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Customer Service on the Floors
2007-12-14 17:07:00
I was a floor nurse for years before I became an ER nurse. I was 'raised' a certain way by the nurses that mentored me and it saddens me to see that a lot of that has gone by the wayside.Number one -keep the hospital clean and shining. Who wants to be a patient where the floors are grimy and you rarely see a housekeeper? Paint regularly. Make sure that the cubicle curtains are clean and in good repair. If you are laying in a bed sick you have a lot of time to look around and notice the little stuff like dirt in the corners.Number two - have enough staff to take care of the patients. Call lights should not be on for more than a few minutes. Have enough aides and nurses. Always have a ward clerk. It is asinine to have a nurse have to input orders and answer phones. The nursing staff needs to be at the bedside, not being a clerk. Bring back Candy Stripers. Not only is it good community service for high school kids, it is great for the patients.Number three. When an admit...
More About: Customer Service , Service , Customer , Floors

The New ER Fad
2007-12-13 20:46:00
The fad of the day in the ER is some form of Provider is triage, Rapid Medical Screening or whatever name admin can come up with. In their endless search to increase business we are now catering to the very business that is bankrupting us, the med-i-caid or indigent self-pay people that rarely pay their bill. Hospitals are dedicating rooms to prompt care to increase the speed at which we see the dental pain, back pain, cold symptoms crowd while the sicker people, who are having oh, say an emergency are still waiting in the lobby for a bed to open up.In administration's ceaseless quest, they are focusing on quantity rather than quality. Well if we see those patients faster it will reduce our left without treatment rate (people that sign in and then leave before seeing a provider.) Have we ever considered that they leave without treatment because they didn't need to be here in the first place?Here's a thought. We want to improve ER flow, improve patient satisfaction and increa...

Elder Care
2007-12-11 18:06:00
"This is unit 62 to base, we are enroute with a 79 year old female from the local nursing home. We were called today for low oxygen saturations. The staff states that the patient has had low oxygen saturations for four days but they were able to get them up after respiratory treatments, today she did not respond to therapy. On our arrival she had an O2 Sat of 59%. We have her on an Albuterol nebulizer at this time, IV established running TKO and a blood glucose of 78. We have an ETA of two minutes."Great, another helpless old person who the local SNF (skilled nursing facility - hah, like there is any skill to be found there.) Has been trying to kill for four days.The doctor, respiratory therapist, another nurse and myself greet the ambulance crew in the room. On the stretcher is a frail little old lady weighing about 90 pounds. She is puffing like a steam engine and clearly on the brink of respiratory arrest. As we transfer her to the ER gurney and swing into action the med...
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Gastroenteritis
2007-12-09 06:16:00
For about the last week we have been seeing about 30 people a day with severe nausea, vomiting, diarrhea and dehydration. We are admitting a lot of these people. Our days are a never-ending saga of retching, vomiting, moaning and oceans and oceans of liquid stool that occurs without warning often when the patient is vomiting.Now we are starting to see the staff getting ill with the same thing so increased patients with less staff. Fun. I am in mortal fear of vomiting so I have washed my hands so much they literally crack and bleed. I've taken to slathering them with bag balm and wearing cotton gloves to bed. Fortunately I sleep alone because sexy it is not.We have gone through boxes of Zofran, Compazine, Reglan, Dilaudid and crates of Normal Saline.And it is just the start of winter.

Step away from the collagen
2007-12-09 06:07:00
Sorry about the PLASTIC SURGERY GONE WRONG, theme. It's like a car wreck, you just can't turn away.I've been depressed about the holiday's this year, for someone who is not really much of a holiday person I am surprisingly bothered at the fact this will be the first year that we are not all home for the holidays. I haven't started Christmas shopping at all, i haven't started decorating.....I just can't muster any interest in the whole thing. I am sunk in inertia.And, I am ashamed to announce, I have been reading PEOPLE magazine. Look at this picture, how about them lips? She is pumped so full of collagen that she can't even close them completely. Why in heaven's name would someone do this to themselves? Good grief. I'll take my crow's feet and laugh lines any day over looking like a suction cup.OK, I promise, no more. I'll return to my regularly scheduled broadcasting and keep my PEOPLE habit to myself. *snicker*
More About: Step , Collagen , Collage

The Harsh Toll of Drug Abuse
2007-12-08 06:05:00
Better living through drugs. On the right is popular singer Amy Winehouse two years ago and on the left is how she looks now. Ick! Currently in a downward spiral she has cancelled all concert dates and recently was found running around outside her home partially dressed.Just goes to show you that being rich does not make you happy. Wonder how much longer she's going to make it.
More About: Abuse , Drug , Toll

Childhood Obesity
2007-12-07 01:22:00
It's no secret that Americans are getting fatter and fatter. Children are the newest victims and here is a news story that illustrates the way of things to come.Bariatric surgery has become a lot of hospitals new cash cow and it looks like there will be plenty of business in the years to come. It won't be long before they start adding pediatric bariatric programs.When I was a child a large Coke was 16 ounces. Now you can get one that is 48 ounces at McDonald's. Fries came in one size, what is now the small. There were no Whoppers, Double quarter pounders, just the regular hamburger and cheeseburger. Mom's didn't work so there was a home cooked meal on the table most nights. Now mom has to work and it's easy to pick up fast food on the way home. Portions are growing and growing. Children are suffering from obesity related problems like high cholesterol, Type 2 diabetes and hypertension. I won't be surprised to see life expectancy rates start to fall. How sad is that?
More About: Childhood , Obesity , Childhood obesity

JCAHO and administering meds in the ED
2007-12-05 06:07:00
JCAHO came up with the brilliant idea that all medications administered in the ER had to first be reviewed by a pharmacist. Anyone that has ever worked in the hospital can tell you what a joke this is, for floor patients if you get a new, 'STAT' order it can take hours for the pharmacy to process it and release the medication, they are just as over-worked as every other department in the hospital. We see almost 300 patients a day, about 80% of them receive one or more medications. We would have to hire two or three full time pharmacists to review and process our medication orders alone. This would bring the already overcrowded ER's across the nation to a complete and grinding stop.So ACEP, ENA etc. banded together and wrote a letter basically saying - "hey, this is retarded." JCAHO agreed and said that we could continue on in our previous manner but 100% of medications had to be retrospectively reviewed by a pharmacist. That has since been revised to state if their is a lice...
More About: Meds , Erin

Dear Hospital Administrator
2007-12-04 05:54:00
We have increased our volume 12% and you have cut our staff by close to 10% and somehow do not grasp why the nursing turnover has increased 16% and patient satisfaction scores are down 9% overall. Hmmmm, how can that be?Helpful hint, do not do an employee satisfaction survey right now, you will not like the answers you get.
More About: Hospital , Administrator

Asystole ain't always the end
2007-12-04 05:25:00
This post over at Nurse Kelly's reminded me of my first experience with a patient surviving asystole.It was back in my ICU career. I was taking care of an adorable elderly gentleman who looked remarkably like Santa Clause, he was a diabetic dialysis patient who was recovering remarkably from a bilateral aorto-bifemoral bypass. I was getting ready to transfer him to the floor and had been visiting with him and his equally adorable wife, who looked remarkably like what you would picture Mrs. Clause looking like.He had been incontinent of a little BM for which he was profusely apologetic. I told him no big deal, I had been wanting to put the air mattress under him anyway before he went out to the floor and this would be a good time. I sent his wife out to the waiting room while we got him squared away and told her we'd be out to get her in just a few minutes.So off she went. I rounded up a tech and we got an air mattress and all our skin cleaning supplies. The tech rolled him ov...

Why I hate Christmas
2007-12-03 05:41:00
The Nintendo Wii, which last month was $249 is now $500 to $600 because of a 'shortage' that is no doubt created by the manufacturer. Does anyone remember the 'Tickle Me Elmo' Christmas ?
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Medication Errors
2007-12-02 21:54:00
This story shows that no one is immune to medication errors and how errors are caused by a combination of factors. Dennis Quaid's newborn twins were given 10,000unit per cc Heparin instead of 10 unit per cc. A pharmacy tech stocked the wrong strength and a nurse took out the vial and must not have ever looked at it, violating the most basic nursing skill taught from day one in every nursing program around the world - right drug, right dose, right route, right time and right patient.Medication administration is fraught with potential peril. On the manufacturing end there are too many drugs that are spelled and sound similar. When the order is being written it is very easy for a doctor's sloppy handwriting to get misinterpreted. Drugs come in a variety of strengths and it is easy for the person who is restocking to put the wrong one in the wrong place. A busy nurse who is distracted by interruptions and phone calls can leave out a crucial step in the process.Why, with all th...
More About: Errors

A Hard Life
2007-12-02 02:52:00
I went in the room to check in the ambulance patient that had just come in. The medics had already transferred her into the bed. She was probably in her late sixties, hair gray and greasy, teeth gone, cheeks sunken. She was cachectic except for her grossly distended abdomen, filled with fluid from her failing liver. Her color was the typically yellow, gray seen with that condition. I placed her on the cardiac monitor and obtained a temp and BP. She barely roused from her lethargy - her brain most likely overwhelmed from a build up of ammonia in her blood, ammonia that a healthy liver cleans out of the blood.I gathered up my paperwork and read the ambulance run report, what I saw there made me stop in my tracks. Her birth date was the same as mine - she was forty eight!
More About: Life , Hard

Change of Shift
2007-11-29 19:41:00
Head on over to Doctor Anonymous for this weeks edition of Change of Shift .

ER Top Ten number 10
2007-11-29 17:39:00
This is one of my favorite devices. The Level 1 Rapid infuser. At the top is two pressure devices that can squeeze a bag of blood or IV fluid in as fast as the guage of the IV or Central line will allow, often just a couple of minutes. The bottom of the device warms the fluid to body temp, important because hypothermia leads to coagulopathy and patients being infused with large volumes of fluid become cold very quickly.Despite looking complicated, it is very easy to use, pull the tubing out of the box, spike your IV bags and the tubing pops into two places, conveniently numbered in case you forget. Open the clamp and it self-primes in a couple of seconds and you are ready to go.Also great for hypothermia resuscitation and massive blood loss, for instance GI bleeders or in the OR.
More About: Number

Cell Phones and why America is going to hell in a handbasket
2007-11-29 04:25:00
I hate cell phones. Nothing is so important that you have to be yakking in the damn thing 24 hours a day. I do not enjoy having the person in the bathroom stall next to me talking while peeing, I do not enjoy regularly having to dodge the idiots on the road who are dialing or text messaging instead of driving their car, I do not enjoy those who carry on cell phone conversations while sitting behind me in the movie theater. I do not enjoy hearing the details of your date last night while I am in line at Starbucks. I do not enjoy hearing about the fight you had with your husband while I am waiting for my hair stylist. GET A FUCKING LIFE. (Sorry for the language.)But on a sadder note, every day I see parents with small children out and about and the parent is yakking on the cell phone instead of being engaged with and spending time with their child. The most precious thing in their life is being completely ignored. Do these retarded people really want their child to grow up and ...
More About: America , Cell Phones , Phones , Cell , Hell

Lateral Violence
2007-11-28 05:35:00
We have had an abnormal surge of patients, in twelve hours we have managed to see almost twice as many patients as normal and admit over 25% of them. We've worked tirelessly to get as many of them dispositioned as possible before night shift comes on and we have the department fairly emptied out when they arrive.As I am leaving I overhear one of the night shift nurse say to another "they didn't even stock the IV carts, it's not like they are ever busy."Why do nurse persist on back-stabbing, bad mouthing and sabotaging each other?
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ER Top Ten number 9
2007-11-28 05:12:00
I'm all for monitoring devices, anything that will monitor my critical patient and free me up to hang meds, titrate drips and assist with procedures is a good thing. Meet the temperature monitoring Foley Catheter. A critical patient needs a catheter to monitor urine output and these come equipped with a built in thermistor that connects to the monitor and continuously monitors my patients core temp. Very handy for hypothermia, blood transfusions, septic and patients under anesthesia. And since they have re-designed the thermistor so it doesn't break so easily, they are even better.
More About: Number

What is Wrong with People?
2007-11-28 04:54:00
So one day I was in charge and was walking down the hall and I hear a baby wailing for all it is worth. I briefly wondered what they were doing to the poor thing when I realized that we didn't have any babies as patients right then. So I stuck my head around the curtain to see what the situation was and I see a 20ish female who is in for flu symptoms lying on the gurney with her arm draped over her eyes and across the room is a car seat with a very red-faced, angry baby. Who is just wailing away to beat the band.I walk into the room and ask her what is the matter with the baby and she tells me she is just too sick to get up and get him. As I recall she was afebrile with a complaint of body aches and congestion. Being polite, I asked her if she was there alone or had someone come to take care of the baby. She told me her boyfriend was coming soon.I'm a sucker for a baby so I ask if I can pick him up. When I do, he is dripping wet. Anyone familiar with today's pampers that m...
More About: People , Wrong

Grand Rounds
2007-11-28 04:52:00
Grand Rounds is hosted by Prudence MD this week, stop by and peruse the med blogosphere's weekly best.
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ER Top Ten, Number 8
2007-11-27 04:24:00
People who come in to the ER in severe respiratory distress sometimes can't adequately maintain their own airway, it used to be those people would get intubated and put on a ventilator. The problem with that is people with chronic lung disease are difficult to wean back off the ventilator and, as with any other invasive procedure, there are risks of infection. And it is not very pleasant for the patient, having a big plastic tube shoved through their vocal cords, it tends to make them cough and gag, that keeps the ventilator from doing it's job. That makes the patient agitated and they will grab at the tube, trying to get it out so we often have to tie their hands to prevent them from pulling it out. We try to keep them sedated but too heavy sedation interferes with weaning.Along came BIPAP. A more sophisticated model of it's cousin, CPAP - BIPAP is a machine that is connected to a tightly fitting mask that fits over the patients nose or nose and mouth and delivers positive ...
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ER Top Ten, number 7
2007-11-26 01:32:00
Back in the old days, we used a Sengstaken-Blakemore tube for GI bleeds from ruptured esophageal-varices. As you can see from the picture, there were two balloons, the bigger ballon sat in the stomack and the smaller balloon in the esophagus to put direct pressure on the varices. The end of the tube had an aspiration port as well as the ballon inflation ports, the esophageal ballon was inflated with the aid of a manometer so you could specify how much pressure to have in the esophagus. The end of the tube was then put to some sort of traction, we used to make the patient wear a football helmet and tied the tube to the face guard.Thankfully with the advent of Vasopressin drips and readily available endoscopy, this tube is relegated to the museum of medical artifacts. Those of us who have used it are not sorry to see it go. To me, endoscopy is one of the greatest things that ever came along for us in the ER. GI bleeds are quickly and definitively treated now and that is much bet...
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A Holiday Surprise
2007-11-24 20:42:00
For some reason the ER is very busy around the holidays, Christmas eve is usually the worst. Between the nursing homes trying to dump some patients, concerned family members who have just arrived home to find Granny isn't doing so well since they last saw her a year ago and elderly folks that can't stand the thought of being home alone at Christmas - the ER is usually hopping.That year was no exception. The ER was packed, the waiting room was packed, we were short staffed. Every room was full and the eight permanent hallway beds had been augmented with ten hallway chairs in an effort to get people seen and dispositioned. The staff all had extra patients and we working as fast as they can, fueled by endless Christmas Cookies and pieces of fudge, counting the minutes until we could go home to our own familiesAbout that time, security informed us that there was an eighteen-wheeler pulled into our parking lot and the driver was at the front window, very upset. They were unable to...
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ER Top Ten, number 5 and 6
2007-11-24 17:23:00
The spit hood is an invaluable tool for police, EMS and ER staff. When a patient is highly agitated they come in kicking, hitting and spitting. To avoid injury to ourselves and the patient we quickly secure their hands and feet to the gurney with leather restraints and cover their face with a spit hood.Agitated delirium can lead to death from hyperthermia, rhabdomyolisis, heart attack etc. so these patients are quickly given a powerful dose of a sedating medication, usually an injection, to get them under control.Hospital staff, EMS crews and police are at very high risk for injury from these type of patients, ER nurses are injured and killed every year by their patients who are often under the influence of mental illness or drugs. These tools are used to protect us and as soon as the patients are under control, are removed when it is safe for the patient and the staff.
More About: Number

Nothing worse
2007-11-24 05:40:00
Heartbreaking, just heartbreaking.

Post Thanksgiving Bliss (and ER top ten number 4)
2007-11-24 04:47:00
It was the day after Thanksgiving and all through the ER could be heard, retching and puking. Every so often a privacy curtain is yanked open and the unfortunate soul it was shielding is seen sprinting for the bathroom for another bout of explosive diarrhea. Vomit bags were the most commonly used item in the department today, closely followed by IV boluses of NS and lots and lots of Compazine and Phenergan.The moral of the Story is......don't eat so much and don't leave food sitting out all day.(For the uninitiated, the barf bag is a great invention that you hold up to your face and has a one way opening to prevent spills. Also great to keep in the car if you have a child that is prone to car-sickness)
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ER Top Ten, number 3
2007-11-24 04:41:00
Dermabond, need I say more? How much nicer to glue small lac's instead of sewing them. Especially great for the very common forehead lacerations that small children learning to walk sustain, hold them down, pinch the wound together, glue, dry, glue, dry, glue and done - thirty seconds tops! And since the advent of the pen, it is even easier to use.
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Best ER inventions ever, part 2
2007-11-22 04:48:00
What can be worse than a critically ill child? Even to seasoned ER professionals it is an extremely anxiety provoking situation. Pediatric doses are complicated and impossible to remember and who wants to try to be doing calculations at a time like that.Enter the Broselow system. A laminated tape measure quickly tells you which color coded drawer to use. Each drawer is set up with the appropriately sized oxygen delivery, intubation equipment, IV supplies, urinary catheters and NG tubes. Flip the tape over and the doses for that size child are right there, quick and easy. As you can see by this site, manufactures make specialized carts and pre-made modules, but if your ER can't afford them, you can easily assemble the appropriately sized equipment into large ziplock bags and label them by color and just purchase the tapes.No one likes taking care of critically ill or coding pediatric patients but the invention of this system takes some of the stress out of it.
More About: Inventions , Part

Top Ten Best Inventions For Emergency Medicine - in no particular order
2007-11-21 05:48:00
This is one of the best things on the market. Easy to use, great for EMS and ER personnel alike, the easy IO. It is fast, easy and safe. Every squad and ER should have it.
More About: Inventions , Medicine , Order , Emergency

When I feel like having a pity party.......
2007-11-21 01:01:00
When I start feeling sorry for myself I read this blog, makes me realize I don't have it bad at all. Make sure you read the whole post including the top 50 reasons.On the other hand, it gives me a glimpse into how my son's life must be right now, which is a topic I'd rather avoid. It is much better if I just imagine him on some generic base in some non-sandy country sitting around, being bored and counting the days until he comes home.
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