart stimulating drugs. We do not defibrillate that which is not there.

In the movie, it IS realistic for the rescuers to initiate CPR. Using chest compressions and rescue breathing for a person who is unresponsive, not breathing and pulseless, is a reasonable first-line resuscitation intervention.

As well, warming a hypothermic patient (something they did not do in the movie) may allow for the patient's heart to beat spontaneously on its own again. The old-adage, "a person is not dead until s/he is warm and dead" applies. But no professional nurse or doctor would use defibrillation in this case.

In the emotionally-charged setting of a resuscitation attempt, it is reasonable for on-lookers to expect us to do everything we can to save a life. It is not reasonable, however, for on-lookers to expect us to do things we know will not help. TV shows and movies encourage the public to expect just that.

Nursing Thoughts in an Airport

Traveling east through Minneapolis/St.Paul airport on my way to a nursing leadership conference (and no, I did not see Idaho's senator in the men's room) I noticed how much bad food and stress exists in lives of travellers. Perfect place and activity for a heart attack.

In the airport these days, however, bright yellow AEDs are stationed along the walls. These devices, when used probably, even by an amateur, can deliver the instructions for using electrical shock to disrupt a chaotic heart rhythm in a person who is experiencing a myocardial infarction in the hope of restoring a normal or at least less lethal rhythm.

I mentioned to my co-worker and fellow traveling companion who is an ICU nurse that if someone collapsed we'd be able to activate a code response. She could grab the AED and I could pull out my handy resuscitation barrier device, a small plastic object that protects a person from the patient's saliva and other body fluids during mouth-to-mouth assisted breathing.

Then I reflected, it has been so long since I have looked at this barrier device that it has probably gone the way of the plastic protective device I carried in my wallet through most of high school. Dried and brittle and probably no protection at all!

Odd, one would be useless in preventing life, the other in preserving it.

Types of Patients VII: Burns

And no, we're not talking about the Scottish poet.

Burns patients often suffer an extreme amount of pain. Not surprisingly, they often describe it as a "searing" pain, ever present and exaggerated by air, alleviated by being immersed in water or covered with salve. In fact, rule of thumb is, if a burn doesn't hurt it is either very superficial or just the opposite: deep and serious. The reason for the latter is that the burn has destroyed nerve endings, representing a deep and potentially debilitating wound.

Alleviating pain with narcotics is a nursing priority, but, as I tell many burns patients, we can take away some of the pain, but it is unlikely we can take away all of the pain. Heavy sedation is necessary for seriously burned patients. We do not do this in the ER; we prefer our patients to be able to recognize their surroundings and talk about what is happening to them. Heavy sedation can be done in a burns unit. We air-transport these patients to Harborview, the trauma center in Seattle.

All burns occur because of heat, but the heat source differentiates different types of burns and also specialized treatment. Thermal burns occur because of direct contact with something hot, like fire, steam, hot oil. Radiation burns result from exposure to radiation, like sunburn. Chemical burns are the result of direct contact with acidic substances, like lye. Finally, inhalation burns are caused by breathing in super-heated fumes from fire, burning chemicals, or even steam.

The first nursing priority for a burns patient is, like all others, A for airway. Specifically, did the burn occur in an environment or a condition that could have affected the airway. The mucousal lining of the airway (i.e., the mouth, nares, pharynx, and trachea) can be easily damaged by each of the types of burns mentioned above. Swelling of or seeping fluids from the damaged airway structures, can occlude the airway. The nurse should be keenly observant of burnt facial hair, lips, nose hair, etc., which may be a telltale sign of complications with the airway.

The second priority is B for breathing. Has the burn caused difficulty breathing? Did the person inhale smoke, steam, burning chemicals? High-flow oxygen may be necessary to help oxygen transport through bronchi, bronchioles, and air sacs that have been impaired.

The third priority is C for circulation. Important here is the issue of fluids. Because skin, the largest organ of the body, is also the main protectorate of everything underneath it, losing it to a burn represents not only an impairment of skin integrity but also loss of insulation and fluid retention. Large and serious burns can result in relative dehydration of the patient in a very short time. Fluid resuscitation (i.e., the administration of massive amounts of IV fluid) may be necessary to avoid hypotension and cardiac dysrhythmias.

Attention to the ABCs is equally augmented by two factors: (1) how much of the surface of the body has been burned, and (2) how deep the burns are.

Nurses need to quickly determine the former by using the Rule of Nines. Basically, for a normal size adult, each section of the body constitutes 9% of total body surface area. A circumferential burn of the arm would be 9%; a burn expanding over the back would be 9%; a circumferential burn of the thigh would be 9%, etc. Nurses initially should guestimate; later and more precise measurement will determine long-term therapy.

The degree of the burn also determines treatment. 1st degree burns are superficial (e.g., a sun burn) and do not often require fluid resuscitation. These burns may or may not blister, and dead skin will eventually slough off. 2nd degree burns (partial thickness burns) go deeper, blister, and may require debridement (i.e., removal of damaged skin layers). These burns will usually leave scarring.

3rd degree or full thickness burns, go completely through the epidermis and dermis layers and can burn into muscle, nerve, even bone. These burns definitely require debridement, the patient requires fluid resuscitation, and depending upon how large an area is burned, the patient probably requires treatment in a specialized burns unit.

Two additional nursing considerations are infection potential and emotional responses. Because the skin protects us from infection, interrupting it with a burn requires a tetanus booster as well as potentially antibiotic therapy. And because burns can often be disfiguring (either through physical loss of structures or through scarring) burns patients may require emotional care as well. The ER nurse can initiate both infection control and emotional therapy.

Robert Burns's Auld Lang Syne is about remembering the previous year and all its friends and events, and turning over a new leaf. Sort of what burns do; the dead skin falls away, and the patient may very well have a reminder of what happened.

Unfortunately.

Empowering Nurses

Regardless of how good we may feel about the work we do, hospital nurses work in bureaucratic organizations which sometimes make our work and how we feel about it difficult.

Recently, I have been involved in a process at our hospital to improve the quality of nursing services. Oddly enough, however, no interest is expressed in improving the autonomy of nurses.

Although the nursing staff constitutes the largest group of employees at the hospital and generates the overwhelming majority of direct patient care hours (approximately 95%), we are not empowered by administration or the board of directors to conceive of ourselves as a organizational entity that may have interests and concerns that do not mirror the organization's as a whole. Hence, we are permitted minimal self-determination.

This is disastrous when the objective is to improve nursing services. Nurses who see themselves as a group taken seriously by administration and other professionals within the organization (e.g., physicians) are nurses who will seek to improve themselves.

An example of how this is not being taken seriously. I am a member of the team that is looking at our compensation package. There is an expressed understanding that all nurses within the organization receive the same base rate wage, and despite this, anecdotes abound among the staff that some nurses are paid more. (Individual nursing wages are kept confidential, unless nurses chose to share this information with other nurses.)

Part of my compensation team's objective was to empower nurses to know whether they are making the correct wage based upon the organization's wage matrix. We suggested making the wage matrix public so that each nurse could figure out on their own how much they should be making. Human resources and administration are adamant that we don't do this. They would rather nurses seek the information from the human resources director or their departmental managers.

Can't treat nurses like adults. Need to have them petition their organizational "leaders" to figure out whether the organization's commitment to equal base rates is true. This is ridiculous and disheartening.

Nurses who are treated by the organization as valuable AND intelligent will be nurses who seek to improve themselves. Hasn't anyone in administration read Maslow?

No Vacancy?

The Prologue

The other day we received several calls (five, actually) from various sources warning us that a patient was coming in by private vehicle with a HUGE laceration!

Now, we all know that what is and is not a HUGE laceration is a matter of perspective. Nicks, scratches, and scraps all can be HUGE lacerations to untrained or frightened eyes. It depresses me when I triage a patient with a HUGE laceration and it fails to impress me as HUGE or even as serious at all, and the patient becomes offended by my professional opinion or my casual demeanor.

People like drama in their trauma. I prefer realism.

The Real Story

Apparently, however, this patient and his buddy had presented to a local clinic in a small town seeking help with his injury. They found it closed and so called EMS. The first call we received was from Dispatch, telling us that they had dispatched an ambulance to the clinic to rendezvous with a patient who had a HUGE laceration.

But the ambulance took too long, so the patient and his buddy began driving to our facility at a high rate of speed. The second call we received was from the EMT on the ambulance who reported that the patient must have a HUGE laceration because he couldn't wait for EMS.

Tearing down the highway, the patient passed another EMT who called to tell us that the patient must have a HUGE laceration, because they were going so fast. A local paramedic in our town called to inquire whether or not we were listening to the radio traffic about the patient with the HUGE laceration coming in?

The last call came from our own admitting department. They wanted us to know they had received several calls about a patient coming in with a HUGE laceration.

Okay. It's nice to have a little warning. We prepped a room for a laceration repair, assuming that if everyone was correct, we were probably dealing with a serious venous injury are perhaps even an arterial bleed. Circulatory compromise to an extremity can mean the loss of it. Never a fun thing.

But what did everyone think? That unless we were forewarned, we'd have shut down the ER, turned off the lights, put up the No Vacancy sign, and gone home? Why so many warnings about a situation we face often and get paid to be prepared for ALL the time?

Epilogue

The patient arrived with a 3 x 1 centimeter laceration to his medial distal thigh. It was barely bleeding and there was no vascular compromise. He had hurt himself with a hand held grinder.

I've seen better lacerations. Even some HUGE ones.

Types of Patients VI: Seizure Disorders

Repeat this phrase: Seizure activity in and of itself does not constitute a medical emergency.

Patients who have seizures are often brought to the emergency department by bystanders or EMTs who have the mistaken impression that the individual is in medical crisis. This represents the widespread misunderstanding of seizures pervasive in our society.

Of course, EMS response, lights, sirens and the resultant rubber-necking crowd only serve to embarrass the patient and create an unnecessary ambulance fee.

A seizure is abnormal electrical activity in the brain. Seizures may manifest physically as convulsive activity of the extremities, trunk, head, face and/or tongue. Convulsions are usually jerking movements which may be subtle or strenuous and violent. The neurological activity in the brain IS the seizure; the convulsion is a symptom of the seizure.

Seizures occur for a variety of reasons: Head injury, stroke, brain tumor, excessive drug or alcohol intoxication, fever, prolonged insomnia are all common causes. However, the source of most seizure disorders (>50%) is not known. When a patient suffers seizures for which there is no known cause, the patient is said to have Epilepsy.

Epilepsy has very negative connotations in our society. In her classic, Illness and Its Metaphors, Susan Sontag describes how some diseases in our society are represented by negative images, thoughts, reactions, and stereotypes. Epilepsy is such a disorder; it is often assumed to be associated with mental retardation or inferiority, and physical frailty.

But, in fact, negative attitudes towards people with seizure disorders have very little to do with the disorder or the patient. Mostly, they are the result of the fear and discomfort experienced by witnesses to seizure events.

Epilepsy and other seizure disorders are often treated with pharmacological agents. These medicines attempt to raise the seizure threshold in the brain, thereby inhibiting seizures. This effect is usually achieved at the expense of artificially sedating the brain. Despite proper administration of medications, however, patients may still experience seizures.

So, when are seizures a medical emergency? Seizures are medical emergencies if:
1) the patient injuries him/herself during the seizure
2) the seizure is prolonged (rule of thumb is >20 minutes)
3) the patient experiences apnea during the seizure and does not successfully recover unassisted breathing
4) the patient does not have a known seizure disorder
5) the patient admits to not taking prescribed medications.

Seizures can be debilitating and terrible for the patient, and they can be horrifying for bystanders. But none of these is necessarily a medical emergency. If you witness a seizure, provide basic first aid along with protective and comfort care, but don't call EMS unless one of the above criteria exists. The person with the seizure disorder will appreciate you for it.

Zen and the Art of IV Maintenance

It is the most common nursing procedure in the ER that frightens patients. The insertion of an intravenous catheter for the purpose of providing fluids and/or administering medicines, the IV start is a nursing psycho-motor skill that must be mastered.

What it IS and is NOT

Myth #1: "I hate the idea of a needle in my arm"

An IV catheter is a small-bore plastic tube about one and a half inches long that surrounds a smaller hollow-bore metal needle. Once the catheter is inserted into the vein, the needle is retracted so only the tube remains. Because the catheter is plastic and thin, it is flexible. If inserted in an antecubital vein in the fleshy anterior aspect of the elbow (a.k.a. the crook of the arm), patients can still move and bend their arm without any further sharp instrument pain.

Myth #2: "It's going to hurt"

Actually, this isn't a myth at all. A nurse cannot put a sharpened piece of metal through a patient's skin without the patient feeling some discomfort. This should be explained because (1) the "pain" patients fear is more than the amount they will feel--in fact, it is fear more than pain that the patient experiences; and (2) there are some patients who believe that nurses can do this procedure without causing any pain whatsoever.

The nurse must help minimize the patient's fear, then, in order to minimize pain. To do this the nurse MUST: (1) be honest with the patient about the procedure, specifically, why it is necessary, what will happen, and what the likely outcomes will be (i.e., fast pain relief from re-hydration or pain medication); (2) distract the patient with constant banter; and (3) act quickly and confidently.

A good nurse demystifies the experience for patients so they know what to expect. Pain that one knows will occur is never as bad as the pain one has no idea is coming.

Myth #3: "I have bad veins"

I hear this all the time. In fact, this and "my veins roll" are the most often repeated phrases I hear from patients when I prepare to start an IV. My immediate response is usually, "you don't have bad veins; you've just had bad nurses!"

Veins are not good or bad, they are merely easy or difficult to access. These qualities are complicated by certain disease conditions (e.g., dehydration) and previous interventions (e.g., chemotherapy which makes veins frail), but the most common problem is obesity. Excessive subcutaneous fat makes veins difficult to locate and access.

Myth #4: "It'll hurt less if you use lidocaine"

For some reason, many patients have become accustomed to getting small shots of lidocaine, a numbing agent, before nurses attempt to start IVs. There is no evidence that this actually decreases the discomfort of IVs. It may decrease momentary sharp instrument pain, but one has to experience momentary sharp instrument pain and the burning sensation of lidocaine in order to achieve this benefit.

As well, the long-term discomfort of less immediately painful but poorly placed IVs can be worse than a momentarily painful but well-placed IV. The numbness caused by the lidocaine, in essence, provides a fishing license to the nurse who can't access a vein. In this case, the nurse might misconstrue a patient's momentary lack of discomfort to mean the nurse is not doing damage by rooting around with the needle, damage that may be very painful later.

Myth #5: "There's an air bubble in my IV line!"

If it weren't for television, no one would ever die of air bubbles in IV lines. And that's usually what I tell patients, "Yeah, those air bubbles'll kill you if you watch too much television."

And then I go on to explain that (1) venous blood can absorb air; (2) IV tubing is 72 inches long because that is the amount of air that the average adult can absorb without injury; and (3) television is evil.

Placing IVs well and least painfully is an art. It is a creative activity that nurses must put effort into in order to develop their craft sufficiently.

But just as there are myths, there are also truths, and the most important truth is, IV starts represent the one thing most patients fear most about ER visits. It is up to nurses to attempt to dispel this fear.

ABCs

Guess I should have brought this up earlier.

The first condition an ER nurse assesses of EVERY patient, whether presenting through triage or via EMS (Emergency Medical Service) is A for airway. Specifically, is the patient's airway patent or obstructed? Nothing else an ER nurse can do makes much sense if this fact is not established and, if necessary, corrected.

If obstructed, the ER nurse must take action to open the airway, either by repositioning the head and neck or by extracting any obstructing foreign body from the throat. If the airway is patent, does the patient require assistance in maintaining his/her patent airway?

Once this fact has been established, the ER nurse can move on to the next essential assessment: B for breathing. The nurse must assess the respiratory effort (if any) of the patient. At this point, nothing else an ER nurse can do makes much sense if this fact is not established and, if necessary, corrected.

Is the patient breathing on his/her own? At what rate? How effectively? Does the patient need assistance to breath? Does the patient require supplemental oxygen?

Once the patient is effectively breathing, either own his/her own or with assistance, the nurse can move on to the next essential assessment: C for circulation. The nurse must assess whether or not the patient has a pulse. At this point, nothing else an ER nurse can do makes much sense if this fact is not established and, if necessary, corrected.

Does the patient have a pulse? What is the heart rate? What is the quality of the pulse (i.e., regular, strong)? Do conditions exist that might compromise blood circulation (e.g., bleeding, blood clots, crushing injuries to vessels)? What is the patient's blood pressure?

Although it is easy to understand why this algorithm of assessment is important in the case of chest pain or gun shot wound patients, it is less understandable in treating patients for back pain or sore throats.

In fact, the assessment algorithm is always implicitly performed, but often quickly and, perhaps, unconsciously by the ER nurse through observation. Patients who present talking (1) have a patent airway, or else they would not be able to vocalize; (2) are breathing, or else ibid; and (3) have a pulse, or else ibid.

Do not think that just because a nurse does not explicitly assess your airway or breathing or pulse when you present for a finger laceration, that the nurse has not done so.

Just like in the alphabet, the letters A, B, C come first.

Types of Patients V: GSWs

The Preface

Guns are for pansies.

No matter what a person believes about the 2nd amendment, no matter how cool a person thinks guns feel or look or sound, hurting or killing people (or animals, for that matter) by shooting them is only for wimps who can't or won't get in close and do it with their bare hands. Easy to kill or mame from 20, 30 yards when one has the right technology...and is weak. And lazy.

But people do because people are. And sometimes in the ER we end up with the aftermath.

Gun shot wounds run the gamut from serious to superficial, intentional to accidental, traumatic to tragi-comic. Not surprising, nursing care for a patient with a gun shot wound must include attention to and management of the patient's emotional state, as well as the emotional states of the patient's family and/or friends.

In terms of trauma, damage to the body from bullets is the result of velocity and impact. Traveling at a high rate of speed, bullets pierce and tear flesh, impact and shatter bone, and penetrate, macerate, or do blunt percussive trauma to dense organs. As well, the trajectory of a bullet once it has entered the body can warp and create greater internal damage than is apparent from external wounds.

If it bleeds it leads applies. First nursing priority after establishing a patent airway and breathing: stop or retard active bleeding. Direct pressure on external wounds is optimal, despite the fact that it might not be enough.

Second nursing priority: replace blood loss with the establishment of two large bore IVs and boluses of normal saline. Preferably, specialized blood tubing should be used on at least one IV line for the purpose of administering blood later when it is cross-matched and available. When in doubt, unmatched O blood can be given.

Third nursing priority depends upon the location of the wound and the possible damage to internal structures.

With wounds to the head or excessive blood loss, neurological assessment and continuous reassessment are necessary. With all disruptions in skin integrity the risk of infection is great, but with gun shot wounds to the head, potential for infection of the brain or cerebral spinal fluid is life-threatening. Once active bleeding is stopped, sterile dressings over wounds is a must.

Gun shot wounds to the chest require respiratory assessment, possibly a chest tube to drain blood from the lungs or pleural space, and bedside ultrasound to ascertain damage to the heart, pericardium, or great vessels. Portable x-ray (these patients should not leave the ER or be left unattended by a nurse) to confirm number of bullets and location is advisable.

Unless the diaphragm is injured and possible paralyzed, abdominal wounds are less life-threatening, but quick radiography and CT are necessary prior to emergency surgery. The risk here is infection, given the fact that the contents of bowel and bladder are contaminants and waste products of the body. Leaking these into the abdominal cavity through bullet holes allows the onset of peritonitis. Injuries to the liver, pancreas and spleen are also common.

Wounds to the extremities are usually through-and-through wounds. Determining entry and exit and the bullet's trajectory is important to estimate and later establish all relevant injury. Orthopedic consultation/surgery might be necessary, especially for wounds to the hand(s).

Once life-threatening situations are controlled and risks decrease, emotional care of the patient begins. Addressing the patient's fear and/or grief of loss of function or appearance is paramount, as well as their emotional response to the situation surrounding the shooting. Even with accidental gun shot wounds, the emotions of anger and blame can compromise the physical well-being of the patient. Addressing emotional concerns of the patient and the patient's family and/or friends is part of ER nursing.

The Epilogue

The NRA and other gun nuts will tell you that guns don't kill people, people kill people. However philosophically true that may be, the fact is that it is the bullet that does the damage.

I know. I've seen it.

Remembrance

9-11.

Used to be just the number you dialed for emergencies. Now it has become the ground zero of national life, the beginning of our collective recognition of vulnerability.

But politics aside, is it really the worse day in memory?

I didn't know anyone who died in the attacks on the twin towers, the Pentagon, or the airliner over Pennsylvania. I don't know anyone who knew anyone. The six degrees of separation between us might come up with some connection, but the point is, what happened in those places on 9-11-01 hasn't affected me personally. It wasn't my worst day.

My worst day was 9-6-95. That is the day my wife of five years died in her sleep in her mid-thirties. For ten months before that horrible morning, I watch cancer eat away her mind and body. I saw it reduce her to a mere shadow of the woman I loved. I saw it take away her faculties, her pleasant personality, and her peaceful nature.

Worse yet, I watched our child watch her die.

Hers was not a violent death. No one accosted her with bombs and guns. Terrorists or criminals did not invade our home. Her disease was insidious, silent. It did not make news. Ultimately it took a jury longer to acquit O.J. Simpson than it took cancer to kill my wife.

When I think of bad days, when I think of the worse day, 9-11 holds no candle to 9-6.

A friend once told me that it does nothing to compare tragedies. After all, what do you end up with...tragedy. I suppose tragedies are not better or worse, they are just tragedies.

Still, ask me to remember 9-11 and I do so with a distant, sympathetic, respectful silence. But ask me to remember 9-6 and I do so with an anger and sorrow and empathy that I reserve for the life of a woman who died too young and very sadly.

And my son and I have no one--no terrorists, no evil doers--to blame. 9-6 is our 9-11. It is,in our memory, the worse day.

Types of Patients IV: Abdominal Pain

Part of the art of medicine is the differential diagnosis.

As mentioned before, with chest pain patients, the differential diagnosis--the things that could be wrong with the patient, given the symptoms--includes gastrointestinal problems like heartburn, respiratory problems like pneumonia, and connective tissue problems like costachondritis.

A complaint that we encounter frequently in the ER is abdominal pain, a disorder that is particularly subject to the vagaries of the differential diagnosis.

The abdominal cavity includes a variety of organs--stomach, liver, gallbladder, intestines large and small, pancreas, spleen, even a couple of kidneys and a bladder--any one of which can be anatomically or physiologically compromised. In fact, there are so many potential problems with the gut that it is divided into four quadrants for the purposes of assessment.

Patients with abdominal pain may have associated symptoms. Nausea and vomiting are common, as well as diarrhea. Loss of appetite and/or weight loss are not uncommon.

The primary nursing response to abdominal pain is differentiated by location of pain as well as the sex of the patient. If the patient is male, it is presumed that abdominal pain is gastrointestinal in origin. Why? Because there is less in the male abdominal cavity than there is in the female's, and almost all of it is the gastrointestinal tract.

In both men and women, right lower quadrant pain (RLQ) is suggestive of appendicitis. RUQ (right upper quadrant) pain is suggestive of cholethiasis, or gall bladder problems, perhaps liver disease in someone with a history of hepatitis or alcoholism. LUQ and LLQ pain are suggestive of ulcers, bowel obstructions, pancreatitis and/or constipation.

For women, the organs of sexual reproduction complicate the diagnosis. In addition to the above mentioned afflictions, women of child-bearing years can experience abdominal pain as the result of pregnancy, ectopic pregnancy, endometriosis, ovarian cysts, ovarian torsion (a twisting of the ovarian and/or fallopian tube), etc.

What does an ER nurse do?

After vital signs and a focused assessment of the abdomen (auscultation of bowel sounds, palpation of the abdomen, history of current pain as well as medical history), the nurse will assess for possible dehydration (the result of excessive vomiting and/or diarrhea, lack of intake) and initiate an IV infusion of normal saline. A blood draw for labratory tests may be conducted at this time.

The nurse will expect MD orders for some sort of anti-emetic (for nausea and vomiting), narcotic (for pain), and some sort of radiographic procedure depending upon the complaint and location of the pain.

Again, the differential diagnosis is informative. If constipation or bowel obstruction is suspected, an abdominal xray series may be ordered. If gallstones or gallbladder disease is suspected, or if gynecological problems are suspected, an ultrasound may be ordered. Other complaints may warrant a CAT scan.

The three objectives are to hydrate; decrease or eliminate nausea,vomiting, and/or diarrhea; and make the patient more comfortable.

Rarely do patients die of abdominal pain, however, there are some abdominal problems that are life-threatening. An aneurysm of the abdominal aorta, ischemic bowel, ruptured appendix, etc., can all be life-threatening and may require immediate surgery.

Again, the differential diagnosis must be ever-present in mind when a nurse triages and cares for a patient with abdominal pain. Unless otherwise specified, an emergency nurse must expect the worst and plan for it.

And when it turns out to be that the patient is just FOS (full of shit, i.e., constipated), then the bases have been already covered.

Joint Commission

No, Joint Commission is not the Marijuana Cigarette Council or the Orthopedic Committee for Range of Motion. Joint Commission is the new and abbreviated moniker for JCAHO, the Joint Commission for the Accreditation of Health Care Organizations. And what an auspicious group!

Utah Phillips used to talk about how stupid it was that U.S. citizens pay taxes so the Forest Service can protect federal lands, our lands, but instead, the Forest Service builds roads and sells logging rights to timber companies at a net loss, only to have the companies cut down trees, ruin the environment, and then sell wood and paper products back to U.S. citizens at a profit! As Utah says, "That's dumb!"

Get this.

Joint Commission is a private, for-profit organization to which the government entrusts the creation of "standards" for health care organizations, organizations which, in turn, pay Joint Commission to evaluate their facilities to see if they meet these standards. Often they don't, so they have to be re-evaluated at an even greater expense, or sometimes pay fines. The federal government supports this inanity (health care corporate socialism) by attaching an organization's Medicare and Medicaid funding to successful meeting of the standards.

That's dumb!

First of all, the only way Joint Commission can continue to profit is to constantly come up with new standards, standards that organizations have to try to meet, and then (again) pay Joint Commission to evaluate their performance. Some standards border on the ridiculous.

Second, no one asks, why should the American health care consumer subject their safety and health to an organization who's purpose it is to profit off of the imposition of standards they've created in order to make money? That's like drivers putting their lives in the hands of an automobile maker whose first priority is to sell cars and make money. Anyone heard of the Pinto?

Third, and the point that should be most egregious to every nurse, is that many of the standards the Joint Commission comes up with amount to "dumbing down" the nursing profession. The aforementioned removal of the abbreviation for morphine is a classic example.

Joint Commission decided that the accurate and time-worn abbreviation MS was confusing. The commission believed that incidents in which nurses confused the abbreviation for Magnesium Sulfate, rather than Morphine Sulfate, had resulted in serious threats to patient safety. Regardless of whether or not this is true, the question remains, how best to deal with this.

Like a totalitarian government, the commission simply said, okay, don't allow health care workers to use the abbreviation; make them spell out morphine or magnesium. Forget education, forget training. Bring in big brother!

But seriously, not knowing whether to give a patient morphine or magnesium is not a matter of a confusing abbreviation. It is a matter of bad nursing. Morphine is given for pain; magnesium sulfate is given to slow down labor. If you don't know whether you're working in OB or emergency, you probably shouldn't be taking care of that patient!

I think there is a reason that Joint Commission's abbreviation is "JC". Its widespread acceptance in the medical-industrial-complex gives it the illusion that it is omnipotent, godly. In fact, it seems to me its just a bunch of profiteers getting rich.

Are we safer?

A Good Nurse is a Good Example

The national discussion about Idaho Senator Larry Craig's situation has many folks on all sides of the political spectrum questioning themselves. On the Right, we have folks saying he should resign because he's gay; on the Left, we have folks saying it's okay that he's gay, he should resign because he broke the law; a fact, they point out, to which he admitted.

In between are people of various political shades who question Craig's (1) previous statements concerning issues of gay rights; (2) vitriolic condemnation of President Bill Clinton's sexual daliance with Monica Lewinski; (3) judgement as a lawyer pleading guilty to something he now says he didn't do (a plea that was apparently not forced upon him); (4) recent behavior in a public bathroom; (5) well-founded reports of previous like-behavior, etc.

Here is what it comes down to for me: Personality and actions that represent the ideal of what a person believes others should see in him/her. Nowhere is this more important than in positions of power and especially in positions of public service. Sen. Craig should know this, but the fact that he doesn't appear to should be reason enough for others to ask him to step-down as a leader and public servant.

I do not care if Craig's behavior was moral or not; I do not care if he is gay or not. I do care that he doesn't have enough sense as a politically powerful man to attempt to be an example of a law-abiding citizen. People should question this. People should expect their leaders to obey laws they create and enact. People should expect their leaders to be...good.

And nurses should pay heed. A good nurse is one who presents to his/her patients an example of health in body and mind. Obesity, cigarette smoking, lack of hygiene, etc. are examples of poor health habits, and yet these are behaviors and conditions prevalent among the nursing population.

Obesity, smoking, and poor hygiene do not inhibit nurses from performing nursing skills or education or research. These behaviors and conditions may, however, create a sense of doubt in patients' minds about how good their nurse really is. What is the old adage: "Doctor, heal thyself!"

Nurses are leaders and public servants in the health industry. They should look like healthy people, act like healthy people, and represent healthy lifestyles.

And they shouldn't be having sex in public bathrooms! YUCK!


P.S. It is funny that the word daliance means "a brief affair..." and the word dalliance means "wasting time while one should be working...".

Abbreviations of the Trade

In all professions a specialized language exists that amounts to no more than shortcuts to express longer or more complex thoughts or observations. Nursing is no different.

Acronyms are most common:
RLQ = right lower quadrant
LLE = left lower extremity
AMI = acute myocardial infarction
MVC = motor vehicle crash
LOC = level of consciousness; loss of consciousness (contextual)

Some acronyms are uncommon:
LOLnNad = little old lady in no apparent distress
FOOSH = fall on out-stretched hand (a forewarm or wrist fracture)

Some acronyms are derisive and never written on the official chart:
LLPOF = liar, liar, pants on fire
PPP = piss-poor parenting

Abbreviations are common as well:
IV = intravenous
PO = per os, orally

Some classic abbreviations have been nixed by an organization called:
JACHO = Joint Commission for the Accreditation of Healthcare Organizations
MS = used to stand for "morphine (sulfate)"

Now, we have to write "morphine" because JCAHO says that some doctors and nurses frequently confuse this abbreviation for magnesium sulfate. Forget the fact that if you don't know whether or not you should be giving morphine or magnesium, it's not the abbreviation's fault!

More about Joint Commission, as it is now called, later...

Types of Patients III: Drug Seekers

If drug seekers would spend as much time, energy, and creativity trying to get their drugs illegally on the street as they do with their Oscar-level dramatics, theatrics and hysterics in the ER, the world might be a better place.

But no!

The problem with street drugs (among many) is they cost money, and the people who sell them are not the sort to send out billing statements that the user can promptly ignore.

So the drug seekers come to us because (1) they know we are required by law to provide them with a medical screening regardless of their ability (or lack thereof) to pay (see "EMTALA"), and (2) they know that they can throw away those billing statements; our not-for-profit hospital is not likely to get blood from stoners.

Who is the typical drug seeker?

Typical drug seekers are people who know the system and are smart enough to make the system work for them. They complain of pain but cannot specify an injury; they complain of 9/10 pain while hobbling in, but are able to overcome their misery as they leave with a narcotics pain prescription.

Drug seekers are recidivists. They return frequently, usually with different areas of complaint but always with the complaint of pain. Dental pain, back pain, migraines are the most common. They make the rounds, going from hospital to hospital, visiting ERs, and sometimes private physicians and clinics, anywhere they can find a narc script.

Fundamentally, drug seekers are liars. But they must also be fearless, because obtaining narcotics under false pretenses (i.e., lying, fake identification, fake name, etc.) is a felony.

Although EMTALA requires that we provide a medical screening for each patient, it does not require that we treat patients who do not have emergent medical conditions. Most drug seekers do not complain of emergent problems; they are never in medical crisis (unless withdrawal is considered a medical emergency).

Unfortunately, as an ER nurse, I am often put in the position of having to search out the information on drug seekers. Checking past records, calling other local hospitals, calling pharmacies. This takes a lot of time that I could otherwise use to care for truly ill patients. I am not a law enforcement officer, but I do this because its hard to care for someone who I know is lying to me.

Some drug seekers leave a sloppy trail, others are more sophisticated. Still, others are too smart for there own good.

One example: A well-dressed 36 year old male patient complained of chronic back pain. He said he had flown into town for a well-known and popular annual event but had forgotten his Fentanyl duragesic patches. He had one on that was due to be changed. Noting this, the doctor ordered a new patch, and we placed it on him. The next morning, EMTs responded to the local homeless shelter where the man had been staying and found him dead with a hypodermic in his arm and the dry duragesic patch with a small needle hole lying beside him. This is your brain obliterated by Fentanyl.

This crime didn't pay.

Suffering

Layers of dysfunction run deep.

Let's not get too philosophical, but there is a difference between pain and suffering. In my ER, anyway.

Pain is the result of physical injury or illness. It has a origin and quality that can be described; it has a location (in the body); it has an intensity; and it should be accompanied by abnormal physical attributes (e.g., increased blood pressure; deformed, fractured femur; amputation).

Pain is usually situational, but can also be chronic. In the latter case, it is usually episodic, ebbing and flowing.

Suffering is a psychological term for a condition that often accompanies chronic pain, situational or complicated (lasting) grief, and/or other coping dysfunctions. Its manifestations include malaise, lack of interest in self-help and self-care, complaints of unspecified pain and unverifiable illnesses. And it is not usually possible to treat in the ER.

Regardless, patients present with it all the time.

EMTALA

There are many reasons patients come to an ER. Severed arteries, acute myocardial infarction, poisoning, crushed limbs/head/ego...all of these can be effectively treated in an ER or other trauma center.

But another reason that many people come to the ER is because they know they will be treated, that despite their ability to pay (or lack thereof), they will receive some sort of attention to their concerns and possible even a remedy.

Why is this?

The Emergency Treatment and Active Labor Act (EMTALA) is a federal law that requires public hospitals which accept Medicare and Medicaid payments from the government to offer a medical screening exam and necessary stabilizing treatment to anyone who presents with a medical complaint. If a hospital refuses, it is subject to substantial fines and revocation of its status as a medicare/medicaid provider (i.e., recipient of government funding).

EMTALA, like so many other government regulations (or lack thereof) in the health care industry, is a good law with some negative side-effects.

The purpose of EMTALA is to prevent hospitals from considering profitability before doing what is best for the patient. "Dumping" seriously ill or injured patients or patients who can't pay or pay much was a common practice among hospitals who believed that high-grading (choosing the best, in this case, the best paying patients) was the easiest way to improve the bottom line.

Of course, for some patients this meant disaster. Being turned away from the closest trauma center often meant wasting precious time for patients who were bleeding, having heart attacks, dying of toxicity, or suffering massive, violent injuries. And for women in active labor, having to find a hospital that would accept them often put themselves as well as their unborn babies at risk. Some people died; some hospitals profited.

So EMTALA made it (sort of) illegal to dump. Sort of, because if a hospital chose to forego government payments it could discriminate at will. For-profit, private hospitals, could choose the best of the best, the most insured of the insured, and the government couldn't do anything about it.

But no good law goes unpunished.

EMTALA has also had some unintended side-effects, the most notorious of which has been setting in concrete the two-tiered system of primary care. Patients with insurance, whether private insurance or Medicare (an entitlement program, not income-tested like Medicaid) can usually see their primary care physician for minor or inconvenient maladies or injuries. This keeps costs down, because expensive ER visits (see, "Let Sleeping Old Men...Sleep") can be minimized.

But many physicians do not accept Medicaid, the government insurance program for the poor. Overhead costs at physicians' offices are too high and government reimbursement through this program is paltry. And there is no federal law that says doctors must accept all patients.

So the poor come to us for their care, much of which is minimal. Again, it is not uncommon to pay at least $300 for just walking through the ER doors, utilizing the services of a department and a personnel staff that are equipped and trained to save lives if necessary. With nearly 35 million Americans lacking health insurance or adequate health coverage, and about a third of the population living below the poverty level, the cost to publicly-funded hospitals and Medicaid is enormous.

And who pays this cost? Anyone who pays taxes. And anyone who pays for their own health insurance.

Who benefits? The usual suspects. Doctors who can pick and choose patients. Private hospitals (read: hospitals for the rich) that don't have to abide by EMTALA. And private insurance companies that are not forced to insure poor people.

Everyone deserves health care. In our society, however, it is apparent that some are served better than others.

Types of Patients II: Chest pain/Cardiac

One of the easiest ways to get attention in the ER is to clutch your chest and complain of chest pain. Mention the proverbial elephant sitting on your chest and a sense of impending doom and you will find yourself on an expressway through triage to a monitored bed quicker than most.

Unfortunately, as explained previously, this is a good hop to the front of the line for a bad reason. Chest pain patients may have an emergent health crisis that, in turn, may have devastating negative outcomes. Impending doom? Not surprising.

A cardiac patient typically feels "crushing" pain to the chest which may radiate to the back, neck, or the left arm. The patient typically indicates the location of the pain by placing a fist on the chest, not pointing with the pinkie finger. This patient may complain of shortness of breath, nausea, and diaphoresis (sweatiness).

What is happening to this patient?

If the patient is suffering a cardiac event, the pain is the result of coronary arteries that have narrowed or been blocked, thereby reducing or eliminating blood supply to the cardiac muscle. The resultant ischemia (lack of oxygen), muscle injury, or muscle death is the source of the pain. In this case, time is muscle, and the quicker blood flow is returned to these areas of the heart the less damage that is done.

When blood flow to a large part of the cardiac muscle is immediately eliminated, sudden death may occur. "Dropping dead of a heart attack" is just that; so much of the heart is instantaneously damaged such that the heart can no longer function properly. It usually does not stop; it enters into a chaotic rhythm that is not sustainable of life. Ventricular fibrillation and/or ventricular tachycardia are lethal rhythms and the only way to "fix" them is with electricity.

"All clear?" Zzzzzap!

If this happens outside of the hospital, the chance of survival is slim, <10%. These patients usually do not arrive in the ER, they die in the field; or, if they do come in--via ambulance, etc.--they are usually already dead. Patients who arrive dead, despite what families and friends think, almost always stay dead.

If a sudden heart attack occurs in the hospital, chances of survival improve, but not drastically. Cardiopulmonary resuscitation (CPR) and automatic external defibrillators (AEDs) were developed to attempt to improve survival.

In my ER, we follow the American Heart Association's guidelines for chest pain patients, or patients with Acute Coronary Syndrome, as it is called by the AHA. Such a patient must be assessed by a nurse, have an EKG done, receive oxygen, have an IV started preferably with a blood draw, and have a medical history taken within 15 minutes, at which time the physician should see them.

Physicians orders to a nurse might include aspirin (a blood thinner), sublinqual nitroglycerin (under the tongue, a coronary artery dilator) or as an intravenous drip, perhaps morphine (for severe pain but also reduces cardiac oxygen demand) and a beta blocker (lowers the blood pressure). Laboratory blood work to look for elevated cardiac enzymes (enzymes released in the blood stream because of a cardiac event, especially muscle injury and/or muscle death) will be ordered, and perhaps a portable chest x-ray, the latter to evaluate for any anatomical abnormalities like an enlarged heart, etc.

In cases where acute myocardial infarction is confirmed (by EKG or by laboratory values), clot busters may be administered. This medicine is like Drano. Got a clogged coronary artery? Retavase can open it (perhaps). This therapy carries with it a host of possible negative side-effects (e.g., cerebral stroke), but if it is offered, many patients choose it regardless because most realize that die now or stroke later...which would you choose?

Do patients present complaining of chest pain who aren't experiencing a cardiac event? Many, perhaps most. But why?

There are several conditions that may mimic cardiac chest pain. Indigestion is the classic. We call it GERD, gastro-esophageal reflux disease, a.k.a. heart burn. (Notice the cardiac reference in the common parlance for this illness.) Esophageal spasms can also produce chest pain.

Other patients may claim they are having chest pain because they realize it brings them to the front of a long line of patients waiting to be seen. This behavior is usually recognized for what it is, but the same protocol is usually followed because despite how many times the patient may cry "wolf," sometimes there really is a wolf.

Erring on the side of life-saving is always a good thing. At least I think so.

Pain

The Fifth Vital Sign.

It not only sounds like the title of a Bergman film, but pain as a vital sign is like a Bergman film in that it amounts to a conceptual sleight of hand. It has been elevated in the medical and nursing communities from a simple statement about a patient's response to illness or injury--the patient's perception of discomfort--to an indication of the patient's vitality; from a personal reflection upon the human condition of suffering to a quantifiable measure of that suffering. A Bergman film? Yes indeed.

Vital signs are measures of the physiological conditions associated with life-- vitality. The four traditional signs of vitality are blood pressure, pulse, respirations, and temperature. It is necessary to possess some quantity and quality of each of these in order to be alive.

Because they are physical, vital signs are measurable. As well, they may change in relation to the various physical conditions to which the human body is subjected, conditions like physical injury or disease processes. Vitals signs DO NOT depend upon what the patient says about them. They are related to conditions the patient cannot of his or her own will easily control or alter.

But what of pain?

As nurses we are told to think of a patient's pain as whatever the patient says it is. Traditionally, nurses "assessed" pain by asking patients where they hurt, what it feels like, how intense it is, when did it start, what exacerbates it, and what they've been able to do to ease it, if anything.

Now, we are encouraged to "measure" pain by having patients rate it on a scale of 0 to 10, with zero being no pain at all and 10 being the worst pain. We have changed pain from an experience that must be described to one that can simply be quantified.

So, what is the problem with this? Why is treating "pain" as a number potentially detrimental to ER nursing?

As a subjective measure of highly individualized experience, pain is not like the other vital signs. A temperature of 98.6 degrees may not be "normal" for everyone, but 98.6 for one person is the same as 98.6 degrees for another, just as a pulse of 80 in one patient is the same as a pulse of 80 in another. As well, 105 degrees is dangerous for anyone, not just those who think it is a high fever, just as a heart rate of 20 is dangerous for anyone no matter what they think of it (if they're able to mentate at all at this rate.)

But is 5/10 pain the same for everyone? Does the same broken bone produce the same pain for everyone? And how do we know that the patient having 5/10 pain is really having 5/10 pain? If it were another patient with the same injury, would the injury result in the same amount of pain? If a patient's pain of 5/10 eases to 3/10, is this the same as when their 7/10 pain eased to 5/10 or when another patient's pain decreass from 5/10 to 3/10?

When you think of it, the number a patient reports really doesn't mean a whole lot. Whereas "blood pressure of 100/60" tells me something specific about my patient, "pain of 5/10" does not. How am I to know how much pain this is? I know its less than 7/10 and more than 3/10, but I don't know what these values mean anymore than I do 5/10.

With the other vital signs, zero values can be interpreted as meaning no vitality. Zero blood pressure, zero respirations, zero pulse or zero temperature means a patient is dead. With pain, however, a patient with no pain (0/10) is not lacking vitality; this patient might be said to be healthier than those with pain. Oddly, the only immediately understandable and specific value on the pain scale is, in fact, zero.

Then there are the patients who complain of 10/10 pain. These patients don't really have a pain problem, they have a math problem. They don't realize that 10 out of 10 represents all the pain possible! I like to ask these patients "If I ripped your arm off, would you have more pain than the 10/10 throat pain you're complaining of now?"

Fundamentally, that is the problem with quantifying pain: it tells you nothing of the clinical significance of a patient's illness of injury. Other vital signs do.

A Bergman film, indeed.

Types of Patients I: Suicidal Ideation/Attempt

My friend Camus once wrote that the fundamental problem of philosophy is whether it is better to live or to die, and that all other philosophical inquiry is based upon one's answer to this question. For if it is better to die, then one should honor that decision and kill oneself. No other philosophical question need be considered.

Of course, in The Myth of Sisyphus, Camus comes down on the other side of the question: regardless of the toil of human life and its miseries and let-downs, it is better to live than die. What one must do in life is find meaning.

Questions remain: why do people attempt to kill themselves; what is the difference between those who succeed and those who don't? The facile answer to the second question is, of course, those who succeed are dead. As for those who don't, these are the one's we often see as patients in the ER.

I divide suicidal patients into two categories: those who I judge have made a serious, truly lethal attempt, and those who have not made a serious attempt. In my ER (and probably ERs nationwide), we see more of the latter than the former. The predominant method of non-serious attempt is overdose. These are patients who ingest large but often unknown quantities of (usually) legal medications, often over-the-counter medicines like cough syrup, acetaminophen, and ibuprofen, but sometimes prescription medicines like anti-depressives or narcotics.

One thing that distinguishes this patient category is that the suicidal individual does not often know what sort of damage the drugs he or she ingested will do. It is not a serious, lethal attempt because the patient hasn't done enough research to know how much to take to kill themselves. Usually the patient has taken enough to harm the liver or the kidneys, but this is damage he or she will more than likely have to deal with later in life.

The smaller category of patients who make truly lethal attempts (some of which become successes), I have found, usually use more violent means. Handguns, hanging, jumping from heights, and machinery are truly lethal mechanisms of self-injury in this patient group. From the patient who laid down on his table saw to the patient who hung himself with a bed sheet, these are the serious attempts. (Incidentally, the former failed whereas the latter succeeded.)

There is often little else that characterizes these groups. Patients are young or old; some have a history of psychological problems, some don't; some have made previous attempts, others not. In fact, the common characteristic of suicide attempts and possible success is the unpredictable nature of the event.

For both categories, however, primary nursing care includes establishing the nature and extent of the patient's self-harm; responding to the patient's injuries with curative and palliative measures; providing a safe environment in the ER; contracting with the patient for no further self-harm (at least, not in the ER); and initiating psychological interventions, whether this be making an appointment with the patient's counselor or admitting the patient to the hospital.

A friend and fellow nurse often says that in order to do ER work a nurse has to "let go of the why." Often we have no idea why our patients do what they do. Suicide attempts are an extreme example of this.

I like to remind patients that self-harm and ultimately self-destruction are long-term solutions to often short-term problems. Whether or not this is helpful to them, I'm not sure. But it probably beats recommending Camus.

My Friend Camus Said I Suffered Existential Angst

I used to be a college professor. I taught sociology at a major northwest university and was writing a PhD dissertation in political sociology focusing on agricultural social movements. I taught introductory classes as well as classes in social problems, the sociology of power, and social research methods. I liked teaching and I thought that it was important.

But it didn't seem important to others. My students just wanted grades and, eventually, a degree. My department just wanted me to offer as many classes I could as inexpensively as possible. The university just wanted me to keep my nose clean and cater to the students. The athletic department, of course, just wanted me to pass its athletes, no matter how deplorable their academic performance. Very few, it seemed, thought that teaching and, ultimately, learning was important.

At the same time, I was writing a dissertation that required me to become involved with political activist groups. The groups were suspicious of me as an academic researcher and the academic community was suspicious that I was becoming an activist, "going native," a la Carlos Castenada. In between these extremes, nobody but myself and my advisor seemed to care about my project. Several times people suggested that I "just do it" regardless of the reasons, as if writing a dissertation and attaining a PhD was no more than replicating a Nike commercial.

I didn't feel like doing that. I couldn't. I longed to find meaning in what I was doing, to understand why what I did was worthwhile, to me, to students, to the world. I played mind-tricks. "Oh, these students will realize eventually that what I taught them is important. Oh, the discipline will realize the significance of my research." But it wasn't happening. In short, I found myself in a state of existential angst.

What am I doing with my life? Do I contribute? Can I conceive of a world in which people who do what I do don't exist? Sadly, honestly, yes. Yes, I could.

And then tragedy struck. Someone very close to me was diagnosed with cancer, and soon thereafter became terminal. University life stopped; my research stopped. My future stood frozen in mid-air, in the stasis of waiting, waiting to see what cancer could do. To make a long story short, it kills.

In the short amount of time my loved-one had, I cared for her at home. I positioned her in bed and bathed her. I sat up with her at nights when she was too afraid to close her eyes for fear that death, not night, would overcome her. I gave her medicine. I made sure she had the people around her she wanted--her son, her friends--and kept the rest, the nonessential ones at bay. We reluctantly welcomed hospice into our life--nurses, aides, social workers, volunteers--and our life became different, defined as much by a prognosis as what we did or thought. I drank a lot.

In the end, at the end, she got what she wanted: to stay home with her child, not to die in a hospital. It seemed so little but it was my last gift to her. Ironically, she died in our living room.

But I got something as well. I realized that I had an aptitude for taking care of others, for nursing. Why did this shock me? I had been my son's primary care giver all his life, and I took care of the home, the yard, the cooking, the cleaning. I was already a nurse, just a nurse without training, without a license. Did it really shock me that I could do this sort of work and do it with pride and a sense of accomplishment?

I had grown up in the midwest. No one there had ever told me that men could be nurses. No one even held that out in front of me as an option. If I wanted to become a doctor, well, that was fine. But I didn't.

My experience taking care of a dying person taught me about what I wanted most: a sense of accomplishment in knowing that what I had just done for someone made a difference. I craved what teaching would not provide, nearly instantaneous feedback about the quality and effect of my actions, my mark on the world. This, I found in the small circle between nurse and patient, for no matter what I did for my loved-one, she responded. If I moved her wrong, she winced or cried; if I held her hand, she smiled; when I brought her son up into the hospital bed, she thanked me.

I realized that nurses receive this immediate affirmation in their daily jobs. They receive it primarily from their patients but also from communities and a society that respect them and their profession.

In many ways, nurses are like trash collectors. Not many want to be one, but we appreciate those who do. In fact, I can't imagine a world without trash collectors, any more than I can imagine a world without nurses.

But that was, literally, a lifetime ago, albeit someone else's life. I honor that life and its unfortunate end every day I go to work, because it helped me see the value of my own life and it is the reason I became a nurse.

A Nursing Pitch

When I decided to become a nurse, several factors influenced my decision. I will address the philosophical, existential factors at another time. Here I would like to discuss the practical factors.

First, no one will get rich being a nurse, but nurses make very respectable living wages. My full-time job provides me about $45,000 per year, and in this small town, that puts me on-par with teachers, plumbers, and even some university professors. I own my home, I have a Subaru, and I take frequent vacations.

Second, when I decided to give up college teaching, I wanted to remain in my small town. Since the university is the largest employer, however, I would either have to remain there or find another decent job that would allow me to keep my home and support my family. So I did some research.

I discovered that not only was there a nursing shortage in the United States (as well as worldwide) but that rural America was disproportionately affected by this shortage. Apparently, urban and suburban areas with large hospitals and complex health care networks took the lion's share of the available nursing population. Since I wanted to live in Smalltown, America, I was almost guaranteed a job if I became a nurse.

Third, the aforementioned nursing shortage also nearly guarantees me a job wherever I chose to work. Given increases in the "old age" population and the crossover into middle age and beyond of the largest surge in United States population, the baby boomers, more and more people require and demand medical care, including nursing services.

FYI: For a look at statistics and opportunities, check out:

http://stats.bls.gov/oco/ocos083.htm#outlook

Fourth, and this fact near and dear to my heart, I work full-time but I work 12 hour shifts, not uncommon in the nursing profession. As a 12-hour shift employee, full-time is considered 3 shifts per week. What this amounts to is 12 shifts (therefore, 12 days) per month and 144 shifts (144 days) per year if I don't take vacation. The average 8 hour, five day a week worker puts in about 260 days per year. In short, I have over 200 days off per year, whereas the aforementioned average worker has only 105 days off. For someone who loves his work but also loves the variety of other activities in his life, nursing was definitely the way to go for me.

But those are just the practical aspects of choosing nursing as a career. Life is not always or sometimes even primarily about being practical. Stay-tuned for a discussion of the other reasons I became a nurse.

Remedial Health Education

Ideas about health vary. What seems like a healthy lifestyle choice to one may not to another.

Usually when we think about health, we think of the things we've been told to stay away from, things we're told not to do. Cigarette smoking, fatty foods, toxic waste dumps, chain saws, lead paint, heroin. We think of the risks we take when we don't heed the warnings of experts: objects are closer than they appear; do not operate while under the influence of narcotics or alcohol; unsafe at any speed; an apple a day...

But what about the things we should do to maintain our health? These axioms do not seem debatable to me: eat right, exercise, be careful. It really is this simple, and the common denominator is moderation.

We are incessantly bombarded by the media, our friends and family, with all the latest health scares and all the newest health fads. Mad cow disease, E. coli, leaded toys, Suzuki roll overs, weight loss diets, Adkins, abdomenizers, gastric by-pass. With all of this, who has time to remember the essentials?

In the ER, many patients come in with problems with which they subsequently leave only to return again at a later time with the same problem. Chronic problems like back pain, migraines, respiratory difficulties. It is discouraging because (1) it seems that we are not helping them maintain their health at all, and (2) the quick fix they receive in the ER often allows them to ignore the underlying issues that cause the symptoms for which they return again and again. Not only is this inefficient, it is dangerous to their health!

The solution, of course, is education, but often the ER is not the most appropriate place to educate patients about the causes of chronic problems. It is easy (and becoming more culturally appropriate) to tell people to stop smoking cigarettes; it is less easy to teach them how or to follow up with an effective health care plan.

And some chronic problems are caused by conditions which are almost taboo to even mention. Obesity is one. Telling a person to take their asthma medication on a regular basis is astute and may be considered good, prudent nursing education. Suggesting that they eat less and exercise more in order to shed the extra 80 pound sack of concrete they tax their diseased lungs with everyday might be considered offensive.

But shouldn't they hear this? Shouldn't someone educate them about the connection between obesity and respiratory problems, how mass affects the function of systems, how the increased size of anatomy may have deleterious effects on physiology?

A recent book by a prominent sociologist questions statistically the obesity epidemic. As an ER nurse, I do not know whether or not obesity is on the rise (although I suspect it is), but I do know that obese patients have problems others don't, and I see a lot of them. For the individual, it doesn't matter whether statistically there is an epidemic or not; one is either over-weight or not, relatively speaking, and morbidity is influenced by this fact.

I think the health education ER nurses should attempt should be simple, albeit remedial: eat right, exercise, and be careful.

Does anyone doubt it?

If It Bleeds, It Leads...Maybe

Triage is the system by which nurses determine the order in which patients will be seen in the emergency room. It is a system that prioritizes care for those most likely to suffer debilitating outcomes from the injury or illness with which they present, the most serious of which is, of course, death. It is an imprecise system that makes caring for multiple patients easier for ER staff, while at the same time, frustrating for some patients.

In most service industries, first come, first served. This because the nature of the services rendered to various customers is usually nearly the same with no one customer's issues being more important or more serious than anyone else's. Think of taking a number and waiting until your number is called. "Now serving..."

Our triage system sorts the severity of health problems into three categories. "Emergent" problems (whether injury or illness) are the most serious, and it is these that lead, bleeding or not. If you come to my ER and you can't breath, or your heart has stopped, or you have severe chest pain, or you're bleeding uncontrollably, then you get served first. The potential negative outcomes of your condition are so extreme that you require immediate attention.

"Urgent" problems have less severe potential outcomes and require attention within about an hour. Asthma attacks, severe histamine reactions, open fractures or fractures with vascular compromise, burns and open wounds without systemic complications...you won't probably die from these, so you drop down the ladder a few rungs.

"Non-emergent" is the category of problems that requires that you be seen sometime today, but literally, you could sit most of the day in the waiting room without any severe or even mildly negative outcome. Yes, it is this patient who sits and watches the severed dangling limbs, the chest clutching heart attacks, and the blue anaphylatic reactions jump to the front of the line.

Of course, sometimes in life it's a good thing not to have to be first.

About 85% of ER nursing is caring for patients with non-emergent problems. These are usually minor injuries (e.g., finger lacerations, eye irritations, sprains and simple fractures) and uncomfortable or inconvenient illnesses (e.g., back pain, hives, nausea). Most of these patients could probably be treated elsewhere, like at their primary physician's office, but they come to us for a variety of reasons (which I'll discuss another time).

Another 10% of ER nursing is caring for the urgent problems of patients who are very uncomfortable and who require more immediate attention than they could probably get going anywhere else. Sometimes the severity of their injuries or illnesses requires specialized treatment, equipment, or procedures that are unusual or unlikely in other health care settings. These patients usually need IVs, x-rays, narcotics, electrocardiograms (EKGs), or oxygen; they may need frequent or constant monitoring of their vital signs, their blood sugar; they might require a surgical consult.

Emergent conditions comprise the final 5% of emergency nursing. These patients arrive by ambulance from traumatic falls, motor vehicle crashes, construction sites where they've severed their fingers or shot themselves with pneumatic nail guns. These patients walk in with the metaphoric elephant on their chest, the swollen and compromised airway due to a peanut allergy, the shard of glass in their back which punctured their lung when they were violently pushed through the plate glass window. These are the unconscious patients with head injuries, strokes, chemical overdoses (e.g., drugs, alcohol, carbon monoxide).

These patients command an ER nurse's immediate attention not because they're more fun to take care of, but because if not cared for immediately and properly, they risk the unforgiving dance with mister D. Nobody should want to be this patient just to be first, and no one should complain that this patient comes first. After all, we may all be this patient or our loved one might be this patient at some point.

Who wouldn't want to wait in the lobby with a sore throat while the ER nurse saves the life of someone else?