Recently I've had a string of patients with ordinary complaints that turned out to be something entirely different. I think I have good assessment skills, both verbally in interviewing patients and in physical assessments. I've been labeled a "sh!t magnetic" in the past, meaning that if I was working on your shift that day, our ER would receive a lot of critical patients. Now the term defines me in a way that we will get strange situations.
Patient's complaint: simple cough. Diagnosis: ischemic stroke.
The patient denied all questions regarding some type of infection. Once I dug a little deeper while triaging him, he answered some questions which revealed he had some tongue numbness and the weakening of his writing hand. "I can't write things anymore." Boom!
Patient's complaint: knee pain from a fall Diagnosis: third degree heart block
The patient didn't want to be there. His wife just wanted his knee checked out because he had problems with it before.
Patient's complaint: possible urinary tract infection Diagnosis: PSVT (paroxysmal supraventricular tachycardia) meaning a very fast heart rate.
While the patient was receiving some antibiotics, she mentioned feeling like there were bubbles in her throat. I threw her on our cardiac monitor and her heart rate was in the 180's.
Patient's complaint: follow up visit from an infected animal scratch. Diagnosis: nonSTEMI (heart attack without ECG changes).
Who could have guessed this?! The patient felt really sore from an injection - it was actually atypical symptoms of chest pain.
Patient's complaint: feeling bad all over and a cough that over the counter cough medicine won't get rid of.
Diagnosis: Stage 4 lung cancer with metastasis.
Patient's complaint: partial facial paralysis, already diagnosed with Bell's Palsy. However, his hearing and vision on the affected side had diminished. Diagnosis: Ramsay Hunt syndrome.
This was a new syndrome for me. I did notice a rash on the side of his ear and his pupils were unequal. I didn't know the diagnosis, but I knew something other than Bell's Palsy was occurring.
Patient's complaint: leg pain of unknown cause. Diagnosis: leukemia
Now the mom of the kid told me he wasn't eating as well, felt really tired lately and he had an enlarged lymph node. I was seriously hoping this would not be the diagnosis.
It's always interesting to hear about a complaint and dig a little deeper. Sometimes a cough is just a cough and then, sometimes it's not.
Friday, April 25, 2014
Saturday, April 19, 2014
It is Done.
It's the straw that broke the camel's back. The last nail in the coffin.
My main ER job went paperless. Now, I have another ER job where we use computers for all charting, triage, etc. It's the wave of the future (unfortunately). The program we use there is emergency department friendly, so it really doesn't take away from patient care and the speed in which we work has not been affected.
The system my main ER decided to use is not designed for the ED. It is a program designed for the floors and completely inefficient for ER use. I know whenever you change a process, it will take the participants some time to adjust and get back up to speed. However, the administration has changed every process the ER. Everyone was slow, extremely slow. For example, a patient I had for a simple antibiotic injection and discharge normally took about a half an hour. That included triage, the nurse's assessment, the doctor assessment, the injection, injection wait time and then the discharge teaching. Not too bad for everything that had to be done. The whole process now took around 6 hours for a simple visit. 6 HOURS.
I had a simple oral dose of benadryl to give to a kid. Before, I could do it in a minute - give the med and chart it. It took over 20 minutes for the whole process to be completed. The inadequate computer charting for medication administration has added 15 additional steps to be completed and this is prior to giving the med. I have more steps after to chart. It also didn't help that the area where my rooms were located does not have good WiFi access. That's just peachy when you have to rely on computers for every task you perform.
We had numerous patients leave in the lobby without being seen, multiple AMAs (leaving after the doctor has seen the patient) and elopements (people leaving after being in a room and not telling anyone).
People were angry. Patients were hostile because they were waiting hours for the doctors to get in there, all the doctors and nurses were because no one knew what the hell was going on and the computer people were miffed because we did not like the inadequate system they had chosen for us. No ER doctor, ER nurse or any ER personnel for that matter was involved when this 'system' was being revamped.
The day and patient load was actually not bad if we had used our old system. It was intolerable with the new system. I'm wondering how we'll have to work when we have a busy day.
I dread going back to work on Monday. Absolutely dread it. I decided to apply for some positions I found online and quit this ER. Although we have lost a lot of nurses recently, I still enjoy working with the remaining nurses and the doctors who I know well and have had a great working relationship with for years. I've been at this ER for over 6 years. I've seen the ups and downs and rode through them. This downward spiral is something I can't ride through.
I hope I get hired for something soon. Very soon.
My main ER job went paperless. Now, I have another ER job where we use computers for all charting, triage, etc. It's the wave of the future (unfortunately). The program we use there is emergency department friendly, so it really doesn't take away from patient care and the speed in which we work has not been affected.
The system my main ER decided to use is not designed for the ED. It is a program designed for the floors and completely inefficient for ER use. I know whenever you change a process, it will take the participants some time to adjust and get back up to speed. However, the administration has changed every process the ER. Everyone was slow, extremely slow. For example, a patient I had for a simple antibiotic injection and discharge normally took about a half an hour. That included triage, the nurse's assessment, the doctor assessment, the injection, injection wait time and then the discharge teaching. Not too bad for everything that had to be done. The whole process now took around 6 hours for a simple visit. 6 HOURS.
I had a simple oral dose of benadryl to give to a kid. Before, I could do it in a minute - give the med and chart it. It took over 20 minutes for the whole process to be completed. The inadequate computer charting for medication administration has added 15 additional steps to be completed and this is prior to giving the med. I have more steps after to chart. It also didn't help that the area where my rooms were located does not have good WiFi access. That's just peachy when you have to rely on computers for every task you perform.
We had numerous patients leave in the lobby without being seen, multiple AMAs (leaving after the doctor has seen the patient) and elopements (people leaving after being in a room and not telling anyone).
People were angry. Patients were hostile because they were waiting hours for the doctors to get in there, all the doctors and nurses were because no one knew what the hell was going on and the computer people were miffed because we did not like the inadequate system they had chosen for us. No ER doctor, ER nurse or any ER personnel for that matter was involved when this 'system' was being revamped.
The day and patient load was actually not bad if we had used our old system. It was intolerable with the new system. I'm wondering how we'll have to work when we have a busy day.
I dread going back to work on Monday. Absolutely dread it. I decided to apply for some positions I found online and quit this ER. Although we have lost a lot of nurses recently, I still enjoy working with the remaining nurses and the doctors who I know well and have had a great working relationship with for years. I've been at this ER for over 6 years. I've seen the ups and downs and rode through them. This downward spiral is something I can't ride through.
I hope I get hired for something soon. Very soon.
Monday, March 17, 2014
Baseball and Hematomas
Well, it's that time of year again for my kids to start baseball and softball season. This means hours spent at the fields in cold weather watching them run around the bases, drop fly balls and swing endlessly at curve balls.
I was at the parent/ coach meeting outside where we would get all the information and have the kids fit for their uniforms. My son was playing with some other boys running around like escaped lunatics. This one in particular was especially rowdy past the point of being obnoxious. I told my son to stay away from him when he started throwing dirt and rocks at other kids. As the meeting progressed, suddenly we hear a scream, crying and a bevy of children running up to parents to 'tell on' the rowdy kid who threw a large rock at another kid's head. The boy came limping up to his father looking like a horror movie actor - blood all over his face and arms, blowing snot everywhere.
I must say, the father showed more restraint than I would have. He loudly told the kid a thing or two and then attended to his bleeding son. I figured that the dad and another adult had the situation under control, but then by watching them, I decided to walk over there to see if I could help. I got a roll of paper towels someone had grabbed out of the little concession stand at the field and led the boy into the bathroom so I could see the cut.
He didn't require sutures, but had a decent hematoma with no obvious skull deformities palpated. I cleaned him up and helped him blow his nose because snot was dripping off of his chin and it was grossing me out. I told the dad what I thought, that ice needed to be applied to the head and then started to advise him of signs and symptoms to watch for and then he interrupted me, "I know these things, I've coached in the past."
"Oh. Okay. Well, I'm going to tell you anyway and you can ignore what you already know."
I continued on and when I was finished, he said, "Oh, I didn't know about those last two things."
Yeah, well, if you notice any of them then take him to the ER for a head CT.
By the time I returned to the meeting, it was wrapping up and I only missed the boring parent behavioral agreement that they have to review with us.
The kid is fine now. I never saw that derelict kid's parents. I wonder if they were even there.
I was at the parent/ coach meeting outside where we would get all the information and have the kids fit for their uniforms. My son was playing with some other boys running around like escaped lunatics. This one in particular was especially rowdy past the point of being obnoxious. I told my son to stay away from him when he started throwing dirt and rocks at other kids. As the meeting progressed, suddenly we hear a scream, crying and a bevy of children running up to parents to 'tell on' the rowdy kid who threw a large rock at another kid's head. The boy came limping up to his father looking like a horror movie actor - blood all over his face and arms, blowing snot everywhere.
I must say, the father showed more restraint than I would have. He loudly told the kid a thing or two and then attended to his bleeding son. I figured that the dad and another adult had the situation under control, but then by watching them, I decided to walk over there to see if I could help. I got a roll of paper towels someone had grabbed out of the little concession stand at the field and led the boy into the bathroom so I could see the cut.
He didn't require sutures, but had a decent hematoma with no obvious skull deformities palpated. I cleaned him up and helped him blow his nose because snot was dripping off of his chin and it was grossing me out. I told the dad what I thought, that ice needed to be applied to the head and then started to advise him of signs and symptoms to watch for and then he interrupted me, "I know these things, I've coached in the past."
"Oh. Okay. Well, I'm going to tell you anyway and you can ignore what you already know."
I continued on and when I was finished, he said, "Oh, I didn't know about those last two things."
Yeah, well, if you notice any of them then take him to the ER for a head CT.
By the time I returned to the meeting, it was wrapping up and I only missed the boring parent behavioral agreement that they have to review with us.
The kid is fine now. I never saw that derelict kid's parents. I wonder if they were even there.
Wednesday, March 12, 2014
Update
Update to the downward spiral of my ER:
To my knowledge the last of the nurse resignations happened a few weeks ago. We had two mass movements of resignations, so we are extremely short in the nursing department. The admin decided to fill in with agency nurses for the time being. Last week, 2 new nurses were fired for legitimate reasons and our brand new director was also canned. She since has been replaced with a newer director. Also, our hospital chaplain retired because according to him "he saw the writing on the wall" and knew he would be laid off next. Unfortunately, he won't be replaced. He provided an invaluable service to our patients and families during critical times and codes.
I was begged to work the other day because they only had 3 nurses on shift for the whole ER for all of day shift. I agreed to work because I felt bad for my coworkers stuck in the schedule and I knew it would be a horrendous day regardless of how busy it was for them. Well, it was a terrible day. As I triaged patient after patient in the little triage room without a break (I managed to leave once to use the restroom), I became angrier with all the bullshit reasons coming into my triage area. I had to take a little mental break because I wouldn't be able to finish the day without yelling at someone. Everyone felt like they had an emergency or that their problem was the most important of the day. People had to wait, a long, long time and they got angry about that. A patient actually called ahead of time to make an appointment which we told her she couldn't do.
I was able to get quick rooms for the truly emergent patients, thank goodness. Those who had to wait for trivial things such as not wanting to buy tylenol for their kid or decided that today would be the day to take care of a problem they had for over a year sat in the lobby. After hours of hearing the snide remarks, the yelling and the insults - I stopped caring about catering to their whims and complaints. We did not have the nurses to open more rooms, their problems were not emergencies and simply put - they would have to wait.
To my knowledge the last of the nurse resignations happened a few weeks ago. We had two mass movements of resignations, so we are extremely short in the nursing department. The admin decided to fill in with agency nurses for the time being. Last week, 2 new nurses were fired for legitimate reasons and our brand new director was also canned. She since has been replaced with a newer director. Also, our hospital chaplain retired because according to him "he saw the writing on the wall" and knew he would be laid off next. Unfortunately, he won't be replaced. He provided an invaluable service to our patients and families during critical times and codes.
I was begged to work the other day because they only had 3 nurses on shift for the whole ER for all of day shift. I agreed to work because I felt bad for my coworkers stuck in the schedule and I knew it would be a horrendous day regardless of how busy it was for them. Well, it was a terrible day. As I triaged patient after patient in the little triage room without a break (I managed to leave once to use the restroom), I became angrier with all the bullshit reasons coming into my triage area. I had to take a little mental break because I wouldn't be able to finish the day without yelling at someone. Everyone felt like they had an emergency or that their problem was the most important of the day. People had to wait, a long, long time and they got angry about that. A patient actually called ahead of time to make an appointment which we told her she couldn't do.
I was able to get quick rooms for the truly emergent patients, thank goodness. Those who had to wait for trivial things such as not wanting to buy tylenol for their kid or decided that today would be the day to take care of a problem they had for over a year sat in the lobby. After hours of hearing the snide remarks, the yelling and the insults - I stopped caring about catering to their whims and complaints. We did not have the nurses to open more rooms, their problems were not emergencies and simply put - they would have to wait.
Wednesday, March 5, 2014
Flying would be fun.
Surprisingly, I had an opportunity proposed to me for a different job. There is a flight nurse position open and I have a contact to get me in the door. This has always been the most difficult part, you have to know someone in order to get your foot into the door. However, there are many drawbacks. The base is 2 1/2 hours away from me. The upside is that they offer 12 hours shifts instead of the usual 24. They do have a base very close to my house, but presently, they are waiting to move it to a neighboring town, so no new positions at the moment. I was told that I could start at the one 2 1/2 hours away and transfer later. The closer base would be massively hiring sometime in the future. The other down side is that the salary is depressingly low. I'm guessing they bank on everyone wanting to have the cool job of being a flight nurse, so they get away with paying lower than normal for a critical care nurse.
Although I want to jump for joy about the possibility of flying, I have to be realistic under the present circumstances. I guess I'll have to wait and see about the hiring at the closer base and make a decision then.
Although I want to jump for joy about the possibility of flying, I have to be realistic under the present circumstances. I guess I'll have to wait and see about the hiring at the closer base and make a decision then.
Friday, February 28, 2014
Praying...
This post is meant to be extremely vague.
Recently, I have seen the aftermath of true, raw evil and it has haunted me. I haven't felt the desire to write this month because of it.
I came home from my shift, hugged my children tightly and told them how much I loved them.
It is unfathomable to me that someone could perform those acts of cruelty on a child.
I've prayed long and hard for this patient. Although the damage will never be undone, I hope there's a chance of a normal life for this little person in the future.
Recently, I have seen the aftermath of true, raw evil and it has haunted me. I haven't felt the desire to write this month because of it.
I came home from my shift, hugged my children tightly and told them how much I loved them.
It is unfathomable to me that someone could perform those acts of cruelty on a child.
I've prayed long and hard for this patient. Although the damage will never be undone, I hope there's a chance of a normal life for this little person in the future.
Monday, February 10, 2014
Vasovagal Morning
One morning this weekend, I was about to get ready for work. It was early in the morning, my family was still asleep. I walked in to the kitchen to get a drink before jumping in the shower and somehow slipped, lost my balance and fell backwards. I didn't seriously hurt myself, but hyperextended my thumb and it hurt like crazy. I couldn't move it and it started to go numb. What happened next was bizarre and uncontrollable.
I had a vasovagal response to my thumb trauma. I suddenly felt that something was not right. I sat on the stairs and couldn't catch my breath. I was acutely aware of what was happening. My heart rate dropped, my blood pressure did the same and I became extremely hot. Sweat was pouring off of my face as I tried to take deep breaths to keep from passing out. The tachypnea was a response to the hypotension and bradycardia.
I thought, "Wow, I'm having a vasovagal epsiode. I need to lie down. Damn, this is my IV starting hand - I hope I can function."
It took about 10 minutes for it to pass. Once my breathing had normalized and my heart rate increased, I felt better. I got up, got ready for work and left.
It was a strange occurrence and I wondered why a simple thing like thumb pain caused it to happen. I've been injured worse before. Who knows? My thumb is sore and swollen, but functional.
Huh.
I had a vasovagal response to my thumb trauma. I suddenly felt that something was not right. I sat on the stairs and couldn't catch my breath. I was acutely aware of what was happening. My heart rate dropped, my blood pressure did the same and I became extremely hot. Sweat was pouring off of my face as I tried to take deep breaths to keep from passing out. The tachypnea was a response to the hypotension and bradycardia.
I thought, "Wow, I'm having a vasovagal epsiode. I need to lie down. Damn, this is my IV starting hand - I hope I can function."
It took about 10 minutes for it to pass. Once my breathing had normalized and my heart rate increased, I felt better. I got up, got ready for work and left.
It was a strange occurrence and I wondered why a simple thing like thumb pain caused it to happen. I've been injured worse before. Who knows? My thumb is sore and swollen, but functional.
Huh.
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