ERnurseyERnurseyAn ER nurses blog. Stories are true to life, sometimes graphic, often humorous. Some healthcare policy. Articles
musings on illegal abbreviations
2008-03-26 01:30:00 JCAHO (I refuse to refer to them as THE JOINT COMMISSION as they now wish to be called) has spent God only knows how much time and how many millions of dollars developing a list of abbreviations which must never be used. Never mind that the whole point would be moot if doctors all had to use computerized order entry so you took their crappy hand writing out of the equation. How many times have you seen a group of nurses clustered around a chart asking each other "what do you think that says" and hazarding guesses? Multiple times every day. Some do make sense for instance trailing zero's. why write 1.0 mg? the zero is completely unnecessary and if the period is overlooked a ten time over dose will occur. Why would anyone write a number like that? It happens all the time. Or .5 instead of 0.5 - a hastily written decimal could be mistaken for a one. Those make sense.For eons medical personnel have used the abbreviation MS for morphine sulfate. JCAHO has determined we must nev... More About: Musings , Illegal
Gotta Have it NOW medicine
2008-03-24 00:55:00 I had a patient that came in today because they had been scheduled for a MRI which required insurance pre-authorization which typically takes a week or so.Instead of waiting a week they came to the ER so they could get an MRI, in fact, their complaint was "Need MRI."So, did the doctor tell them they didn't have an emergency and could wait for the outpatient MRI? Of course not.Is it any wonder that ER's are over-crowded? When did we become so afraid to say no? More About: Medicine , Gotta
Rectal Temps in Pediatrics
2008-03-22 18:52:00 A previous commenter suggested we stop doing rectal temps on infants and use tympanic temps.If you google this you will find myriad articles available on comparisons of different methods of obtaining a temperature on kids- Here is one of them. Temporal artery scanning is the worst then comes tympanic. I worked in a pediatric ER where we did our own study and typanic temps correlated to rectal temps in less than 66% of the cases, temporal artery scanning correlated less than 42% of the time.Rectal temps are the GOLD STANDARD of obtaining a temperature in neonates and infants. I would never take the chance of missing a temp in a septic kid even if it means the chance of getting splattered with baby poop. A little baby poop never hurt any one. More About: Pediatrics
Rivers of Baby Poop
2008-03-20 00:28:00 As we finish up the RSV season, we are no longer going through gallons of Albuterol - now we head into the spring season of Rotavirus . Little kids with rivers of liquid yellow poop. Poop that runs down their legs, poop that shoots out of diapers and poop that splatters the unaware nurse attempting to obtain a rectal temp. And they are all dehydrated and need IV's . Kids getting poked scream, poor things. Usually they are screaming more from being held down that the actual needle stick. It's not easy to put an IV into a screaming, wiggling, dehydrated kid. That means time bent over them with them screaming at full volume into your face. It also means wrestling with hot, sweaty angry kids until you are also hot and sweaty. I left yesterday with my head pounding from the continual onslaught of noise and my back aching from the constant bending.I'm very good at peds IV's so I do them a lot. I don't enjoy it, kids don't understand that you are doing the things you are doi... More About: Baby , Rivers
Taxes
2008-03-18 04:22:00 Please excuse me for a couple of days while I do my taxes which involves a lot of pain and suffering and Merlot. Be back soon. More About: Taxes
The End of the Code
2008-03-17 03:40:00 The patient arrested at home, family started CPR and EMS were on scene quickly, transport time was minutes but despite all efforts she did not survive. She was an elderly woman but had no real medical history to speak of and had always been in good health.I went with the doctor to the family room to deliver the bad news. The family was devastated, especially since they had lost their father, her husband of 63 years, just a month ago. Ever since he died, they told us, she had been despondent and withdrawn-barely eating.Diagnosis? death from a broken heart.It is not as uncommon as you think. More About: Code
Great Moments in ER Nursing
2008-03-13 06:11:00 A post at Ten out of Ten reminded me of my own experience of accidentally administering a drug to myself.Last year we got these new insulin pens, there is a needle that you screw onto the pen and then you push it down onto the patients skin until the plastic shield retracts before administering the dose. That part is important because if you don't do that the needle will not penetrate the skin and the insulin dose will get dripped onto the patients skin making you look like a complete moron.We got a brief inservice on the device but then they didn't come for almost a year after that so of course everyone forgot everything they ever knew.One day I came to work and they insulin pens had come. I read the instruction pamphlet and went into administer the insulin. I must have missed the part about pushing the device down onto the patients abdomen until the plastic shield retracts before administering the dose so I dripped the insulin on the patients skin. I'm thinking WTF just ha... More About: Great , Moments , Nursing
Grand Rounds
2008-03-11 15:56:00 Grand Rounds is North of the Border this week at Canadian Medicine. More About: Grand
Oh My God, there are drugs in our drinking water
2008-03-11 05:32:00 Our drinking water has drugs in it. And as pointed out by Whitecoat Rants, not just drugs but drug metabolites which means pee and poo remains in our drinking water, yuck.Just one request...........is there some way we can get a little more Haldol and Ativan in the water? From the looks of my ER today, we really need it. 1/2 of the patients this afternoon were being watched by a guard for various reasons, the notable exception is the guy who had 6 big strapping sheriff's deputies guarding him, he made the rest of the crazies look absolutely normal by comparison. More About: Drugs , Water , Drinking
Spring is Springing
2008-03-10 04:12:00 For those of you who living in the snow-belt, you might want to skip the following post.It was 78 today. The flowering quince, forsythia, tulip tree's, ornamental pears, plum and almond trees are in full bloom. The willows have leaves and the other trees have large buds that will soon be bursting open. The highway is lined with wildflowers and long, lush green grass. The birds are twittering and the frogs are singing.I've had to mow the lawn for the third week in a row today.I love spring.And for those of you in the snow-belt, three months from now everything will be brown and California will be like a blast furnace - feel free to tell me about your lovely green weather then. More About: Spring
Time Limits and How America is Heading For Disaster
2008-03-10 03:52:00 Thought provoking post by Mousie. Patients are supposed to be in and out of the department in less than four hours, admirable but not if you LIE about it. Massaging and fluffing your statistics will only hide issues, not fix the underlying cause.This is a message America needs to hear. More and more hospitals - in an endless effort to cram more and more patients through departments that can no longer handle the load - are considering forcing their ER physicians to have a time limit on disposition decisions. Once again, an admirable goal but what can end up happening is patients bouncing back because of rushed, incomplete treatment or being admitted when they don't really need to.Let's focus on the true issues - uninsured patients who can't find primary care, frequent fliers who abuse the ER, Medicaid programs that have no oversight - allowing covered patients to come to the ER as much as they like for non-emergent issues, lack of nurses to accept admitted patients, forcing ER... More About: Time , Disaster , Limits , Heading
Signs, Signs Everywhere are Signs......
2008-03-09 02:41:00 And Girlvet has a few to post in the ER. More About: Signs
One More Thought on the Medication Reconciliation Form
2008-03-08 21:51:00 I hate it.Seriously, whenever anyone even says the words to me I want to scream. Why are people so lame? How can you take medications everyday and not know what they are? And, if you have been to the hospital 74 times and been asked to make up a list, when do you think you might get around to it? Don't leave off your Viagra, I don't care if you need help with your willy but I do care if I give you a nitro for your chest pain and I kill you because you took Viagra which bottomed out your blood pressure. We need to know what medications your are taking to keep you safe.And yes, Birth control pills are a medication. We may want to know that you are taking them especially if you are 21 and complaining of chest pain - it may speed up the diagnosis of pulmonary embolus - something we don't normally suspect in someone your age.Don't forget to tell me that you take an opioid pain reliever, otherwise when I give you Nubain for pain it might be really unpleasant.Medication reconciliat... More About: Thought , Form , Reconciliation
Change of Shift
2008-03-08 21:40:00 I neglected to link Change of Shift this week which can be found over at Emergiblog. If you haven't already been there, head on over and check it out.
More JCAHO madness
2008-03-07 02:10:00 Well we had our JCAHO inspection this week. Oh, and by the way, they are now to be called Joint Commission. Good God, the lunacy.In their ceaseless efforts to improve patient care (heavy sarcasm) they are concerned that we:1. Tell them that we set our watches by the atomic clock every day.2. Label lab specimens at the bedside even if we are in the way of the code team.3. Have a policy that deals with, and a check off place on the crash cart check list, changing the batteries on the ZOLL. Apparently having the monitor tell you the battery is low and possessing some common sense just doesn't cut it.4. They don't want you to call people by name from the lobby, apparently they want you to go out there and look at the one hundred or so people sitting out there and use your ESP to determine which 70ish year-old lady with "weak and dizzy all over" it is you want.5. They are not happy with "patient does not know what medications he takes." on the medication reconciliation form, they... More About: Madness
The New Customer Service Model
2008-03-02 17:59:00 In reading blogs I've notice a common theme. Hospitals are expecting staff to do more with less. Less equipment, less nurses, less support staff, less linen and so on and so on. But still provide excellent customer service, which to their mind means service with a smile, a warm blanket and a TV.BULLSHIT. (Pardon the language.)This ain't a hotel. Good customer service in a hospital means that your nurse is highly skilled and knowledgeable so that if you begin to develop problems or complications they know what is going on and how to help you. It means that there is enough nursing staff so they have time to teach you about your illness, how to manage it, about your medications and how to cope at home - not just run into your rooms and quickly give you med's before running on to the next task. It means that there are enough aides and tech's to answer your call light quickly when it rings. It means there are enough physical therapists to work with you every day. It means serv... More About: Customer Service , Service , Customer , Model
Pandemic
2008-03-02 05:42:00 These last couple of weeks have given us a miniature taste of what a pandemic would be like.It started off slow, first we noticed that we were seeing a lot more sick elderly, then we noticed our daily census increasing. Then our ratio shifted - normally we see about 1/3 of our daily patients in fast track, so say 50 there and 100 in the main ER, now it is more like 30 in fast track and 170 in the main ER. The hospital was full and we started holding patients. The number of holds and length of time we held them grew every day. Patients were sitting in the lobby 3 to 4 times longer than normal because we had half our normal beds to see way more patients than normal. The patient acuity keeps climbing, normally we admit about 18% of our patients and now we are admitting 25-27%. Then the ER staff started getting sick. So we were seeing more, sicker patients with less beds and less staff.It wasn't pretty. Toward the end of this week the hospital census evened out and we started hol... More About: Pandemic
This is why we do what we do
2008-02-26 05:06:00 Ok guys, I am POOPED. We saw about twice or normal daily census today and they were all SICK. So no new post from me, sorry.But over at Disappearing John I read a great post that explains why we do what we do. Go read it.
Nurse Over the Edge
2008-02-25 05:41:00 Well.Tomorrow is Monday.Monday's are the worst days in the ER. I don't know why.I'm sitting here with a large glass of something alcoholic dreaming up reasons to call in sick.If I'm thinking of calling in sick, things have gotten really bad.Really bad.But I can't leave them shorter staffed than they would be anyway. We've come to judge how bad the day will be by the number of hospital beds we walk by on our way to the break room. Today we counted fourteen.Come on June, Come on June. More About: The Edge , Nurse , Edge
Nurses on the Edge
2008-02-23 17:09:00 Come on June, come on June.June is when we typically have a slow down in our ER and hospital census. Every year when this happens hospital administration 'freaks out' and starts calling off staff right and left. Soon the staff gets sick of not enough hours so they quit. Positions aren't filled.Then winter comes and we get slammed with patients, there aren't enough nurses to take care of them. The nursing staff works a lot of overtime to try and cover until they start getting sick and injured. The staff illness and injuries further reduce the staff numbers until things reach critical proportions. Staff is hired but have to have orientation so they aren't really any help during the crisis.Is it too much to ask for administration to look back over the years and see that the SAME THING HAPPENS EVERY STINKIN' YEAR? Are we really saving that much money calling everyone off when we balance it against all the overtime, sick calls and medical leave that follows? I truly doubt i... More About: The Edge , Edge , Nurses
A New Way to Irritate Me
2008-02-20 17:11:00 I was working away the other day and my boss came up to me and says: "we want you to stop charting that you tried to give report and the nurse was unavailable."WTF? So I ask why and she tells me that the quality people don't like it as they feel it makes the floors look like they are delaying care.Um. Isn't that what they are doing? If it takes me an hour and a half to give report and get the patient up to the room after I have received a room assignment then I for DAMN SURE am going to chart why unless you are asking me to falsify documentation."Well no, I'm not asking you to do that. Perhaps you could make it more generic then - for instance 'attempted to call report, nurse not available.' (I suspect this came from a chart where I tried to call report for close to two hours and got every excuse under the book: the nurse was at lunch and the break nurse was unavailable, the charge nurse was off the floor. Now the nurse is back and is in an isolation room. Now the nurse ju...
The Most Fabulous Day
2008-02-20 00:00:00 I had the most fabulous day at work recently. I had a series of patients who were all legitimately sick and very thankful for the care I gave them. One lady had fallen and spent the night on the floor of her apartment and had been incontinent. I actually had the time and the supplies to give her a nice warm bath and then bundle her up with a pile of warm blankets. She had undergone a terrifying ordeal and told me how much it meant to have someone spend the time to clean her up and make her comfortable while she waited for a hospital bed. I also had a child who had a febrile seizure, his parents were understandably freaked out but I had the time to spend reassuring them and teaching them.The number one dissatisfier of nurses is the feeling that were are giving inadequate care. I hate it when I feel like I have given the bare minimum. When I now a patient is wet and i am too busy to get right in an change their beds. When I know they are in pain and I can't get too them righ...
Breaking News......Arnie is an IDIOT!!!
2008-02-18 06:15:00 I see a news bullet in my paper today that Arnie has authorized two million dollars in budget cuts to help chip away at the 14.5 BILLION dollar deficit in California. Guess where most of those cuts will be? Schools and payments to doctors and other health care providers that treat Med-i-Cal patients.Beautiful. Already reimbursements to providers and facilities from MediCal are ridiculous. Most communities have very few MediCal providers because of that which forces a lot of MediCal patients to come to the emergency room where they are assured of receiving care there.Here is what is happening in our area.....One dentist in the whole county that will take MediCal patients. A couple of doctors and nurse practitioners that will. No orthopedic surgeons will so if you break something and we refer you to ortho, good luck. Two OB/Gyns only so prenatal care is hard to come by. Break your jaw and don't have private insurance? Hope you have a lot of cash. Have a back injury and need ... More About: News , Breaking News , Idiot , Breaking
Here we go again
2008-02-15 20:25:00 I have a morbid fascination with plastic surgery disasters and I have found a whole blog about them.Check this picture out, what a hot babe.
Well Duh.
2008-02-14 17:45:00 I wonder how much of our tax dollars went into this study? Meanwhile, schools are laying off teachers, clinics are closing for lack of funding, state parks are being closed and so on and so on.
The Statement of the Day
2008-02-13 04:55:00 23 year old female that has had chest pain with deep breath for FOUR months. She is pissed because she has been waiting for two hours while most of the ER staff dealt with a major trauma involving three victims. As I ran by her looking for more blood tubing she stopped me and asked how much longer it would be. When I told her probably awhile she says:Wait for it:"Well if I would have known I'd have to wait this long I just would have made an appointment with my doctor." More About: Statement
They Won't Stop Coming
2008-02-12 04:58:00 The ER was full when we arrived. So was the waiting room. There were three ambulances off-loading patients in the ambulance bay and 4 police cars in the parking lot. We were two nurses short.And they wouldn't stop coming.Four more people signed in for triage. We were holding two ICU patients and three tele admits.And they wouldn't stop coming.The lady in room 21 respiratory arrested. She was successfully intubated and became our third ICU hold. Another 8 people signed into triage and two ambulances called in patient reports.And they wouldn't stop coming.The ER doc helpfully accepted two ER to ER transfers that should have been direct admits. We went on diversion, that stopped the ambulances for awhile but 6 more people signed into triage. The police brought in a raving psychotic in several pairs of handcuffs and hogtied.The phones rang incessantly and the monitor alarms chimed in.And they wouldn't stop coming.The other three hospitals in town went on diversion which made... More About: Stop
You Might Be Having a Bad Day If (Shamelessly copying 'You Might Be a Redne
More articles from this author:2008-02-11 04:48:00 When the patient in V-Tach on an amiodarone drip is your most stable patient, you might be having a bad day.When the blood is pouring out of the patients rectum faster than you can infuse the units into the central line, you might be having a bad day (and the patient certainly is.)When your first person of the day pukes right onto your socks, you might be having a bad day.When you grab the choking little old man from behind and give him a heimlich maneuver and he has copious liquid stool right down your pants, you might be having a bad day (but he'll live to see a few more.)When Doctor Huge Workup has every single one of your patients, you are definitely having a bad day and their orders all look like this: IV NS 1000cc bolus, 16 different lab tests, EKG, Chest Xray, CT scan of something, orthostatic VS, IV Pepcid, IV Compazine, Aspirin, IV Lopressor times 3, Nitro SL times 3, some sort of vascular study and an MRI. A list of nursing tasks that involves about 45 minutes and at le... 1, 2, 3, 4, 5, 6, 7 |
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