Emergency Nursing Notes

Letter to a Young Nurse in Hope of Finding Solace

2009-03-29T09:52:00.000-07:00

Recently, a friend of mine who has been a nurse less than a year, was involved in an unsuccessful resuscitation attempt. There is nothing so difficult in our profession as to feel that our efforts didn't make a difference. Below is a letter I wrote to this nurse after hearing that she was disturbed by the code. I realized after I wrote it that it says as much about nursing, in general, as it does about her specific quandary.

I was both happy and sad to hear that you experienced a code the other night. Happy because you need that experience (because it will happen again), and sad because codes aren't fun and can be emotionally trying and exhausting, especially when there are good reasons to save the patient other than the patient--I heard that a relative, a young boy, was present.

I hate to have a professional philosophy based upon a television show, but I remember an episode of M*A*S*H* in which Colonel Blake consoles one of the doctors after a soldier's death. I'll paraphrase. Blake says, there are two rules he's learned about the health care profession. Rule number one is, people die. Rule number two is, doctors and nurses can't change rule number one.

Despite the fatalism, remembering these rules can make the difference between despair and acceptance. People in pain, people with problems, come to us and ask for help. More often than not, we're able. Sometimes our help has positive outcomes, but not always, and sometimes not in predictable ways. There are some problems too complicated or too far gone for us to do much about. Recognizing this is not the same as failing to try.

And that's what you did, you tried. You tried against great odds. Unfortunately, this time the outcome wasn't what everyone hoped for and everybody lost. That's a real drag, but then, the rules are a drag.

As I heard somebody say recently, "We're living in a rented world," and saving lives is a game of odds. Sometimes you win (and your patient wins) and sometimes you don't. But no one lives forever, so for every patient, there has to be a time when you lose. It's a drag to be there when that time comes, but, because you never know when that will be, being there is the only opportunity you have to attempt to delay that time. You'll never eventually prevent it, but then, that isn't your job.

You (and nurses in general) are there when a lot of other people aren't. Between that and doing the best you can when you are there, that should make you feel good, and proud, and provide some solace. I'm sure the patient, his family, and your co-workers appreciated your presence.

That said, don't be afraid to talk about your experience and your feelings. Debriefing is a valuable process. Like with so many other strong, emotional experiences, talking about your feelings is a good way to exorcise the more damaging aspects of pent up emotions, frustrations, etc. We all have these after a code, successful or unsuccessful, and it never gets any easier. We just get a little thicker each time. That might not be something to look forward to but it'll happen, incipiently, sooner or later.

Emergency nursing is both a difficult physical and emotional occupation. Some events underscore this fact more than others.

Popular Misnomers

2008-07-07T16:41:00.000-07:00

Not that you need to know but I just returned from a long, much needed vacation. A month away from work yet paid, barbaric in its paucity by European standards, does a wage-laborer good.

I mention Europe only because that's where I went, traveling among a couple of the heathen national health countries of the U.K.--you know, the one's that have greater life expectancy than the U.S. and a greater percentage of the population with access to quality health care.

But let's not pick nits (unless you have lice...)

And what did I get for my travels? Pneumonia.

But since I'm still up and about, the popular term would be walking pneumonia, as if the infiltrate in my left lower lobe has sprouted legs and become a peripatetic infection!

No, it's just pneumonia. Probably been living too high. What are vacations for?

None of This Has Anything to Do with Nursing

2008-06-07T14:37:00.000-07:00

The hospital at which I work is much more than just a building. It is a bureaucratic organization of interrelated statuses and roles stratified upon a hierarchy of authority and power coordinated to provide health care to our community. Most members of the community only see the end result. When they are sick or injured, they come to us and we care for them.

What the community doesn't see or see often is the corporate culture embraced by some elements of the organization. This culture is characterized by all the slap and tickle, buzzwords, and managerial guru crap popular in corporate culture these days. Some at my hospital are completely ga-ga for it.

Take for instance their newest corporate embrace, a program supposedly designed to "hardwire excellence," whatever that means. (Don't ask them, unless you want to be drowned in a sea of corporate cliches, 7 habits, and all those cool folks you're supposed to meet in heaven!)

The program is the infamous source of the low-middle-high performance assessment tool. And what a handy tool it is...for determining not so much the worth of employees as their allegiance to corporate authority and their willingness to agree with and align their own interests with managers and administration, even against their own ethics and best interests.

Fully 75% of the assessment tool in this program is subjective! Questions like, how much does this employee accept and support the decisions of his/her managers? How comfortable do I (the boss) feel when this employee is on shift? What is the attitude of the employee toward his/her workplace, manager, administration?

Now, if ours was a totalitarian organization, I could see where these questions might truly reflect the value of an employee. Or at least ferret out those who need to be eliminated. But, let's be honest, these questions have very little to do with how well an employee does his/her job!

Objective questions could do that, and would be easier to defend as a true performance assessment, while keeping the subjectivity of like and dislike out of it. Why wouldn't a health care organization that wants to provide quality nursing services be more interested in how well nurses perform rather than how well they mouth the words of the corporate line (for they really don't want nurses to say anything)?

One reason is that an assessment tool of objective criteria of nursing performance is harder to devise than one based on subjectivity. You can't really get it out of a guru's book, and I'm not sure that they are smart enough to do it themselves.

A second reason has more to do with the manner in which the subjective assessment tool can strike fear into the workplace of those who have it used capriciously against them (see the most recent two entries). No objective criteria to tell me I'm a bad nurse? Just tell me I have a negative attitude! That's a great reason to fire a good nurse, despite this era of nursing shortages.

Of course, as I mentioned in the last entry, the low-middle-high assessment tool is a one way street: those at the top evaluate those underneath them, and never have to be evaluated by them. That means, the top dog is the one whose attitude and belief system is what everyone else in the organization has to agree with or at least espouse, at least at work. But the top dog isn't the pope, doesn't wear a funny hate, and isn't infallible. Excellence hardwired doesn't seem to account much for that fact.

And, if you're not the top dog, don't go mentioning it; you'll be labeled a low-performer.

Labor Remembers (For P.R.)

2008-06-06T21:51:00.000-07:00

On a more somber note, the same administrative players who attempted to terminate me turned around and did the same number on my boss, the ER director. Oddly enough, one of their complaints about her, what they say made her such a "low performing" manager, was that she failed to leave a paper trail long and deep enough for them to fire me without fear of a wrongful termination lawsuit.

Of course, they didn't say it in so many words.

The fact that both events occurred within the same week and the fact that it was the CNO's last week of employment in the organization suggests to me that both were attempted hatchet jobs. The fact that the CNO chose her last day and her last two hours of work to attempt to discipline my ER boss suggests that she (the CNO), and not my boss, had done her job poorly.

Think about it.

You are the Chief Nursing Officer in an organization, the tallest hog at the RN trough, and yet you tolerate and fail to reprimand two "negative" and "malcontent" nursing employees for almost two years, waiting only until your last week on the job to do anything about their "divisive" behavior? Talk about a bad manager! Low performer, indeed!

But Idaho is a "right-to-work" state (read: right to be fired at will for any reason at all) and so I guess you don't have to be good at managing or administrating in order to fire an employee any time you want to, regardless of whether or not you've followed your own organizational policies (which, in fact, in my case, they didn't). Power seems to be the administrative remedy for lack of competence, finesse, or adherence to organizational rules.

My boss and I took different paths, however. I chose to fight back and keep my job. My boss chose to tell the CEO (for the CNO had already cut and run) to take the job and their evaluation of her and shove 'em.

I respect her for that, and for sticking up for me when she did. Just goes to show, the ethical aren't always the winners, and those at the top who think they've won aren't always ethical, or winners.

In fact, if I had to rate their administrative performance, I'd say they're pretty low performers because they really made a mess out of this. Not only am I still an employee, but now the ER is in shambles for lack of a director. Makes me wonder who is the greater threat to the organization's ability to meet its stated goal of quality and compassionate health care.

Nursing Interventions for Corporate Amnesia

2008-06-01T11:00:00.000-07:00

"I am not a critical person by nature."

I said this a lot when I was in graduate school studying sociology. My friends noticed about me a propensity to be hyper-critical when it came to examining the hypocrisy and unfairness of power structures. In saying this about myself, my point was that it is not natural to be so critical...one has to learn the skill. I learned it well.

No longer a social scientist by trade, I have not been able to shake off the critical legacy of those years. Even as a nurse, when faced with bureaucracy, hierarchy, and corporatism, I tend to revert to my sociological underpinnings to reveal the negative aspects of these realities in my workplace.

Others around me--nurses and administration--don't seem to understand this, and I am not sure why. Wouldn't my nursing and my understanding of the organizational context within which I do it be different if I brought to it a different background: literature, law, mortuary science? Of course.

In short, some don't understand why I think about such things. More specifically, administration does not understand why I, as a nurse, think at all.

Recently, I was fired. Ostensibly, the reason for the termination was said to be "insubordination," a euphemism (in my opinion) for having a different opinion.

In fact, the reasons stipulated on the disciplinary action plan that they eventually agreed to after tempting me to voluntarily resign rather than face termination, had more to do with subjective interpretations of my words and attitudes than they do any objective assessment of my nursing skills, performance, or any realistic "threat" I present to the administration or the organization, in general.

Ironically, the overall attitudinal problem they seem to think I have is that of believing the organization is divided into two main groups, nursing staff and administration, and that when problems arise, this division often plays out as a "them versus us" scenario. Ironic because the very concept they accuse me of believing and espousing (at times) is the reality they were using to try to eliminate me as an employee!

As Yosarian said, "That's some catch, that Catch-22!"

Okay. Am I a member of the same bureaucratic organization as they are? Does the same hierarchy of power exist in their world as mine? Does one's position--them on the top, me/us near the bottom--really blind one to an understanding of the nature of authority and the perceived inviolability of command?

What dream world do they live in?

I once heard--and I think E. P. Thompson, the famous English labor historian originally said it--that the real difference between owners and workers, between corporations and labor unions, is that the latter have memory while the former exhibit selective amnesia. In corporate hospital culture, even though in this case it is a non-for-profit corporation, the same is true.

How else to explain how the CEO and CNO can tell me I'm fired one day and then several days later confront me with smiles on their faces, wanting to chat about how things are in my life? If they are just trying to save face, I wonder what sort of face they see in the mirror.

Call it my negative attitude, call it my dark humor, call it my knee-jerk reaction to authority. But don't sweep it under the rug! Challenge me, make me explain myself, TELL ME I'M WRONG!!!

No. It's easier for them to say I'm rude or sarcastic...so much easier than saying I'm mistaken, or wrong, or a bad nurse.

What is the cure for this corporate amnesia? Learn to be critical, learn to be honest, learn to speak truth to power. That's what I've tried to do with my life. I did it when I was a social scientist; I'll do it now as a nurse. For I didn't leave everything behind when I became a nurse.

Wonder why they don't understand this?

Follow-up Care

2008-05-08T17:04:00.000-07:00

The other day a former-ER patient called and asked for Ed. I told him that there is no one named Ed who works in the ER.

He seemed confused and flustered. He also sounded intoxicated.

Often, patients call to follow up on discharge instructions, or to ask questions about what they are supposed to do next to take care of themselves.

So, I asked the patient the nature of his call and the nature of his original complaint, and I attempted to verify whether or not he was taking his prescribed medications properly, one of which was a narcotic pain reliever.

After speaking with him for about five minutes, I realized that he was taking about twice as much pain medication as he should have been. He admitted to drinking alcohol as well, something I immediately advised him not to do while taking narcotics. Then I reiterated that he should not drive or operate machinery, given the potentially dangerous combination of intoxicants he was taking.

Eventually, I had addressed as many of his issues as I could over the phone and I told him if he felt he needed to be re-seen by an ER physician we would be glad to see him again.

He replied, "Thanks. Are you sure Ed isn't there?"

"Sir, I've already told you there is no Ed in our department. Who told you to ask for Ed?"

"It's on my discharge instructions...If problems persist, call Ed."

Silence.

"E-D, sir. As in, Emergency Department."

Types of Patients XI: Animal Bites

2008-04-21T16:38:00.000-07:00

I've already mentioned the mandate that ER nurses notify law enforcement when we have reasonable suspicion that a crime may have been committed. As well, a reader's comment mentioned the interest of public safety in such reporting. This is never more true than in the case of wounds caused by animal bites.

Regardless of whether or not an animal bite constitutes a crime, reporting such events to law enforcement or to public health is essential to avoid the possibility that a menace to public safety is left unchecked. The menace might be a mean dog (provoked or not), a feral cat, or (and, yes, I have seen this) a vicious squirrel, etc.

The purpose of mandatory reporting of animal bites is not punitive; it is to improve public safety. Whereas cases involving pet owners (e.g., pet dog bites passing neighbor) may seem to be predicated upon sanctions--for the owner and the pet--in fact, very few responsible pet owners are prosecuted if they do the right thing by their pet and by the public (i.e., up-to-date vaccinations, payment of damages, hospital expenses, etc.) and few end up losing their pet.

Irresponsible pet owners suffer more. These are the owners who don't vaccinate their animals, don't attempt to train them, and usually don't put much stock in animal restraints. In fact, some owners of this ilk actually intend to produce vicious animals mostly for the purpose of protecting property.

Mandatory reporting does not require that I as an ER nurse investigate or understand the reasons for the incident. I leave that to law enforcement. As I told one dog bite patient who didn't want me to notify the police about the neighbor's dog that attacked him because he thought it was his (the patient's) fault: "What if you were a four year old child?"

And I've seen four year old children scarred for life in just this way. I do not pretend to know that it is somebody's fault. Many of these incidents are, in fact, accidents. Mandatory reporting intends to minimize the repetition of such "accidents" in the same way that mandatory seat belt laws intend to save lives.

The ABCs:

A -- Most animal bite victims have injuries to extremities; therefore, airway is usually not a problem.

B -- For similar reasons, breathing is usually not an issue either unless there exists some sort of co-morbidity, such as asthma, attacks of which can be exacerbated by the intensity or ferocity of the animal attack.

C -- But bleeding can be an issue. Like other bleeding injuries, animal bites require direct pressure to stop bleeding. Tourniquets are ill-advised unless used as a last resort.

Animal bites also require copious wound care. Wound irrigation. Closing the wounds either by sutures, staples, steri-strips, or occlusive dressings. And antibiotic administration (either oral or IV) to prevent further adventitious infections.

And lastly, because animal bites represent a disruption in skin integrity, tetanus vaccination status must assessed, discerned, and updated if necessary.

No one likes being bit by an animal, domestic or wild. And very few pet owners like to hear that their pet bit someone. I don't really like reporting such incidents to law enforcement, but I do because I realize it might be my child next time, and the bite might not be so very innocent.

Deathday?

2008-04-10T19:00:00.000-07:00

Why does our society not have a specific term that refers to recognizing the anniversary of a person's death?

Anniversary generally refers to marriage. Birthday, of course, refers to just that. But we have no term expressing our commemoration of the day a person died.

Perhaps it is because death is sad, and we don't want to acknowledge our sadness over someone's death in a public way year after year, as we would celebrate birthdays and anniversaries.

Perhaps it is because death is fearful, and recognizing the passing of others on a yearly basis in a public way reminds us too much of our own mortality. But some other cultures do. The Mexican Day of the Dead is a very good example.

Perhaps it is simply the harsh, guttural alliteration of a term like "deathday."

To be sure, it is not a festive event to memorialize the day a loved one left this world. But it is fitting and respectful.

Today is the deathday of my friend and co-worker, A.R., in 2001. I want to always remember this day and all the days before that I knew her.

HEC

2008-04-09T11:01:00.000-07:00

With all the acronyms and CorporateSpeak in the health care industry these days, I sometimes wonder if any of us health care workers will ever speak in plain, unabbreviated English again. From the look of the work place project in which I am now involved, it doesn't seem so.

Our ER is preparing to change from a paper-based patient charting system to an electronic medical record (EMR). The project is called HEC (Healthcare Electronic Charting), and the program template that has been presented to us by the corporate provider (to remain nameless for obvious reasons) is filled with acronyms and some very bad grammar. The corporate representatives (I call them THEM) don't seem to be bothered by this.

Both of these facts, that the template is so poorly written AND that the corporate people don't seem to care, infuriate me. Together, THEM and a group of my co-workers and I spent two days looking at the template, THEM doing their corporate slap and tickle and me getting more and more frustrated the whole wasted time.

When I was a college professor (see entry 8/25/2007) I was sometimes confronted by students who did not think I should correct their spelling, grammar or punctuation because, after all, "this isn't an English course." Apparently, I was one of those mean, unreasonable professors who demanded students be as accountable for the accuracy of their expression as for the quality of its content.

I'm finding similar problems in the HEC project.

The most important issue I see in contemplating and preparing for a change from paper to computer charting is whether or not the electronic medium will improve charting. Two subcategories of this issue are efficiency and quality, and therefore, two questions need to be answered positively.

1) Will electronic charting increase the ease and speed with which charting is accomplished and a completed chart generated?

2) Will electronic charting improve the quality of charts in terms of accuracy and precision?

It is interesting to consider technological development in health care for a moment. Some technologies accomplish the former (efficiency) without affecting the latter (quality). Dictaphones are a good example. Doctors can dictate their charts easier via the device, but the quality of the dictation is only as good as the doctor's ability to communicate.

Other technologies can do both. Automatic sphygmomanometers (blood pressure measurement devices) enable nurses to take successive blood pressure measurements easier (i.e., remotely) and more accurately because of the elimination of subjective differences among human operators.

Will electronic charting accomplish both?

Given what I've seen of HEC, the system has tremendous potential to increase efficiency. Potential. What has to happen is THEM have to stop their corporate mucky-muck yucky-yuck and begin to examine the work methods and rhythms well-established in our ER, what THEM call "nurse work flows" (and I wonder if the mean "floes?"). So far, this has happened minimally, and when I called this to their attention, they looked at me as if I had two heads. Then, relenting a bit, responded in a shocked tone of corporate voice, "That's a good idea."

Glad I thought of it. When do I get paid?

However, also given what I've seen of HEC, I'm not certain that the program will improve the accuracy of charting. Call me anachronistic, call me a language Luddite, but I sense the electronic format THEM have provided us ruins the ability for nurses to express themselves accurately by constraining them to badly worded (and sometimes badly spelled) pre-established charting responses.

One small example.

The template allows us to indicate the Informant who provides the nurse with information about the patient. Informant. Singular. All of the response categories are also consistently singular with one peculiar exception: Parents. Why this is the only plural response category I have no idea.

Do THEM assume that when patients come in with Parent(s) that they always come in with both? In this day and age? Rampant divorce. Custody issues.

I requested that the response category be changed to singular or an S in parentheses be used, and allow the nurse to further indicate whether or not the Parent(s) is/are mother, father, or both. I even thought it might be important to indicate biological versus social parents.

I was told by THEM that the template could not be changed in this way at this time, but in the next version the change will be considered.

I cannot believe that I was they first one to raise such an objection!

Okay, it seems small, but the ramification is that we will be generating potentially inaccurate charts, charts that are considered legal documents! I can't imagine why any health care organization would willingly do this.

We'll see how things turn out. Until then, sitting in meetings with THEM, I feel like I'm really in HEC.

Soooo, the CAH-lege Kid says... (Part 2)

2008-04-08T16:59:00.000-07:00

There seems to be a run of female patients being brought in by friends or ambulance for problems related to over-indulgence in alcohol. Similar to the patient I reported on recently who couldn't believe that alcohol alone would cause her to be unconscious at her sorority, many of these are college-age women...

...like the female patient who returned today to find out about culture results from a urine specimen obtained the night she was brought in by the local police, drunk, an alcohol level of 0.17. I dutifully reported the results.

The young woman asked me if I could tell her the names of the officers who were with her that night. I told her we don't usually document that, but if she told me what they looked like, maybe I would know.

"They were wearing police uniforms."

I think drinking is the least of this college student's concerns...

+++

And for all those who don't believe that obesity is a growing problem (no pun intended), check out the recent article in the NY Times that discusses the need to build different EMS equipment to accomodate large patients...gurneys and ambulances designed to lift and transport patients up to 1600 pounds.

These devices usually cost about 40% more than regular equipment built to accomodate patients within a normal range.

If only obese patients were paying for this extra service, that would be one thing. But all of us pay via the increased cost of service equipment. This means that all of us are disadvantaged by other peoples' poor health and poor eating habits.

Just like with smokers. And I don't see anyone willing to pay more for Smoking versus Non-smoking ambulances!

HIPAA

2008-04-03T21:14:00.000-07:00

File this under "Don't blame the ER nurse..."

Frequently, we receive phone calls from people requesting information about patients. Usually it is someone who knows the patient--family, friend, co-worker. Other times it is someone who only has a passing interest--the good samaritan who brought the patient in, law enforcement officers, reporters from the local newspaper.

If the patient is present, awake, and able to converse, we transfer the call to the patient so they can give any information they choose. However, if this is not the case, ER nurses are bound by law to protect the privacy of the patient.

Some people don't understand this.

Once, I received a call from a person who identified herself as a patient's mother. She wanted to know why her son was in the ER, how he was doing, and if he was going to be admitted or discharged. The patient in question was drunk and unconscious, and an adult. Legally I couldn't tell the woman anything.

"But I'm his mother!"

People always say things like this, as if parentage trumps federal law. Who am I more afraid of, this woman or the feds?

ER nurses and others in the health care industry are restricted in the amount and type of information we can release about patients. The federal law that stipulates this is called the Health Information Portability and Accountability Act (HIPAA). Like most legislature "acts," HIPAA is verbose, complicated, and confusing, and has a misleading monniker. A better name would be "HIPPA: the Health Information Privacy and Protection Act".

The act does allow us to reveal the following. For a patient who is identified by name, HIPAA allows me to tell a caller whether or not the patient is in the ER, discharged, admitted to the hospital or transferred to another facility, and give a one word description of the patient's condition (e.g., critical, serious, fair, stable, poor, etc.)

That's it! It does no good to ask for more. People do, but I don't tell them. My stubborn refusal to do so angers most callers.

+++

Probably the most bizarre incident of not being able to disclose information about a patient that I've experienced occurred when a patient's wife called about 2 hours after he had been discharged. She asked the typical questions: why had he been in the ER, what did we do, and what should he do now.

Me: "We did have a patient by that name. He was discharged in stable condition."

Her: "I know. He's right here, at home. Why was he in the ER?"

"I'm sorry, ma'am. By law, because the patient is an adult, I am not allowed to disclose any other information to you without his expressed consent."

"But I'm his wife!"

"I understand that, ma'am. Allow me to suggest that you ask your husband why he was here."

"I did."

"And...?"

"He won't tell me."

"Won't tell you? And I'm suppose to?"

"Yes. I'm his wife!"

"You've already said that, ma'am. But I'm sorry. If I tell you any other information, then I will have violated your husband's right to privacy...AND a federal law."

"But I'm his wife!"

"I understand that, ma'am. What I'm asking you to understand is that that doesn't matter. I can't tell you anything else about the patient."

There was a long pause.

"But I'm his wife!"

"Yes, ma'am. Is there anything else I can do for you, ma'am?"

Soooo, the CAH-lege Kid says to the POE-lice...

2008-04-02T12:37:00.000-07:00

Drunken university students are a dime a dozen on weekend nights in our ER. Many are unconscious, some are abusive, and others are downright funny. Most blame their inebriation on their "friends" who plied them with drinks they don't even remember consuming.

Friends?

+++

When nurses treat patients whose condition or injuries suggest that a crime may have been committed (e.g., an assault, child molestation, etc.), we are required to report our suspicion (sometimes via our supervisor) to law enforcement, despite the fact that this may place us in an awkward or even adversarial position vis-a-vis some patients, especially those who would rather their injuries not be disclosed to the police or who would rather protect others from prosecution.

However, in the case of underage drinkers (which most of our drunken college students are) when we KNOW a crime was committed (underage drinking), we are not required to report this. In fact, because the drinking age is 21 but patients are legally adults at 18 and therefore accorded certain federal rights to privacy, we are not permitted to report a patient's drunkenness to police, the university or even to the patient's parent(s) without the patient's consent.

+++

Coincidentally, many underage drunken students are covered by their parent's insurance which ends up being charged for the ER service.

+++

An underage sorority sister called the other day to find out the details of her ER experience the night before when she was brought in by ambulance after being found unconscious in her sorority house. She wanted to know what tests were done and especially whether or not a drug test had been performed.

I felt sorry for her for several reasons. First, she had no recollection of the experience. Drunk is fun (maybe); drunk and unconscious is dangerous.

Second, we conducted multiple lab tests and very expensive cervical spine xrays and head CAT scans (because in her unconscious state, injury could not be ruled out any other way). Drunk is fun (maybe); drunk, unconscious, and requiring ER treatment is expensive.

Lastly, she wanted to know if a drug test was done because she suspected that someone had slipped her a drug that would explain her unconsciousness. I had to explain to her that, although a drug test was not performed and therefore foul play could not be ruled out, I was pretty certain that her blood alcohol content (BAC) could more than account for her unconsciousness.

Her ETOH (alcohol) level was 0.3...drunk three times over by state standards!

Triply drunk and unconscious with a huge ER bill. There's no crime in that?

To Thump or Not to Thump?

2008-04-01T12:00:00.000-07:00

In my comments on The Abyss back in September, 2007, I suggested that misconceptions people have of medical interventions for serious medical problems are often reinforced by the misrepresentation of these in movies and television.

Viewers believe what they see. Therefore, they believe things like patients in asystole (the proverbial cardiac flatline) can have their hearts "jump started" with defibrillation; that many patients spontaneously revive with just a few seconds of CPR; that long large needles pre-filled with epinephrine are often stabbed right into a patient's heart when it stops, etc.

In cases of sudden collapse with suspected cardiac arrest, one misrepresentation seems ubiquitous in movies and on TV (and occurs in a recent movie with Morgan Freeman and Greg Kinnear, entitled Feast of Love): the fist strike to the patient's chest, often accompanied by medical personnel jumping onto gurneys and straddling the patient, etc.

Otherwise known in medical circles as a precordial thump, this practice was a component of early Cardiopulmonary Resuscitation (CPR). The theory was that striking the sternum could produce a mechanical shock to the heart that would instigate a spontaneous rhythm. The practice has since been discontinued because it was found to be highly ineffective and more likely to injure a patient who was mistakenly thought to be having a heart attack.

In the movie mentioned above, a young male character collapses during a friendly football match. When he does not arouse, several people run to his aid including a female character who we know to be an emergency physician. In my willing suspension of disbelief concerning Hollywood portraying resuscitation attempts accurately, I actually thought the doctor might follow the ABCs for resuscitation. But what did she do? THUMP! THUMP! What happened? The patient regained a pulse!

Well, I won't spoil the movie and tell you what happens thereafter, but I'll point you in this direction:

http://www.nytimes.com/2008/04/01/health/research/01heart.html?nl=8hlth&emc=hltha1

If you witness someone collapse, don't be a movie star. Don't thump the patient. Just follow the ABCs. Call 911. Then...

Does the patient respond? Yes? STOP No?

Check the patient's Airway. Obstructed? Open the airway. Unobstructed?

Is the patient Breathing? Yes? STOP and wait for EMS. No?

Does the patient have Circulation (a pulse)? Yes? Reassess A and B. No? Press hard and fast on the lower portion of the patient's sternum until EMS arrives.

No Hollywood, No Heroics. Just the common sense of ABC.

RN, LPN, BSN...Hike!

2008-03-21T23:00:00.000-07:00

A recent article in a Idaho newspaper described the education of a smalltown mayor as including a "registered nursing degree." Aside from being a political non sequitor, this strange piece of information illustrates the widespread misunderstanding about nursing education and licensing. In fact, a registered nursing degree does not exist!

Like many professions, working as a nurse requires both completion of an accredited educational degree as well as passing the state board exam for the purpose of being licensed. Achieving the former does not necessarily mean obtaining the latter. However, obtaining the latter requires the achievement of the former.

Clear as mud? Okay, here:

There are four types of nursing degrees. There is the "gold standard" Bachelor of Science in Nursing (BSN) which is fast becoming the "entry level" nursing degree required for obtaining a nursing-related job in most states. A BSN is like any of bachelors degree in the sciences and requires four years of college-level education.

Another common degree is an Associate Degree in Nursing (ADN). This degree is a two-year degree focusing on the brass tacks of nursing (i.e., clinical skills) and eshewing the more esoteric ancillary courses typically included in a traditional four-year college program (e.g., nursing management, health care finance, etc.).

BSN and ADN graduates are eligible to take the state board exam to become licensed as Registered Nurses (RNs), so-called because they become licensed by the state (registered) to practice as a licensed professional nurse.

Alternatively, with a lesser amount of education, one can obtain a licensed practical nurse (LPN) license. The scope of practice of an LPN is more narrow and restricted and LPNs are not very prevalent in the profession as a whole.

Does a BSN or ADN have to become licensed? Only to work as a nurse. In essence, becoming an RN is no more necessary than becoming a CPA after obtaining a bachelors degree in accounting!

Two other nursing degrees, Master of Science in Nursing (MSN) and a Doctorate of Nursing (PhD) also exist, as well as several "advanced practice" state licenses. Advanced practice nurses have MSNs in a particular field of nursing and may become licensed/certified in that field. For instance, those who obtain MSNs in anesthesia programs may become CRNAs (Certified Registered Nurse Anesthetists) and those who obtain degrees in midwifery may become CRNMs (Certified Registered Nurse Midwives), etc. Nurse Practitioners (NPs) are Advanced Practice Nurses with MSNs.

My point is, a nursing degree and a nursing license are two different, mutually exclusive accomplishments. Don't assume an RN has a bachelor's degree, but equally, do not assume a BSN has a license!

The Immaculate Infection

2008-03-12T18:20:00.000-07:00

I wasn't surprised by the recent news item that reported a study showing 1 in 4 teenage females between the ages of 14 and 19 have a sexually transmitted disease.

I wasn't surprised by the apparent fact that the rates of STD infection are highest among African-Americans and Mexican-Americans.

What surprised me was that the majority of the female subjects with STDs in the study denied ever having sex!

Apparently 1 in 4 teenagers have an STD, but 1 in 2 suffer extreme denial! Might be how they come by the STD in the first place.

Types of Patients X: Alcohol Detox

2008-02-19T09:58:00.000-08:00

Despite (or maybe because of) its status as a legal drug, alcohol consumption is nearly culturally universal, as is addiction and abuse, and the health complications of alcohol use occur across the lifespan.

Although recent research has shown that certain races and individuals with specific genetic profiles may be predisposed to alcoholism, defined as physical dependency upon ethyl alcohol (ETOH), the social and psychological aspects of alcohol addiction exist in all races and cultures.

As well, whereas legal consumption of alcohol is restricted in most societies to certain age groups, the negative health consequences of alcohol use effect all age groups. From alcohol-related accidents to fetal alcohol sydrome (FAS) to liver disease, etc., alcohol consumption, excessive or not, results in untold costs in terms of lives and health care dollars.

One group of individuals often ignored when we talk about the effects of alcohol addicition and abuse is, ironically, the addict. News stories and statistics usually track the unintended victims of abuse--sober accident victims, infants born with FAS--but addicts themselves are usually blamed for their problem and therefore the negative health effects of alcoholism upon them are usually assumed to be chosen, inexcusable, unnecessary...ultimately, a drain on the health care system.

For this reason, alcoholics seeking treatment for alcoholism present a challenge of compassion to ER nurses. Usually we treat patients whose injuries or illnesses are unintentional. With alcoholism, we treat an illness that is the result of the patient's volition. Other illnesses are similarly the result of individual's choices--smoking and lung disease, obesity and just about everything else!--but addiction to alcohol (or other drugs) seems a less sympathetic and more dangerous consequence of an obnxious habit.

I focus on the physical aspects of alcoholism and the nursing interventions necessary to protect the patient seeking detox from the untoward side effects not of alcohol abuse but of the detox process, itself. Attention to the psychological aspects of alcohol abuse and addiction is a more proper intervention while the patient is inpatient, not in the ER. Therefore, aside from supporting the patient's decision to seek detox, I leave philosophical and psychological discussions out of my nursing care.

A-B-C-Ds. Not hard. Usually patients seeking detox are functional, at least from the standpoint of body functions.

However, in the secondary survey (a nursing assessment that takes place after the primary ABCs are assessed and intervened, if neccessary), the D indicates differential diagnosis and/or disability. Aside from the psychological difficulty of breaking a habit, there are potential physical dangers to the patient attempting detox. The initial intervention for these occurs in the ER.

Alcoholics are often relatively malnourished and the sudden cessation of drinking can induce biochemical changes with serious side effects. The most serious side effect is seizure activity. Relative deficiencies in various B-complex vitamins due to malabsorption, specifically Thiamine and Folic acid, predispose the patient to seizures.

Nursing, therefore, must intervene by administering these essential nutrients, usually via IV, and engaging seizure precautions: intravenous access, oxygen and suction supplies at the bedside, and the administration of a benzodiazepine. Usually lorazepam is used because it has both sedative/anticonvulsant as well as anti-anxiety properties.

The anxiolytic property is necessary to permit the patient to get beyond the physical effects (mostly euphoria) of alcohol intake that are often the source of compulsive drinking. The more anxiety the patient experiences, the more likely their decision to detox wanes. Successful detox, therefore, relies upon the transient use of a substitute drug.

Basic lab work is also necessary before the patient is admitted. Complete blood count (CBC), comprehensive metabolic panel (CMP), blood alcohol content (BAC, or medical ETOH), and a urinary drug assay.

The rest, of course, is up to the patient. I can treat detox patients but I can't ultimately detox them. They have to do that for themselves.

(Don't) Dial-a-Nurse

2008-02-12T11:02:00.000-08:00

One of the most frustrating aspects of working in an ER is fielding calls from people who want to discuss their symptoms over the phone and expect a diagnosis, home treatment plan, or advice about whether or not to seek emergency treatment. Sometimes these individuals are calling about themselves, but most often it is a parent calling about a child's symptoms.

Ostensibly, my hospital does not permit ER nurses to give advice over the phone. The reason for this is liability. If I gave advice to someone about symptoms I cannot properly assess in person, I run the risk of misdiagnosis or mistreatment or both.

Similarly, I have a 50/50 chance of recommending correctly whether or not someone needs to seek emergency treatment. If I tell them to come to the ER and they do and, in fact, they have an emergent condition, then I might be their hero. But when they are stuck with a bill for an unnecessary ER visit, I'm the villian.

And, worse, if I suggest that they do not have an emergent condition when in fact they do, perhaps life-threatening, and they don't come in, well...

The belief that it is easy to distinguish emergent or life-threatening conditions over the phone is the subject of this short (and scary, to an ER nurse) article.

www.nytimes.com/2008/02/12/health/12magn.html?_r=1&th&emc=th&oref=slogin

Regardless of my hospital's policy, the administration continues to publish the ER's phone number against our requests and will not allow us to have a phone message to answer as many other businesses, doctors' offices, and health care agencies do (a message that usually begins, "If you have an emergency, hang up and dial 911..."), claiming that such a message is too impersonal.

(Ironically, the only department in our hospital that has such a messaging service is Human Resources!)

How do I negotiate this mine-field?

I try to put myself in the caller's place and tell them what I would do if I were experiencing or witnessing the symptoms they are relating to me. Telling them what I would do if I were them or if it was my child strikes me as offering an informed opinion, not advice, and is a reasonable way to communicate what I think but ultimately leave the decision up to the caller.

They should just be happy I don't give them my mother's stock advice: "It'll be better in the morning."

Nursing Compliments

2008-02-02T11:00:00.000-08:00

Recently, I completed a recommendation letter for a fellow nurse who is applying to a graduate program in trauma nursing. She wants to become a Clinical Nurse Specialist, similar to a Nurse Practitioner. I've known her for awhile, like her, and thinks she's a good nurse. It was not hard to think of a few good things to say.

But I didn't just want to say "good things." I wanted to say the best thing!

Thomas Merton, a Trappist Monk, once wrote, "Build a chair as if for an angel." His meaning was clear. If you are going to produce something, do it in the best way and for the highest good you can imagine.

Writing a recommendation letter for someone is tricky business. You don't know who will read it. Who are the members of the selection committee? Is there a selection committee? Will the reader be a sticky organizational bureaucrat, or is there room for creativity, levity? Knowing these things is important if one is trying to say the best thing for the circumstances.

I erred of the side of saying the best thing I could say regardless of the circumstances. Along with all the hagiographic blah blah blah, I simply wrote: "I would have no difficulty entrusting Ms. (Nurse) with my patients, with myself as a patient, or with any of my family members as patients."

Certainly the highest compliment one nurse can bestow upon another.

Hospital O'Hare

2008-02-01T17:33:00.000-08:00

I've been a nurse for awhile, and after a few years, like any other job, I've exhausted the opportunity for new and unique experiences. Most of what I do everyday on the job is like what I do every other day on the job. As monotonous as that sounds, at least these ordinary experiences are fun and interesting to me.

That said, I experienced a "first" a few days ago.

When I started working as a nurse, I was on a medical-surgical unit. This is the main nursing floor in most hospitals, a place where patients stay for awhile, either with an illness that is not quickly treated or after surgery, recovering.

What I liked about this sort of nursing was the familiarity of patients from day to day. Often I would have the same four or five patients for days at a time. The length of time I had with them allowed me to build reporte, often finding out more about their ordinary lives, their likes and dislikes, what made them tick. This amount of time also gave me a greater opportunity to influence their thoughts about health habits and how they might change their behaviors to encourage and maintain maximum health.

But this consistency also had some draw backs, the most depressing of which was taking care of really obnoxious patients for days at a time.

In the emergency room, however, I see patients for maybe a couple of hours, half a shift at most (6 hours). This means I see more patients and a greater variety of patients in each twelve hours I work. The trade-off is I also have less opportunity to chat, figure them out, influence their health-related choices.

Not so the other day.

The other day I received report on a patient from the night nurse--the patient had arrived at 0545--and I duly reported off on the very same patient to the very same night nurse twelve hours later. In all, the patient spent fifteen hours in our ER, long enough to develop new symptoms that she hadn't even come in with! That was a first for me.

I attribute this to a scatter-brained, passive-aggressive ER doctor, an internist by training who has no sense of time-management and who has to fix everything about a patient (and sometimes their families!) This doc had patients circling for hours that day--my patient wasn't the only one--like "Discharged from ER" was a busy airport where patients couldn't land. I've seen worse up-in-the-air at O'Hare!

And it was an overtime shift for me...

Fact, Not Fact: Statistics By Any Other Name

2008-01-31T14:28:00.000-08:00

I received this tidbit yesterday. Proof-positive that whereas statistics don't lie, people can lie with statistics.

"Guns don't kill people, doctors kill people!

"According to the U.S. Department of Health and Human Services, there are 700,000 physicians in the United States. The number of accidental patient deaths per year is 120,000. Therefore, accidental deaths per physician is 0.171.

"According to the F.B.I., there are 80,000,000 gun owners in the United States. The number of accidental gun deaths per year is 1,500. The number of accidental deaths per gun owner is 0.000188

"Statistically, doctors are approximately 9,000 times more dangerous than gun owners.

"NOT everyone has a gun, but almost everyone has at least one doctor. Please alert your friends to this alarming threat.

"Ban Doctors, Not Guns!"

Okay, so it was sent to me tongue in cheek, but many similiarly ludicrous ideas about safety are based on similiarly silly statistics.

Like this one: You're safer flying than driving because statistically there are more car crash fatalities per year than fatalities in plane crashes. Fact is, the average person travels in a car far more often than they do in an airplane, therefore the likelihood of being in a car accident is much higher. In fact, also, it is far more likely that one will survive multiple car crashes, whereas surviving an airplane crash is far less likely.

Or this one: You're safer not getting a tetanus immunization shot because statistically you're more likely to die of an anaphylatic reaction to the shot than you are of tetanus infection. Fact is, the reason more people die from the shot than from tetanus is not because the shot is more dangerous, but because tetanus infection is rare due to widespread immunization. However, the likelihood of surviving anaphylatic reactions is far greater than surviving tetanus, which, if you get it, has a survival rate of almost 0%.

And if one more person tells me that you're safer in a rollover accident without your seatbelt on because you're less likely to get stuck in your crushed or burning vehicle...

Types of Patients IX: "Bad Babies"

2008-01-26T12:32:00.000-08:00

A touchy subject.

Yesterday, I accepted the care of a 53 day old female with respiratory distress. There is nothing more frightening to me as a parent and as an ER nurse than a baby that can't breathe or isn't breathing well.

As a parent, I recall a time when my infant son choked on a small cracker, and how the minutes he did not seem to be able to breathe shortened my life, I'm convinced, by years.

I recall, too, the several times I have had to resuscitate him when he did not regain spontaneous breathing after having seizures.

There is nothing worse than a child who will not breathe!

As a nurse, flashes of parents' hopes for their child as I care for him or her rush through my head and I realize that I am somewhat the keeper of these. I also become entrusted by the parents as easily, it seems, as one would entrust their poorly running car to a mechanic. I do not want this responsibility, but by virtue of my training and career, I have tacitly agreed to accept it.

Okay. ABCs.

A. Baby's airway was patent but compromised by mucous and secretions from what we suspected was respiratory syncytial virus (RSV), a viral infection of the lungs and airways of children primarily less than 1 year old. It is a common source of bronchial infection and pneumonia in infants.

Attend to positioning, initiate suctioning, both with a bulb syringe and wall-mounted vacuum suction via a Delee suction device, stimulates baby to breath as well as helps keeps baby's airway clear. Check.

B. As already noted, baby's breathing and oxygenation were poor. Respiratory rate was in the 80s-90s (normal values are in the 40s-50s) and oxygen saturation (a less than completely accurate measure of tissue perfusion, i.e., how much life-sustaining oxygen is getting to the organs and tissues) was approximately 88% (normal is 97%-100%).

Provide supplemental oxygen. But for a small infant this isn't the easiest intervention. Nasal cannulas and infant oxygen masks are notoriously less than effective. What is needed is an environment completely rich in oxygen, like in an incubator. We don't have this technology in the ER.

Thanks to our Respiratory Therapist (RT), a infant "hood"--a plastic dome, sort of like an astronaut's helmet, with a cut-out for the neck and sliding access panels--was placed over the baby's head as she laid on the pad of the baby warmer, a special device for infants that is no more than a treatment table with a warming light over it and oxygen tanks and suction canisters attached.

Check.

C. The baby's heart rate was in the 180s (normal is 130-140s). Increased heart rate is, in part, a compensatory response to poor oxygenation and dehydration, a condition that increases when babies are sick. If tissues aren't receiving enough oxygen, the body will attempt to increase oxygen supply by passing more blood through the tissues. To do this, the brain stimulates the heart to beat faster. However, when the heart beats faster, more oxygen is consumed by the heart and the muscle begins to tire. And so, a vicious cycle ensues.

If intervention is too slow or inadequate, baby will literally wear herself out. With a heart rate of 180 and oxygenation of 88%, we were already "behind the eight ball" as a popular expression goes.

Supplemental oxygen is a good first step. Next, intravenous fluid boluses to increase the volume of fluid in the blood stream to off-set the effects of dehydration. Intravenous access also allows for easier drug administration.

Thanks to a Family Birth Center nurse, IV access was achieved within the hour of baby's arrival in the ER. Why didn't I do it? For the same reason I don't change the oil in my car...I can do it, but there are people who specialize in this sort of thing. Part of being an ER nurse is the wisdom and foresight for judicious use of resources. FBC was my resource in this case!

Circulation, check.

There is a D as well (ABC,D): Differential Diagnosis.

We suspected RSV but other conditions could cause what we were seeing. Cold-stress is another possibility. Hypothermia forces a baby to increase heart rate and breathing in order to maintain body temperature. Assessment: In fact, baby's initial rectal temp was 95.4 (normal is, of course, 98.6). Intervention: warm baby up. Using the baby warmer is standard. Warmed IV fluids helps. A special infant chemical-warming pad was also used.

Hypoglycemia is also suspected. Low blood sugar reduces metabolism; reduced metabolism decreases body temperature. No fuel for the fire. Assessment: Baby's heel stick blood sugar was 66, normal. Intervention: IV glucose (if necessary).

Check.

For three hours, we (RT, the FBC nurse, and I) attempted to improve baby's breathing, all of us, baby included, suffering through pronounced and prolonged apneic periods during which baby would stop breathing for up to 7 and 8 seconds at a time. I began to wonder from which episode baby would not recover, requiring a resuscitation effort, the survival rate of which is low.

I don't pray, but I have wishes. I wished that it wouldn't come to this.

Eventually, we transported baby via helicopter to a pediatric emergency room and, I assume, NICU (Newborn Intensive Care Unit) at the nearest large hospital. Although I haven't heard, I assumed baby's prognosis is good.

I would be lying if I denied being relieved and happy that baby was gone and out of my ER. I know my nursing limits. Baby's condition was pushing and, in some ways, surpassing them. I'm not embarrassed to admit it.

We often joke among ourselves concerning triage that there are two categories of infants: good babies and bad babies. Nearly 97-99% of babies brought in by parents are of the former category. Most of these suffer from what we call PPP, piss-poor parenting. It's the other 1% or so that scare me.

My "bad baby" experience reminds me that, no matter what my demons, I need to be ever-mindful of my skills and abilities and the limits to these, and to swallow my pride when it comes to the health of a infant. I hope I did and will always do the right thing.

Health Care Rights (and Wrongs)

2008-01-23T11:00:00.000-08:00

Is health care a right? Should everyone in our society have access to health care? Should this access be free? Equal? Or, should it be based upon need, or an individual's ability to pay, or some other category of restriction (e.g., the relative contributions people make to society)?

These are the fundamental questions about health care that we, as a society, have not yet fully addressed. Currently, our health care system functions upon a sickly jumble of half-answers.

It is easy to say that everyone has a "right" to health care, but very few absolute rights exist. Most rights are accorded with exceptions or with responsibilities and obligations placed upon the recipient. (More about obligations and responsibilities another time.)

What are the exceptions to an individual's right to health care? In our society, most exceptions concern the nature and extent of care one can expect.

By virtue of EMTALA, all individuals regardless of ability to pay have a right (see entry of 9/3/07) to a medical screening in an emergency room of a facility that participates in the federally-funded programs of Medicare and Medicaid to determine whether or not s/he is experiencing an emergent condition requiring treatment and/or stabilization and transfer. However, one does not have a right to demand certain treatments or interventions, even if another person may receive these.

In essence, one has a right to treatment for emergencies, but one does not have a right to an MRI for a headache, or a bone scan for "brittle bones," or a heart/lung transplant for organ failure.

Just as one has a right to free speech, one cannot utilize this right wherever and however one wishes. There are restrictions and exceptions.

In the emergency room, what is prudent and customary care for the condition a patient is experiencing and not simply the patient's ideas and desires or even their ability to pay, determines the sort of care they receive. It is the right of the patient to have what is prudent and customary (sometimes called the "standard of care").

But this is not a right transferable to the private sphere of health care. Just because one has a right to such treatment in the ER doesn't mean they have the same rights at the local Family Medical Clinic, or Dr. Joe's, or even at for-profit, privatized hospitals. These services can be exceptions to the right of health care.

In fact, one of the reasons ERs are often saturated with individuals who are un- or underinsured is because physicians and other clinicians in private practice aren't obligated to fulfill an individual's right to health care. Many private practice physicians only accept patients on Medicaid as a small percentage of their overall clientele, and virtually none accept uninsured patients unless they have cash up front. This is sometimes referred to as The American Way.

What this effects is a two-tiered (actually, multi-tiered) system of health care in which privately insured individuals and those with retirement-age or disability-qualifying Medicare can usually access private health care, while poorer individuals who can't afford private insurance or don't work at jobs that are required to provide it (e.g., part-time, seasonal, small businesses, etc.) must rely on Medicaid or no insurance at all.

These latter individuals are those who the New York Times apparently has a problem with gumming up the ERs. Where else are they to go?

If health care is a right with exceptions and restrictions, then these sorts of problems are going to acutely inconvenience even those at the top of the system. However, I suspect these problems inconvenience those at the bottom more often, in fact, chronically.

Inject for-profit motives of private insurance companies, and these problems multiple precipitously. The system, the entire system, is in need of an overhaul.

Roe V. Wade V. Bush

2008-01-22T09:46:00.000-08:00

On this day in 1973, the supreme court issued a ruling that stated first trimester elective abortions were indeed legal.

On this day in 2001, President G.W. Bush signed an a "memorandum reinstating full abortion restrictions on U.S. overseas aid" (NYTimes). In other words, according to Bush, abortions were not permitted in countries receiving U.S. aid.

What was I saying about inequality when it comes to the U.S.-style "health" care?

What's in a Name (of a Disease)?

2008-01-22T09:17:00.000-08:00

http://www.nytimes.com/2008/01/22/health/22dise.html?th&emc=th

Apparently, much more than the disease itself. Although I am not so sure it's a good thing to have a disease named after you, I am sure it's better than being named after a disease.

And I have not done any research on the issue, but I am sure we could find in the history of medical research and development plenty of instances in which what we know now was, in part, generated by nefarious activities of clinicians and scientists. Some of these were members of the Nazi party; some were American scientists and doctors.

The institution of medicine is not immune to the same racism and sexism that plagues society in general (no pun intended), and often this is seen in the "naming" of conditions, procedures, or remedies.

Even one of the most honorable of health-related issues is subject to this: pregnancy and childbirth.

The EDC, which so many confuse for "estimated date of conception," actually is the acronym for "Estimated Date of Confinement." In other words, that time at which the baby will likely be born and the mother will be "confined" to a hospital bed for a week. Now, we know that this rarely happens any longer, that most new mom's go home within a day or two of an uncomplicated birth. But the term persists.

With multiple miscarriages, a woman hopeful of bringing a fetus to term may be labeled an "habitual aborter"! And with each miscarriage, unless there is a known cause, the failure of a conceived pregnancy is said to be a "blighted ovum". In other words, it's the woman's fault, when in fact there is no reason to suspect the ova over the sperm. But a male-dominated medical institution would hardly want to point fingers at themselves and their kind.

What's in a name? A name. But a load of other things that may bother people.

I hold to my original statement, and I'm glad my name isn't Anna Plastic Tumor.

Waiting for Goddarn Doctor (Part I)

2008-01-19T09:37:00.000-08:00

http://www.nytimes.com/2008/01/19/opinion/19sat3.html?th&emc=th

Whereas, in my opinion, the New York Times is right-on about the negative effects of two-tiered health care coverage--that emergency room wait times have increased thereby decreasing the speed with which the sickest receive necessary treatment--I disagree with the slant of the editorial, revealed in the first sentence, that these negative effects are mostly a problem because they inconvenience those who are on the top tier.

Let's face it, "insurance" is an immoral business. (It's called "protection" in the world of organized crime.) Corporations and individuals reaping huge profits from other individuals who fear illness and injury and the catastrophic costs associated with treatment. These same insurance companies more often than not hedge their investment by accepting only the healthiest clients or at least those who have the most ability to pay premiums, only to eventually deny claims for reimbursement at every turn until such a time that someone, often the court, makes them pay.

It is time for our society to eliminate the ability of a few to profit from the fear of illness or injury of the many. A single-payer, government-regulated system is the answer.

Dispatch Interpretations and Other EMS Debacles

2008-01-16T20:52:00.000-08:00

Emergency Medical Service (EMS) is an important component of any community's health care system. 911 dispatchers, EMTs (Emergency Medical Technicians) and paramedics, extrication teams, etc. are the individuals who, paid or otherwise, are responsible for ensuring that your medical "emergency" is taken care of.

Why the quotes? Because "emergency" is a euphemism for whatever a 911-caller says is an emergency. It is also whatever the dispatcher thinks is an emergency. Tremendous variation exists.

It begins with the interaction between caller and "dispatch," a group of EMS individuals with limited or no medical training who answer 911 calls--usually answering with the phrase "Police and fire." Dispatchers use latitude in interpreting the emergency nature of any particular call.

In our community there are five response levels for medical emergencies based upon the nature and/or severity of the emergency. These levels indicate to EMTs, etc., what sort of problem the caller is experiencing or witnessing, how serious it may be, and what sort of personnel and equipment might be necessary for a successful intervention.

An "alpha" response is a non-immediate transport of a patient for a minor problem or illness, or the transfer of a stable patient from one medical facility (e.g., nursing home, hospital, etc.) to another.

A "bravo" response is more serious and emergent. It is used for motor vehicle accidents in which unknown injuries may have occurred or for patients with undisclosed medical emergencies, whether injury or illness.

"Charlie" designates a serious emergent illness that is potentially life-threatening (e.g., chest pain, shortness of breath, severe allergic reaction).

A "delta" response may indicate a serious accident in which there are known injuries, a serious traffic accident requiring extrication of patients from vehicles, and/or a serious medical problem like uncontrolled bleeding, etc. EMT and/or paramedic assistance is necessary as soon as possible.

"Echo" response is reserved for problems requiring near-instantaneous attention, like an on-going resuscitation attempt by by-standers or the need for CPR. This response usually means someone is as close to being dead, either because of illness or injury, either this side or that side of death, as they can possibly be. Needless to say, echo responses don't usually result in successful interventions.

However, the amount of interpretation dispatchers employ in translating 911 calls into responses varies.

Some examples. Recently, four patients were brought to the ER by an out-of-area ambulance after it had been dispatched to a rollover accident. Initially, all of the individuals were assessed by EMTs and refused transport. After the ambulance had returned to its station, however, a second call went out for EMS response to the the same accident. Apparently, the "victims" realized they didn't have a ride home!

A woman calls 911 because her husband is bleeding. The woman, an ICU nurse, says to dispatch, "We need an ambulance quick! My husband's cut his arm and is bleeding from an artery." Serious? Perhaps...probably. But here is how it got called out:

"EMT Ambulance, Echo response for a hemorrhage, 41 year male, attempted suicide!"

Where that last part came from, who knows? The man had been working with a metal range hood that fell on him. Clearly, what is interpreted as an emergency, and what are the circumstances of the emergency, are as much affected by who makes the 911 call as they are by the 911 dispatcher who answers.

The Danger of Driving on Cell Phones

2008-01-15T20:24:00.000-08:00

A picture is worth a thousand warnings. Please do not talk on you cell phone while driving. As the popular bumper sticker in Seattle says, "Hang Up and Drive!"

On the Eve of Resolution

2007-12-31T17:12:00.000-08:00

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

2007-12-28T13:44:00.000-08:00

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

2007-12-26T14:20:00.000-08:00

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

2007-12-14T09:46:00.000-08:00

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

2007-12-10T12:08:00.000-08:00

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

2007-12-08T13:51:00.000-08:00

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

2007-12-05T13:15:00.000-08:00

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

2007-12-03T23:00:00.000-08:00

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

+++

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

2007-09-26T10:05:00.000-07:00

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

2007-09-17T13:24:00.000-07:00

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

2007-09-15T15:11:00.000-07:00

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

2007-09-13T12:16:00.000-07:00

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?

2007-09-12T09:06:00.000-07:00

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

2007-09-11T18:35:00.000-07:00

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

2007-09-10T09:01:00.001-07:00

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

2007-09-09T09:29:00.000-07:00

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

2007-09-08T09:00:00.000-07:00

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

2007-09-07T23:59:00.000-07:00

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

2007-09-07T08:58:00.000-07:00

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

2007-09-05T21:35:00.000-07:00

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

2007-09-05T10:41:00.000-07:00

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

2007-09-05T09:04:00.000-07:00

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

2007-09-04T21:31:00.000-07:00

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

2007-09-04T10:32:00.000-07:00

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

2007-09-03T13:40:00.000-07:00

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

2007-09-01T07:55:00.000-07:00

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

2007-08-29T13:29:00.000-07:00

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

2007-08-26T08:20:00.000-07:00

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

2007-08-25T14:02:00.000-07:00

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

2007-08-24T11:07:00.000-07:00

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

2007-08-20T16:13:00.000-07:00

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

2007-08-20T08:24:00.000-07:00

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?

A Matter of Perspective

2007-08-19T12:26:00.000-07:00

I am often asked, what is the difference between nursing and (to follow form) doctoring? It is an important question.

I first thought about the difference when in my 30s I decided to switch careers. I had been a kindergarten teacher (read: college professor at a major northwest university) and I thought about becoming a nurse. An acquaintance, a doctor, asked, "Why nursing? You're smart enough. Why don't you become a doctor?"

Ignoring her annoying condescension, I told her flat out, "Because I don't like doctors."

Now, a little older, mellower and perhaps wiser, I realize that this is not entirely true. What I know now is that I like what nurses do more than what doctors do. We often talk of doctors "practicing medicine" and refer to it as an "art," but we talk about "nursing" flatly as a verb, a noun, and an adjective. Doctors practice medicine; nurses do nursing.

Aside from the semantics, the main difference between being a doctor and a nurse (in my opinion) is best understood vis-a-vis the patient: doctors diagnose and treat problems; nurses address the plethora of potential responses patients have to the problem(s) they are experiencing.

A doctor diagnoses a malignant tumor, perhaps cuts it out or reduces it by radiation or chemotherapy. Clearly, it is the doctor against the tumor, and the doctor is successful in as much as the tumor ceases to be a problem.

But what of the patient's pain and fear; the occupational and family crises that result from a diagnosis of cancer; what of the alopecia (hair loss), anorexia (appetite and weight loss), the parasthesias and paralysis and the myriad other side effects of cancer treatments? Who "treats" these? In fact, nurses do.

Doctors cure illnesses and fix injuries; nurses do almost everything else. This is why more than 90% of a patient's care is done by nurses.

Ultimately, however, the total care of the patient is a team approach. This is why I've changed my mind about (some) doctors. In my ER, nurses and doctors work very closely together despite our differing foci and roles. We have a truly collegial relationship, and all for the good of the patients.

I didn't go to nursing school because I wasn't smart enough to be a doctor. I became a nurse because I was smart enough to know what I wanted to do, and that was to care for people, not just fix problems.

Let Sleeping Old Men...Sleep

2007-08-19T09:34:00.000-07:00

It is true that medical care, especially emergency medical care, is expensive. Although I don't know much about how much things cost, the rule of thumb I use to help potential patients estimate the cost of being seen in the ER is "at least $300 just to walk in the door."

Part of this is a facility's charge (the cost of maintaining the space and equipment of an ER and staffing it with nurses, aides, etc.) and another part is the professional fee of the physician. Invariably, people complain about their bills.

I am often asked by friends and acquaintances why their ER bill was so high. More times than not, of course, they came to the ER with a trivial complaint about a pain or injury that was not life-threatening but merely inconvenient and annoying. They easily could have seen their primary doctor, but they didn't want to wait a few weeks, days, sometimes even hours, to have their problem addressed.

"Don't you realize," I answer them, "that you came to the ER with a sore throat, but we have to maintain the equipment and training and skills to resuscitate you if your heart and lungs stop! Pharyngitis sounds like it should have a cheap fix, but you came to a place where we can literally bring you back to life if you die!" That has to be worth something.

This happens all the time. The extreme happened yesterday.

The ambulance ($300 right there!) was called out at 0710 to an unconscious patient at a local assisted living facility. The patient was a 89 year old man with a cardiac and diabetes history. Upon arrival he was pale and somnolent, but responsive to verbal stimuli. Blood sugar was normal, there was no external injuries, and he had no complaint of pain. After a couple of cups of coffee, he was alert, interactive, and managed to feed himself breakfast.

Diagnosis: Drowsiness, possibly related to abnormal sleep pattern.
Cost to Medicare: probably in the $500-$600 range.
Cost of a McDonald's Egg McMuffin Meal* with coffee: $3.29.

Clearly it is not emergency care which is expensive; emergency care for non-emergency conditions is expensive.

Let sleeping old men sleep. It's cheaper.

* Of course I do not endorse fast food as a healthy alternative.

Nurses Do It with Patience

2007-08-17T13:30:00.000-07:00

I know what you're thinking: Did he spell that right?

I did. In fact, I emphatically did!

Truth is, to be a nurse requires both patience and patients. To be a good nurse requires a lot more of the former, but a lot of the latter make it more interesting, albeit sometimes more frustrating.

Like most social statuses, a nurse can be defined in a variety of ways and in relation to various other social groups. Nurses are sometimes said to be care givers, healers, physician-lackeys, pill-pushers, even pill-poppers. Sometimes we are therapists, other times janitors, sometimes we are just the people who drunken patients spit on and curse.

Nurses vis-a-vis doctors might be understood differently than nurses vis-a-vis patients or members of the EMS (Emergency Medical System). It depends which side of the nurse you're on.

However you want to define the status, whatever roles you might assume nurses play in patient care, in nursing departments (e.g., ER, ICU, etc.), even in health care organizations and the national system (sic) of health care, there is one ubiquitous element of nursing: the essence is patience.

Nurses wait, and are required to understand the importance of waiting. We wait for doctors to write legible orders, for patients to finally confess their two pack-a-day habit or decide they'd rather have the enema than the pain of severe constipation, for EMTs (emergency medical technicians...those folks on the ambulance) to call in from the field to tell us how many patients we can expect from the head-on on the highway.

If nurses were not required to have patience, health care organizations would be poorer because people wouldn't utilize them; families would be burdened with the care of their own; and many sick people might be horribly misunderstood.

Odd that nurses need to have so much patience but doctors are not expected to have much of it. Compared to what nurses do, for doctors, health care is like McCare, WalMend. Patients want quick and easy diagnoses, quick procedures, and quick scripts. Doctors want to be in and out of patient rooms. Doctors, by and large, get paid by the patient--piece work. Nurses generally receive a salary or hourly wages. For nurses, patience pays off in ways it doesn't for physicians.

So, next time you see one of those bumper stickers "(blank) Do It with (blank)," remember where the nurses go, and that its patience, not patients.

Human Nature (as opposed to the other kind)

2007-08-17T10:49:00.000-07:00

What is it that encourages an emergency room nurse to want to share thoughts about the work he does? I suppose the same thing that encourages people to have children: the desire to see our tangible, and sometimes, irrevocable dent on the world.

It is true that most every profession is somewhat of a mystery to those who do not engage in it. Perhaps it is the mystery of emergency nursing--its mysterious language, tools, methods, etc.--that I would like to share. Perhaps it is the unusual situations I find myself in, the unusual patients I encounter during an average work day. Perhaps it is the all too common events--"accidents"--that damage and sometimes destroy peoples lives.

Perhaps it is just an impulse to try to dispel the effects of television. I have to do this in my job a lot. I thought I might do it in this space as well.

I want to make it clear at the outset that these opinions are mine and mine alone (of course, heavily influenced by the people and events around me) and are not to be confused with medical advice or information or official positions of individuals with whom I work or organizations for which I work.

Of course, I am open to suggestions and comments. Nurses are trained to listen well. Although I realize that blogs are not proper dialogues, I encourage you to share your thoughts and questions with me via this space. I will do my best to address them. As I say often in triage, "I am a nurse. What seems to be the problem?"

Oh, one more thing. If you are the sort of person who looks at or writes blog posts daily, you may be disappointed in my effort here. Whereas I usually have an opinion, I don't always have an opinion to share or time to share it. After all, I am an emergency room nurse.