Sunday, March 31, 2013

Speaking Their Language

On another night in the Jail Ward ER, local PD drunk driver task force delivers to us Mr. Jose Jimenez, their latest catch. He's pretty harmless-looking, despite the official escort, and while a bit groggy, is soft-spoken and quiet, with a Central Casting voice that sounds close enough to Bill Dana's Astronaut Jose Jimenez that I have to stifle a giggle.

They need him to get checked out and medically cleared, so they can book him for DUI, evading arrest, etc. etc.

Seems that they observed him weaving, hit the flashing lights, he floored it, and in his haste to escape, crashed into half a dozen cars. So they pulled him out, noted his slurred speech, absence of alertness, and generally out-of-touch demeanor, hooked him up, and brought him to us for the once-over before getting him a bunk at the jailhouse. Another drunk off the road.

So they help him wobble into our mini-ER, pour him into a handy chair, and we began getting his info, checking him over, and such.

And my Spanish, far from flawless, is passable. I paid attention to four years in high school enough to get As the whole time. Which was great for passing tests, learning vocabulary, grammar, and syntax, but about worthless for holding an actual conversation. Two years in Hell, with native fluent Spanish-speaking staff, however, has given me all the medical vocabulary I never had, and a few thousand pacientes to practice on. So I figure I'm about a fourth-grader in my espanol, which ain't bad for a white kid, especially compared to the Californicated hispanic staff members born here whose only Spanish is "Taco Bell" and "margarita".

So between me and the doc in the jail ER, it transpires in our interview that Jose claims to have had no alcohol. Which screws up the math. Normally, you have to use the metric conversion, because anyone who admits to having had 2 beers, really had 36 beers. You arrive at this truth by doubling the reported number and adding 32, the same way you roughly convert Celsius to Farenheit. Countless blood alcohol level tests have shown my math to be a far more accurate system than simply relying on the truthful recollection of those who imbibe.

Further exploration of Jose's history reveals that he does, in fact, have the diabetes, and is not a bad diabetic, defined in my lexicon as one who sometimes forgets to take the meds, never forgets to have a meal, and always has dessert;but is rather more of a mediocre diabetic, in that he always remembers his insulin, but sometimes forgets minor details like, say, dinner. As happened tonight.

So putting a hold on other things, I grab a quick Accucheck of his blood sugar. Which, in the event, winds up being 22. It is "kind of low" only if you'd refer to a 747's wheels a few feet over your rooftop in the same manner. Jose's about to crash. Actually, already did, if we're counting cars.

So after getting some orange juice in Jose's hand, and then an IV, and then a couple of amps of D50 going in with some D5W, we get him tucked into a nice gurney, and doc calls the admitting resident about a reservation for a party of one.

After getting things settled a bit, I wander out for a little update with Jose's escorts, to update them on the possibility that his accomodations plans will likely be a little different than they'd planned.

"But he looked right at us, and took off the second we hit the flashing lights!" protests one of the officers, sure as anything he'd nailed an actual drunk and racked up another stat.

"Well," says I, "I went to nursing school, not the police academy or law school, but unless there's a radical change in things, I don't think you'll be getting him for DUI. I'm betting his insurance is going to be liable for those cars he hit, and I'm absolutely happy you got him off the roads tonight, but he's probably not drunk based on what we're seeing. But if it makes you feel any better, besides the lives of anyone he might have hit, you absolutely saved the guy's life, because he's about a half an inch from going to sleep and not waking up. Ever. And if he'd just been put in a holding cell, and checked on in the morning, this'da been a coroner's case. Glad you brought him. Maybe you can tell that to his family, in case they're any kind of pissed that he got busted tonight. Jose really owes you guys big time."

"And, much as using anything but English annoys me, and probably you, you might want to brush up, just a little, on your Spanish. It couldn't hurt."

"Probably not. Saved his life, huh? Thanks for the info. Really, thanks. What's the plan for him?"

"I'm pretty sure the doc's making arrangements to keep him here tonight. Which beats me finding him on the roads when I drive home, or you finding him cold and dead at the end of shift. Nice going. The doc or I'd be happy to tell your sergeant, if you want."

See, you just have to know how to talk to people.


Saturday, March 30, 2013

The Towering Inferno

The ER at the Seventh Circle Of Hell Hospital is state-of-the-art 80 years ago architecture, with 5 seconds ago state of the art practitioners.

But some - okay way too many - of our visitors are simply Neanderthal @$$holes.

So some small number of months into my then budding career, Doctor Captain Kirk is the designated King of the Plebes, the most experienced 4th year resident non-board-certified ER MD in charge of various less-experienced docs.

Shortly after start of another glorious night shift in Fun City, paramedics deliver unto us Mr. Prince. His royal lineage is apparent, as he's wearing the Royal Gold Robe of Backboard, and the Most Excellent Mantle Of The C-Collar. And given his absolutely blueblood pedigree, in this case, probably mostly either Johhny Walker Blue blood, or perhaps Bombay Sapphire blue blood, but in any event, definitely 86-proof, he deigns to speak to us lesser mortals in the universal language of our local royalty, by greeting all and sundry doctors and nurses as "motherf*****s."

Then, in case we don't understand his meaning, he switches back and forth from English to Spanish to Drunkish, but peppered with frequent and liberal sprinklings of F and MF bombs, which, in a curious linguistic trait worthy of neurological and psychological investigation, is the only word of English the Egregiously Polluted Drunkaholic ESL student can retain with flawless presentation and enunciation, in 100% of documented cases.

Whereupon, Doctor Captain Kirk dons his cape and goes to work.

He's already at the head of the bed, ready to do his baseline exam on Mr. Prince, with a view to clearing his C-spine, etc. just like the last 5,000 traumas he's done in 3 1/2 years of residency. But Mr. Prince is apparently the Official 1,000,000th F-Bomber, and has just won Doctor Captain Kirk's Special Attention, delivered thusly:

Doctor Captain Kirk, no tiny man he, leans over the patients head and shoulders, grasps the C-collar firmly with both open hands, and from about 8 inches above Mr. Prince's face, gives him THE WORD.

"SHUT.THE.F###.UP.@$$HOLE!
I've taken care of you drunk @$$holes for 4 years, and I've had enough of your stupid $#!^. You may be hurt, and we're going to help you. But what we're not going to do is listen to your drunken ranting, or tolerate your filthy backtalk for one more minute. So just lay there, answer my questions, let us do our jobs, and
STOP."MOTHERF###ING".ME!,
STOP."MOTHERF###ING".MY.NURSES!
AND.STOP.MOTHERF###ING.TALKING!
Until you can act like a goddamned human being, don't say another word. We're busy, and we don't have time for another minute of your obnoxious shit.
We're all sick of it. So just shut it.You got that??"

Whereafter Mr. Prince squeaked out the most contrite, humble, and nigh inaudible
"Yes" ever uttered, and proceeded to conspicuously shut up and let us get to work.

I know this because Seventh Circle Of Hell Hospital has no doors, just curtains for each cubicle, so from every corner of the ER, Doctor Captain Kirk's Straw-That-Broke-The-Camel's-Back monologue has echoed off the walls, and swear to Buddha, I can hear the fists of 20 nurses throughout the department pumping skyward, as they're all telepathically screaming "YEEEESSSSS! YEEEESSSS! YEEEEEEESSSSSSS!!!!!!! and doing the ER Happy Dance right on the spot.

One of my co-workers turns to me and confesses, "I've been wanting to give that speech for 4 months."

Only the absolutely typical way-too-soul-crushingly-busy patient load, and state laws against vandalism, prevent us from gang-rushing Doctor Captain Kirk, carrying him around the ER on our shoulders, and having his face graven in the stone walls of the hospital entry beside the statues of Galen and Hippocrates.

Best. Bedside. Manner. Ever.


Friday, March 29, 2013

The Education Of Doctor Bambi

Not being a girl, and thus expendable in the taxonomy of the charge nurse du nuit, I'm rather uncomplainingly floated to cover the jail ward with one of the ER docs in training.
The potential's always there for danger, but it really isn't that bad, because the inmates are usually hoping to stay, for better food and less chance of getting knifed, plus cable TV. Acting up would interfere, so they're usually model citizens in our house, right in the middle of 2 dozen deputies, and random transient police from a dozen agencies bringing in the folks we need to screen before they can be booked, or admit them because they're too jacked up to go to jail.

So after being buzzed into Mordor, and given the 5 cent tour, we settle in to see if the night will bring us business, or a chance to catch up on our reading.

Around 11 PM we get our answer, as deputies deposit on our doorstep an unfortunate lad with a face looking something like steak and eggplant casserole.

So after I get vitals, Doctor Bambi ascertains from our somewhat the worse for wear patient that the mechanism of injury was falling out of his bunk.

Physical exam and x-rays determine all of his teeth are intact, he has a skull of iron, flawlessly uncracked anywhere, but apparently poor luck with the laws of gravity, in this case, the gravity of standing too close to someone who didn't like him.

Doctor Bambi sends him back, with an order for the nurse actually at the jail to give him Tylenol for pain as needed, and we hand him back to the gentle care of the county's custodians of the criminally stupid.

Then Doctor Bambi pops up, and asks where the sherrif's officer in charge has his office.

"What for, doc?" I inquire.

"Because," says she, "that's the 5th patient this month I've had who fell out of his bunk. I'm going to let them know that they need to do something about that, put up safety rails, or something. This is just unacceptable, even if they're criminals."

"Uh, Doc, how long have you done Jail Ward?"

"I didn't do any last year, this is my 3rd rotation this year."

"So, just the two shifts, total, besides tonight...?"

"Yeah." Then, "Why do you ask?"

"Doc, NONE of those patients "fell out of their bunk". They pissed off someone bigger, badder, or different colored, or all three, maybe even a gang of them, and so they got their @$$%$ kicked. And they're stupid, but smart enough to know if they rat somebody out, their next run-in might be toothbrush poisoning, when someone stabs them for snitching. So they "fall down" a lot, from the bunks, in the showers, whatever.

Just as a 150-watt bulb snaps on 6 inches over her head, Doctor Bambi does a facepalm, and says "I am so NAIVE! Dohhh!"

So about 1 AM, we get another case of Malignant Bed Syndrome, this one with both a fractured cheekbone, 2 cracked ribs, and a beautiful imprint of a popular shoe as plain as a tattoo right in the middle of his upper back.

Mechanism of Injury: Fell out of bunk.

So, along with a scrip for some Tylenol with codeine for pain, Doc gives him a classic sendoff as I'm getting the papers for our latest winner of the Victim Lottery ready to roll back to his new temporary home with his custodians:
"Mr. Perp, I understand you had a tragic fall from your sleeping area tonight. I don't know what might have caused this unfortunate problem, but as a doctor, I'd advise you to stay away from that bunk, and any of that bunk's friends, unless you can sort out whatever's causing you to fall out of it, because if you keep falling out of that particular bunk, the next time you're liable to end up in the ICU with internal injuries. You understand me?"

I stiffle a snort. Looks like Doctor Bambi's growing some antlers tonight.

Monday, March 25, 2013

Not A&O, But At Least His Priorities Are Straight

College kid, suffering brief loss of consciousness after broomstick to head during broomball game at local ice rink, comes around within about a minute.

Witnessed questions first asked by patient immediately after regaining consciousness:
"Who am I, and who am I dating?"

Sunday, March 24, 2013

Diagnosis Of The Week

Nigh on Impossible Stick and IDDM diabetic patient (and family entourage) on their 3rd visit in 7 days, and their 15th in 3 weeks time.

Pt. totally out of it, with a blood sugar reading of 1246 on initial lab draw.

After yet another half-night's being carefully flown down to the mid-300s, and yet another overnight ICU admit, pt. candidly admits to doing level best to kill most of half a gallon of delicious mint-chocolate chip ice cream that day.

While the initial urge to call this Sugar Suicide is a good choice, sober reflection will correctly diagnose this condition as
Low Grey Matter Titer.

And my state's Health and Welfare and Penal Codes notwithstanding, I'm firmly of the opinion that a diabetic eating a tub of ice cream meets the textbook legal definition of Informed Consent For Therapeutic Headslapping, (normally an independent intervention, but also backed up resolutely by the ER doc, as usual) and a serious argument for having granted Power Of Attorney to do the same to the rest of the Tard Family, for watching these proceedings from lunchtime to ICU, inclusive.

That scene in Harry Potter: Goblet Of Fire, where the dragon spews fire at the rock he's cowering behind is what I'm calling tonight's "patient education" portion of my nursing interventions for this patient. And if I can find a brochure for the local mortuary to hand them for the inevitable funeral planning, while everyone in the room is alert, conscious, and breathing, it should be the cherry on their cake. (You should forgive the pun.)

Saturday, March 23, 2013

Mother/Father Of The Year Award

Okay, so honestly, I was going to type the title as Motherf****r Of The Year Award, which amounts to the same thing.

So now, for all nominees, word to all you motherfathers:

When your age is some number higher than 21, and your son or daughter's age is something I could count to even after a massive aphasic stroke, simply by using my fingers,

And whereupon, in describing a procedure or treatment to you, as the nominal parent of said child,

You immediately defer and confer all decision-making capacity to the puppy-sized and stegosaurus-brained petite screaming pre-adolescent "No"-factory sitting on the gurney as the reason for tonight's visit,

You have just demostrated to me which member of your family is the Brains Of The Outfit, and who, in all likelihood, is the de facto dictator of the little Happyland banana republic you call your home.

So I swear to Buddha, I'm going to bring a bag of barbeque briquettes (say that five times fast) into work (mainly because health laws forbid me from serving you one of the carefully baked brownies I'd like to give you, lovingly made from water and a heaping scoop of 100% bullsh rose fertilizer) and hand you a lump of coal as notification that you've made this year's semi-Finals for Worst Parent In The Entire Universe, Ever. Believe me when I tell you the judges will have their work cut out for them.

Don't take it personally. Okay, just kidding, do. But maybe, take the charcoal home, grind it up, mix it with water, and drink the slurry. Because then it might suck the poison out of your system, but it's definitely going to create enough backpressure to stand a decent chance of popping your head out of there before your sociopathic little monster precocious and spirited little angel ends up on a tower shooting at pedestrians down below someday because you didn't cut the crusts off his lunch sandwich.

Take that lesson to heart, you spineless motherfathers.

Friday, March 22, 2013

Mamas, Don't Let Your Babies Grow Up To Be Douchebags

Okay, I took one for Florence Nightengale from way back, and sat through the endless lectures on cross-cultural nursing, and I really do get it. I expect certain things from certain groups, because they covered it in school ages ago, and frequently it helps me do my job and better care for my patients, and their families.

So I know that the 29-year-old, 6'4", 275 pound scary prison/gang-tatted 2-time felon sitting on the gurney in the back row with you, cold, lifeless, and fenestrated in the X-ring by 3 well-placed .40 slugs will, to you, always be your "sweet baby".

And I get that to you, his mother, he was a poor, misunderstood sweet little child who could never do any wrong, and all those other people just made everything up for 20 years.

But seriously woman, if I can step beyond my culture, maybe you can inch away from yours too, if only long enough to grab some air.

Because when you're so ostentatiously bewailing the cosmic cruelty of the universe that robbed you of your sweet little snookiewookums, it's not a human being mourning the loss of a loved one, so much as it's a delusional enabler bitch-slapped by reality, and still not recognizing the handprint on your face.

Especially when the nice little 5' 5" grocery clerk your sweet baby was repeatedly punching in the face and stabbing in the chest across the checkout counter is sitting, very much alive, in the trauma room just a dozen feet away, battered, bruised, punctured, bleeding, but very much still with us, and now assaulted again by listening to your hissy fits.

So all you're accomplishing is to get the cops, the doctors, the nurses, and literally busloads of humanity you'll never know, to disregard you and dozens like you in days beyond your reckoning, while those of us right there right now are most inclined to compliment our live patient on his excellent marksmanship, and steely determination to stop a thug from killing him, or anyone else.

While as a human being, I'm sorry you or anyone should ever have to suffer the death of their child, at any age, as a citizen of the same city they both live in, I'm thinking that for the day so far, we've all come out ahead.

So why don't you STFU, let one of the 27 relatives take you home, and cry by yourself for all the times you pretended everything was all right when sweetums was out with the gang, covered for him with the school, the teachers, the cops, friends and family, and beat yourself up as hard for covering for him all those years as he beat up on so many other innocent people, mainly just because he could.

My patient didn't know your son, and he had less than 30 seconds to decide to live, and make a terrible choice, and he'll carry that emotional burden with him, and the nightmare of your son's last seconds, for the rest of his life.

Hopefully, so will you. Because you had a lot longer than 30 seconds, even if not a full 18 years, to turn things around so this day wouldn't come. If only you were weeping that you were sorry, instead of questioning why this happened, maybe I could see it.

And it's frankly self-indulgent childishness to weep and moan with such histrionics, when all that happened was that in the vast restaurant of life, you just got the check. Your son already paid his share. And I suspect like the thief on the cross next to Christ, right at the end he knew too, however fleetingly, that he had it coming.

And when someone gets what they certainly had coming in this instance, it's callously offensive to pretend that it's otherwise.

So under the heading of tough love, c'mon back to reality, and see what you can do for the rest of your life to start making up for what you failed to do. It may be hard, but not nearly as hard as listening to you pretend, with every sob and shudder, as if your son died throwing himself on a grenade to save a busload of schoolkids, or testing a cancer vaccine, or somesuch worthy sacrifice. Not to mention how hard it is for your audience to tolerate another moment of the Raspberry Award-winning performance you're giving in tonight's episode of "Why, O Why, Is The Universe So Unfair, And Fate So Cruel?".

The universe has a quota for b.s., and you've exceeded your limit. Stop cheapening every honest tear that's ever shed in this place.

Besides, like Sean Connery said, he shouldn't have brought a knife to a gunfight.

Thursday, March 21, 2013

Nurse Sherlock Holmes

So, I'm in triage (which is about like saying "I was breathing"), and it's well after midnight. And for once, things have actually quieted down, like they used to do every night, instead of once every leap year. But tonight wasn't looking like it was going to be too bad.

And then in comes a certified relative of Wile E. Coyote, Supergenius.

Mr. Wiley has a towel around his left forearm, and announces loudly "I been shot."

Okay, we're not a trauma center, so minus 5 points for being not-so-bright. But we're on the barrio border, so it's not like this never happens.

And, with normal vitals, little apparent blood, and after minimal questions and a visual check, it turns out he has, indeed, only been shot in the forearm.

So during the abbreviated triage, it comes out spontaneously that Wiley, quite the party animal, was "looking for a party" in Not-so-nearby City when Sumdood (damn him!) shot our hero in his left forearm, as he drove by just minding his own business with the arm on the windowsill. Trying to get the mechanism of injury down, he's very certain that he was shot from outside the vehicle as he was driving.

So he then apparently had the presence of mind to drive through 6 surrounding cities, and then come to our not-a-trauma-facility for his emergency gunshot injury.

So I quickly get him settled in the back, notify the doc, and make the obligatory police agency notification, to spare the nurse in back another headache. And because I speak fairly fluent cop, and am pretty darn bitchin good at making mandatory calls painless for us and them.

Therefore I know that on an assault with fists and no desire to report on a busy Friday night, they'll only want us to inform the patient that they can always file a complaint report at the station later, if they change their mind; but I know that when a firearm injury is involved, police will drive across several counties to take the report. People getting shot in their jurisdictions tends to get their constituencies rather upset. So I know this guy is getting a visit, even if he doesn't.

With no one else to deal with, I go outside to let the parking minions know not to park, move, touch, or breathe too closely to Wiley's vehicle, because it's now a crime scene until further notice. Pity that he couldn't have shown up at 7PM, it might have chased a few more folks away to see their regular docs in the AM, but oh well.

So I take a quick look at the car from outside and a few feet away, through the open window. I notice after a minute's inspection that there doesn't appear to be any obvious blood inside the vehicle, nor any extra holes in the cabin. And on the outside, I notice there's a whole LOT of blood, up high and behind the driver's window, and sprayed back towards the rear.

Now, I'm not a cop, forensics examiner, or even a huge fan of CSI. But I know a tad bit about guns, and physics. So, as a rule, when a bullet passes into and out of your arm, blood usually spatters in the direction of the projectile. And people shot in the arm, don't, as a rule, wave their arms higher than their heads outside the car, for the 5-10 minutes it would take to create the Jackson Pollock-like canvas evident on the upper outside of Wiley's car. And the odds of them doing that without having a single drop get inside the car, and having a handy towel for the bleeding, and not having a single drop of blood on their clothing, and somehow driving past a dozen ERs before arriving at ours, are approaching Lotto Powerball numbers.

And, because it's slow, and the PD from Not-so-nearby City won't arrive in 2 minutes, it means I have time for a brief confab with the treating ER doc. We don't get into official forensic caliber diagnosis, nor describe entry and exit wounds. That's for the professionals and pathologists. But Wiley, it turns out, has suffered a very small hole consistent with a .22 on the medial side of his top L forearm, and a somewhat larger hole on the lateral side. Not diagnosing, mind you, but that's consistent with a bullet from inside the car going through his arm towards the outside. And Wiley, it turns out, was right-handed.

I file all this away, until about half an hour later, when a sergeant from Not-so-nearby City arrives. He questions me, and I volunteer my observations, and let him conduct his investigation and draw his own conclusions.

He notes the same data points. And during his investigation, recovers the loaded magazine for a .22 caliber semiautomatic pistol shoved inside the passenger seat crack. With one bullet less than a full load in it.

Then, last of all, he has a chat with Victim Wiley. Whereupon it transpires that Wiley can't remember the party he was looking for, any of the names of people who would be at the party, the supposed address (or approximate zip code, area code, time zone, or hemisphere), or where he was driving when he was shot "by Sumdood" closer than about a 10-mile radius. How...curious. He also has no explanation for what a magazine for a pistol got into the car next to his seat, nor where the towel came from, nor for why the car and his clothes are spotless, but the sidepanel looks like a butcher shop.

He isn't charged at the time, but elects to leave AMA after we bandage his wounds. And the police tow his car for further investigation.

So as a word to those with Low Grey Matter Titer, when you're a black guy with a multi-page rap sheet of prior gang-related offenses on your greatest hits list, cruising around an overwhelmingly asian neighborhood at 3AM "looking for a (mythical) party" in an area where you have no known friends or contacts, and you're resting the muzzle of your heater across your outer forearm while trying to set up a nice drive-by, you need to either avoid those "Pulp Fiction" style bumps in the road, or at least keep your booger hook off the bang switch, to avoid shooting yourself through the arm, having to go home, ditch the gun, and change all your clothes,  grab a towel, and drive across town and make up a total horseshit story before you get treated at an ER 30 miles away, hoping the cops won't show, and we'll swallow all that fertilizer like we were born yesterday.

But at least in this case, the stupid, it burns.

Wednesday, March 20, 2013

The Hearing Goes Last

Enter sorority version of Calista Flockhart, same 89 pounds, but in this case all of 19 years old, and nearly catatonically unresponsive from the probably two whole beers she drank earlier that night at Horrendously Expensive Drinking Academy: "We put the HIGH in Higher Learning!"

She's dressed, has no ID, no hovering friendlettes, and not much else to go on, and regretably the paramedics were forced to use the Dreaded Sternal Rub in triaging her responsiveness.

Which also failed to get any response.

So, out of ideas as we wait for an open room, I lean down and tell her, rather loudly and near her ear, that she needs to wake up and talk to us.

Her left hand slowly rises from the blanket, she presses an extended index finger to her lips, and without opening her eyes or any other response, she gives me an earnest "Ssshhhhhhhhhhhhhhhhhhhh!"

Scratch out that U, and insert a V on the AVPU score.

BAC Score: 124 mg/dL - Amateur Lightweight class
Rx: 4 hours of monitored naptime, ride home with friend

Tuesday, March 19, 2013

WMD: Why Everyone's Gonna Die Pt. 2

Yesterday's scenario was (thank God) purely fictional.

And to some tiny minority of disaster planners, largely unlikely.

Then, there's everybody else who knows how it works in the real world.

So, purely for informational purposes, let's note that there are three places the FAA has made it absolutely verbotten to fly over:
The White House
The Capitol
a small playground with a rather well-known mountain right next to a famous castle and run by a large four-fingered rodent.

That would seem to indicate those are considered, upon mature reflection, high-value targets for terrorism.

As a consequence, for over a decade since 9/11, besides spending gazillions on other things, the feds have pumped wildly ridiculous sums of money for training into local cities' budgets, for responding to terrorism, and the equipment and such to deal with such a scenario's management and response.

So imagine, just for informational purposes, that very close to one of those high-value targets, a report of a huge plume of unknown chemical composition is observed spewing from the roof of a building. Some things might come to mind in a prudent response.

Such as, for example, dispatching police units to arrive post-haste and set up a cordon, well out of the zone of airborne contamination.

And having some means of knowing the wind direction and speed, before making that call.

It probably isn't a good idea to park your first-in fire response vehicles directly under the descending chemical plume, and coating those vehicles and crews with the unknown chemical in their street clothes.

It's probably even worse, when all the inhabitants of the building are running out, jumping in their cars and driving off madly in all directions, just as that first arriving unit pulls up to a stop.

Then, noting said cloud overhead, you probably wouldn't send your guys inside to "see what's going on" with no protective equipment on.

And you wouldn't want to grab the first contaminated victim, and load them straight into a paramedic ambulance, without decontaminating the patient, or suiting up the paramedics first.

And you really wouldn't want to then drive the now entirely contaminated patient, paramedic, ambulance, and driver, out of the hot zone, and off to the local emergency room.

And no one would want you to fail to inform the receiving hospital, let alone your dispatch center, God, and the world, that you had the first of any number of chemically-contaminated patients en route from an unmitigated hazmat disaster.

It would also be the height of stupidity, lacking any notice to said hospital, to bring your contaminated selves, and your contaminated patient, straight into the inside of the main ER on a busy night.

And then, you'd be really stupid to place that patient directly into a room vented to not only the rest of the huge and busy ER, but also to the main radiology department for the ER, and to all the outside waiting rooms.

And then, and only then, let the staff know that the patient was contaminated by a mystery chemical, and you did all those things above, is pretty bad too.

Because you might have killed your police officers, your fire crews, your paramedics, and contaminated God knows how many other sites when all those unrestrained contaminated victims flooded 100 other ERs anywhere within 100 miles, plus any responders if they had any number of accidents en route to home, or one of those other ERs, or their families and neighbors. And then contaminated and/or killed not only the original receiving hospital's entire staff of doctors, nurses, PAs, techs, and support staff, but also all their patients, and all the patients in the lobby, their family members accompanying them, plus the security guards, the parking attendants, the maintenance men, the cooks in the cafeteria, and so on ad infinitum, but then also repeated the scenario dozens of times over, wiping out healthcare for half a state in short order.

And of course, not acting like any of that had happened, and waiting to see if anyone drops dead, is probably not the recommended course of action a prudent hospital receiving this chain of situational incompetence would want to follow either.

Because, I think we can agree, that would be baaaaaaad. M'kay?

So, see if you can guess what unnamed fire department, unnamed police department, unnamed location, unnamed hospital, and unnamed emergency response region did when presented with this in real life, and guess exactly how many of the above Bad Ideas actually occured, spontaneously, without any effort or malicious intent to deliberately do a bad unbelievably horrible job, and potentially endangering thousands to millions of lives as cavalierly as juggling lit dynamite sticks in the control tower at LAX. 

If you guessed anything under 100% Pure Undiluted Fail, thanks for playing, and we have some lovely parting gifts for you.

Every possible commonsense best practice and meticulously-trained for, briefed-on, drilled-for, and paid for with tens hundreds of thousands millions of dollars of your taxes training on "Rules For Hazmat Incidents" procedure was omitted. We may as well just take the notebooks and throw them in the landfill, and tell everyone to run for the hills, or kiss their @$$es goodbye.

Because that's where the cream of the crop is, 10 years after 9/11.

And if they ever tell me we're getting such an incident, I'm probably clocking out and leaving on the spot, unless I see the fresh transplant scars from healthy brain donors on about 50 heads of Those In Charge of the monkeyhouse.

And these are good, professional folks at all levels, who deliver excellent care in a literal megalopolis, not the staff of Barely Adequate Hospital and Fairly Normal Emergency Services in Outer Podunkville.


Sleep tight, America.

Monday, March 18, 2013

WMD: Why Everyone's Gonna Die Pt. 1

 The following is purely fictional. Please realize that if I could dream this one up, somebody in a cave in some third-world trashcanistan already has a notebook full of drawings and/or a laptop Powerpoint lecture with the details already halfway worked out.
Nota bene that Tom Clancy had his villain crash a plane into the US Capitol a decade before 9/11 happened. With that prologue, consider the following notional scenario:



As people streamed into the Staples Center for the night’s game, the sun was just going down on a beautiful early spring day in Southern California. At separate entrances, and separated by several minutes between arrivals, 12 elderly Middle Eastern senior citizens were wheeled inside by doting younger relatives. Grandfathers and grandsons, uncles and nephews. Each one sat in a standard folding wheelchair. Behind each elderly man were 12 identical “C” size oxygen canisters. Each passenger helpfully had a nasal cannula hooked beneath their nose, but a carefully placed blanket or jacket in each case concealed the fact that they weren’t connected to the cylinder outlets, just dummied in place. One by one, they found their seats at the railing of the upper level, spread around to each number of the clock, beside an aisle. The wheelchairs were left behind the back row, folded up, but the O2 bottles were carefully carried alongside each elder until the pairs had found the seats and settled in. They say down and waited. They stood for the national anthem, and let the game start. Precisely 5 minutes into the first period, each pair got up. To get a hot dog, visit the bathroom, whatever. As they stepped away, each young attendant, having checked to see the spray outlet was pointed at the center of the arena over the railing, quickly but nonchalantly twisted open the valves, and then hopped a quick couple of steps, calling after their elder charges, and headed to the upper landing. Whereupon a miraculous change in spryness enabled each pair to calmly but quickly exit the arena, again by different exits, and were picked up in each case by a third accomplice who brought the cars near the curb. Within a couple of minutes, they were all heading outbound towards one of the nearby multiple freeways, and back to their safe houses. Back in the arena, a dozen cylinders all poured out an invisible vapor of aerosol droplets. The twelve tanks had been smuggled north from Mexico, after being delivered from a freighter off the coast, and run into a shore rendezvous off Baja, then smuggled along drug routes through the border deserts before winding up at the group’s warehouse near downtown L.A. Each was painted to resemble an oxygen tank of medical O2, but all in fact held under pressure a particularly well-made batch of Sarin liquid nerve agent. Air currents inside the venue distributed it widely, and within minutes, people on the lower level began to feel “wrong”. Their vision was constricted by closing pupils and teary eyes, they were coughing, then noses ran, then they began to gag and gasp and vomit. Their nerves spasmed, they stumbled, and as they all began to slump to the ground, lost control of their bladders and bowels as they landed heavily on the floors and aisles. As others noticed that something must be going on, they tried to flee, but the vapor cloud found most. Especially bad was the fact that everyone inside the ring of death had to pass under the cascading aerosol of droplets from above. Pretty much everyone on the lower level was minutes from death the moment the cylinders were cracked. The people on the upper level had things somewhat better, having only gotten a mild dosing from what the air circulation system distributed. But what nerve gas didn’t kill, panic did. Dozens were trampled in the melee for the exits. Some who’d received gas in their eyes, noses, and mouths began to go down in ones and twos, in a trail leading from the seats to their cars. Others who had a few more minutes from skin exposure lost it trying to get to their cars, strewing bodies all over the parking lots. Some smaller number succumbed on nearby streets and freeways, creating the mother of all traffic jams in every direction, and every accident a contaminated hazmat response.

And all the while the carnage was broadcast live on TV to millions of viewers, some by stunned cameramen, some by cameras whose operators were already dying under the lenses. In the confusion and panic, it was over 3 minutes before someone in the truck yanked the signal feed circuit. One of the vehicles was simply driven away with no attempt to disconnect, and toppled a dozen fleeing bystanders before the cable snapped on a fenceline.


At Los Angeles MFC, dispatch started getting panicky radio calls, and several fire and police units were dispatched. Long before they arrived at the "Major Emergency - Hazmat", they were called off, and a perimeter was called for upwind. The Hazmat Response crews were dispatched. By the time they arrived twenty minutes later, and took another ten minutes to get suited up properly, it was a body hunt and forensic investigation. Inside over 10,000 people were dead. Another 1000 bodies were scattered throughout the facility, and there were over 200 nearby traffic accidents. An unfortunate number of the first arriving paramedics and patrol officers became secondary casualties in short order, leading to futile attempts to establishing several hundred secondary contamination zones, and evacuating thousands of residents nearby and downwind. Between 24 hour news and sports radio, and cell phones, panic spread at the speed of electrons.
The populace collectively lost their minds. To both nearby residents and those listening and watching the game, it quickly became obvious that somebody had used something. People started grabbing car keys, and maybe whatever they could grab in 30 seconds, and hit the road en masse. A cascading traffic snarl spread outward from south of downtown, near the original incident. As word spread from city radios to commercial broadcast about the secondary sites at accidents nearby, getting in a fender bender, instead of getting out to exchange info, became a game with rules somewhere between a demolition derby and Death Race 2000. And as the cars fled the locus of disaster, outlying cities and surrounding counties fumbled and wondered what response to take. No one had ever tried to deal with 5 million cars all headed out of L.A. at the same time, driven by people ranging from cautiously determined to ragingly hysterical.


Between the incredible number of traffic accidents, including the contaminated victims, and the number of slightly contaminated or uncontaminated but terrified spectators and their families arriving in the local ERs, hospital after hospital was flooded with patients. Operating on the ragged edge of disaster on a good day, the entire county’s emergency medical system had a stroke. Ambulances nearby were contaminated, some crews dead, others couldn’t get to calls, let alone the normal nights’ tally of gunshot victims and heart attacks. Diversion of ambulances to and from farther and farther away spread like ripples in a pond, and within an hour crashed the entire system. Which in turn impacted the systems in surrounding Ventura, Orange, San Bernardino, and Riverside counties. By 10PM, nearly 10% of the population of the United States – 30 million people - centered on Los Angeles was effectively left without any emergency medical service until further notice.
Not that there were more than a 100-200 doses of atropine in all the local hospitals combined, and it would be hours before anyone could access federal stocks of nerve agent antidote. By which point, everyone who’d need it would probably be cold and dead anyway.

Sunday, March 17, 2013

Diagnosis Of The Week

My batting average at diagnosis/guesstimating fractures is nearly a perfect 1.000 average. By which I mean, I've been, I recollect, 100% wrong when thinking a bone is fractured, and complementarily 100% wrong when thinking a bone isn't fractured. This has been confirmed by diagnostic radiology studies in a lengthy host of instances. I note with some measure of reassurance that many of my colleagues are similarly handicapped in the Superman x-ray vision department. Which is why my default answer to someone is that we need to get an x-ray and actually see.

The one exception to this abysmally bad knack for prognostication is the subject of today's little chat. That exception is the Stevie Wonder Fracture. Some people who aren't radiologists or orthopedists, and are doubtless destined to be future Final Jeopardy contestants, may pride themselves on knowing every obscure type of bone fracture in the atlases and professional references.

You will not, however, find the Stevie Wonder Fracture listed therein.
Fortuitously though, it needn't be.
Because, quite simply, any anatomical structure with an underlying osseous substrata which is so obviously malformed as to require a broken bone is, in fact, a Stevie Wonder Fracture.

When 10 year old arrives, self-splinting a forearm in the shape reminiscent of the Mark Of Zorro, and it's so brokedy-broke that a blind person, without any medical training whatsoever, and forced to assess solely by Braille, would diagnose a broken bone, you have sighted (pardon the unintentional irony) a Stevie Wonder Fracture.

When the wannabe ski bunny arrives, and I or one of my colleagues tells you, in a style reminiscent of Blaine Edwards/Damon Wayons in the "Men On" segments of In Living Color, that your arriving patient has a leg with "3 snaps in a Z formation", you can report to the doctor with 0% chance of error that the patient has a Stevie Wonder Fracture.

Nota bene that there is no requirement for the bones to be currently nor at any time subsequent to original injury, actually protruding through skin to any degree. The true benefit of the Stevie Wonder fracture diagnosis is that it doesn't rely on such cheap parlor tricks as actually seeing the jagged fragment of a formerly intact bone in order to justify the diagnosis. And besides, that'd be cheating.

Saturday, March 16, 2013

Read This Until You Get It

I know, with the 24 hour newscycle, and the endless rotation of stories that suit the agenda of Damning The Things The Liberal Media Hates intersects so nicely with Ratings, Ratings, Ratings Until Our Heads Explode, that lately certain stories pound you on the head until you think you have to opine.

Rule One of Having An Opinion: Make sure it's an informed opinion. Take it to the library and read to it, maybe get it a cable subscription and learn a thing or two, before you turn it loose in the city unaccompanied. Sort of precisely like you'd do with those other supergeniuses of Western civilization, your teenaged offspring. Until that point, resist the urge to prematurely launch.

And I know that some people mistake having earned certain letters after their name with The Right To Think For All Those Great Unwashed Stoopid People Over There.

So whether you're a doctor, nurse, professor, butcher, baker, or candlestickmaker, I would counsel that before you let your mouth, or your fingers, run away with you, you steadfastly avoid plopping out opinions that, much like your smelly socks, ought to be kept to yourself on Some Weighty Topic. Because usually, they just stink, and you embarrass yourself.

My case in point:

"I'm a really bitchin trauma nurse who's seen too many shooting victims, and if only people had to see what I saw, they'd set the Constitution on fire and melt all the guns down for scrap, just like I want to do. But they haven't, so they're not as smart as me. You don't need any gun I don't like for anything that isn't absolutely criminal."*

When you spew that much non-sequitr magical thinking childish psychotic nonsense out in one breath, you aren't speaking as a nurse (or a doctor, professor, etc., etc.). You're speaking purely as as a fucktard jackhole, and you've just wasted the few brain cells that your body hoarded all those years to maintain a pulse and respirations, and shot them right out of your ass. In front of the entire Internet, forever.

Unless you think that once someone had seen enough diabetic patients, they should be allowed to discuss banning Twinkies and Ding dongs.
And that once someone had seen enough rape patients they should be able to demand all men surrender their penises.
Or that after seeing enough drunks, we should re-enact Prohibition, or that enough MVA patients would justify banning all cars. Because, really, who NEEDS anything faster than a skateboard, unless you're a criminal, you frightened stupid babykilling kitten-stomping loser??

That's the level of retarded jackassical thinking we train 3 year olds out of, and which we document as proof of psychosis in crazy people.

If guns bug you, there's a far simpler solution: don't buy any. By no strange coincidence, that approach is also entirely legal under the Constitution. You can even tell your friends that in the realm of being a victim, you've elected to surrender, rather than risk being able to defend yourself against someone younger, bigger, stronger, and meaner. And to make sure all your family members are equally helpless, including children and infants. So if you don't have the moral resolve to announce what a cowardly jackass you are, don't try to ascend the mountain of your own imaginary moral superiority, and tell everyone else to follow your example, or worse, declare fiat ex cathedra that you'll just do all their thinking for them, based on your superior global omniscience.

"Medical misadventure" and pharmaceutical mistakes by doctors and nurses kill 10 times more people annually than all 300,000,000 guns in this country, going back to probably Jamestown Colony. Shouldn't we ban doctors and nurses then, because really, who needs a doctor more than once a year? And why should doctors be allowed to see more than 15 patients a week? Only a criminal would want to give them access to more victims.
I'm sorry you were sick the day they covered logic in school every year from about 10th grade to your Ph.D., but it doesn't work like that.

And such monumental jackassery is exactly the reason the Founding Fathers of this republic made sure that the closest you came to directly voting for anyone was to elect a bare 1 congressperson, thus ensuring that at any one given time, almost 49% of the brilliant "people" would be soundly ignored in each district, and up to 49% of the congress would be ignored in the capitol, on every issue, on every vote, forever. And they saw this limit on your would-be dictatorship as a feature, not a bug.

So next time you great a great idea, and you want to hear it echo because of its pure brilliance, go to the local big box hardware store, buy a galvanized bucket, put it over your head, then launch into your tirade, and drown out the sound of the rest of us with the cacophony of your own awesomeness.

Both you and we will be properly ecstatic at the results that step will guarantee on future results.





*Lovingly edited and paraphrased so that you'll never find out the actual identity of the intarwebxz Soopergeneyus who plopped that nugget out, while carefully paraphrasing every thought so that you, gentle reader, got the full impact of the author's self-evident rhetorical brilliance.

Friday, March 15, 2013

Soundtrack 2.0

To get you through another weekend of too many patients, too much drama, and too little sleep between shifts, ER DJ presents another oh-so-apropos 21-track block of Music To Treat Patients By, for your listening pleasure:

"Don’t Come Around Here No More" – Tom Petty
"Shot Through The Heart" – Bon Jovi
"Cold As Ice" – Foreigner
"Baby Baby" – Amy Grant
"Can’t Always Get What You Want" – Rolling Stones
"Would I Lie To You" – Eurythmics
"Crazy Train" – Ozzy Osbourne
"Margaritaville" – Jimmy Buffett
"Hurts So Bad" – Linda Ronstadt
"Knockin’ On Heaven’s Door" – Bob Dylan
"Slip Slidin’ Away" – Paul Simon
"Another One Bites The Dust" – Queen
"Dazed And Confused" – Led Zeppelin
"Wake Up Little Susie" – Everly Brothers
"The Bitch is Back" – Elton John
"Nervous Night" – The Hooters
"Bloody Sunday" – U2
"Cocaine" – Eric Claptom
"Comfortably Numb" – Pink Floyd
"Every Breath You Take" – Police
"I’m On Fire" – Bruce Springsteen

Thursday, March 14, 2013

Some may cry "cowardice". I say Active Listening.

Baby Huey, late 20s, 6'6", and 290 pounds of him, was brought in by the local constabulary some number of hours earlier for "probable ingestion of PCP".
Which was very likely an excellent surmise, given that he wasn't brought to us by some members of the local PD, but by the entire shift in the division, some 23 officers, supervisors, a K-9, 2 sheriff's deputies, and quite possibly a tow strap attached to a black-and-white SUV.

It took an additional half dozen of our officers to adequately restrain him, and a not inconsiderable amount of Rx medication IM to sedate him back under the threshhold of combativeness, while maintaining his ability to breathe independently.

Consequently, when our never-without-a-smile 90 pound triage nurse was asked, in the wee small hours of the shift, by a calm and pleasant Baby Huey if he could please go home now, because he was feeling much better, she hesitated not one second in granting her assent, and pointing him towards the exit.

He thanked her, and then she watched him carefully, and with steady gait, calmy walk out past the line of patients extending across the lobby awaiting triage, and turn towards the ambulance ramp on his quest to return home.

Whereupon she calmly picked up the phone, and asked Security if they might, pretty please, take the trouble to retrieve Baby Huey - "yes, that's right officer, that guy from earlier tonight" from the ambulance ramp, "You can't miss him", and return him to our observation room where he had been resting until shortly before his request for self-discharge was granted.

And in moments, a veritable Keystone Kops clowncarnucopia of security officers, at least 6, went thundering down the hall and out the ambulance ramp. There was a loud thumpBANG, and then they rather calmly wheeled Baby Huey horizontally back past the same triage nurse's station, still strapped to the 200+ pound steel gurney to which he was also attached spread-eagle by four point leather restraints and waistbelt, just as he had been minutes earlier when he calmly walked up to her desk and asked permission to leave, standing and walking out on his own two feet, arms spread wide, and gurney projecting rearwards like his own Magic Backpack.

And as he passed by upon his return, he was very earnest, but polite, in explaining to the officers that the nurse had told him it was okay to go. But he understood why the hospital wanted to make sure he was all better before sending him home, and that we weren't sure about that status quite yet.

Wednesday, March 13, 2013

Pegging The Needle

So we've got a guy left to us by the PD, who were summoned because Skinny Dude, all 90 pounds of him, was acting the fool in public, and left to us because he also managed to acquire an open tib/fib fracture of the right leg in cavorting around on the roofs of cars butt naked before he was arrested.

He claims he must've gotten some bad pot. Doc Hearditall isn't buying that explanation. Either way, his leg's box-splinted, so we're just waiting for a bed on the ortho floor. Which we get, but unfortunately, about 2 minutes after the paramedics radio in to say they're 3 minutes out with a full arrest.

So the CNA someone gifted us with for the night, and I, get elected to pull Skinny Dude's gurney out and get him out of the center ring in the circus, and up to the Ortho floor where he needs to be, and please, before the main event gets here.

CNA, unfortunately, is of the "I'll get around to it when I get around to it" school of union hospital employees. So naturally, we're just pulling Skinny Dude, who only used pot, out of the circus at the exact moment that a dozen firefighters and paramedics are coming in, with a guy they're doing full CPR on.

All Skinny Dude sees is a lot of guys in really dark blue uniforms, and so he figures the PD has had a change of heart, and they're coming back to get him.

And with that brilliant misappraisal of his situation, who can blame him, as I'm trying to tell Miss Pokey to get a move on, for reaching out and grabbing anything he can get his hands on to stop us from taking him to those police-looking guys and all the ruckus, headed right at us?

Which, in this case, is the blood bank refrigerator with about 20 units of O negative blood for those traumas with no time to wait for a type and crossmatch. Skinny grabs ahold of the refrigerator and pulls it open.

Trying to duck around 8 paramedics swarmed around the incoming dead guy they're trying to save, I lean on the door, before Skinny can start grabbing units of blood, and turning this into a Hazmat disaster worthy of a B-grade horror flick.

So of course, Skinny grabs the blood bank Batphone. It's there because opening the refrigerator makes their phone ring when you open the door (which Skinny just did) so that you can let the blood bank know "John Doe GSW, we're spiking units K and L on him" and they'll know they've got a stat Type and Crossmatch coming as soon as we get a blood tube drawn.

So doubtless the nice little old lady hematology clerk on the other end of the phone was expecting a terse but calm professional report, when instead, she got the ear-shattering screech of Skinny Dude screaming into the phone "BITCH TRY TO KILL ME!!! BITCH TRY TO KILL ME!!!"

So now, keeping one hand on the fridge door panel, I reach the other hand over to hang up the phone, knowing that it's probably too late, and the clerk downstairs likely already has a blown eardrum and is possibly twitching into a stroke from the shock. As soon as I try to pry the handset out of Skinny Dude's hands before he decides to start hitting someone with it, like a mongoose he lets go and darts a hand to the now vulnerable blood refrigerator door, again.

This time, I lean my not inconsiderable bulk back against the door, thinking I've outsmarted him at last, and we can soon be on our way. Best laid plans.

Skinny Dude instead yanks 10 pounds of metal handle right off and out of the door. And now has a heavy metal weapon, complete with half a dozen screws sticking out. Deciding I'm not getting clocked with that, it's ON.

Worthless CNA is nowhere to be seen, most of the department extra hands are helping out trying to save Full Arrest Guy, and I'm going 5 rounds with Skinny Dude and his Spiked Mace Of Death.

I pry that too out of his hand just as the first hospital police officer arrives. We'll call him Officer Kong. He's a whipsmart black officer, roughly the size of a walk-in freezer, with a huge smile most times, and the moves of a college all-star linebacker, which he was until a knee injury forced him into other career choices.

Kong and I get along great, and we work as a team without a word. But just as I get the door handle out of Skinny's grasp, he pushes off the gurney, stands up to his full 5'5" height on the unbroken leg, and with Officer Kong holding his other arm, he proceeds to try to kick us with the broken leg, still in the cardboard box splint. I watch blood splatter, as he swings his leg, complete with today's extra knee joint in the middle of his calf, and watch it swing and bend like you expect a double broken leg to flex. Which is both fascinating and sickening to behold, if only I had the time to take to appreciate the sight.

You might have expected the excruciating pain from this to slow a guy down who'd only smoked some pot, but he was just getting warmed up. Kong and I finally get tired of dodging his foot as it makes the extra flopping pivot and flings blood everywhere except us - so far - and we each manage to grab a shoulder and vault Skinny Dude up and backwards onto the gurney. Then the two of us, waiting for more help and hard restraints, throw our bodies onto Skinny's chest to keep him from getting any crazier or grabbing anything else.

And all 90 pounds of him starts throwing 300 pound Kong and 200+ pound yours truly around like we were Barbie dolls in a bowling alley lane. We're being tossed 2-3 feet upward, and each time we come back down on him, he throws us up in the air again.

I should mention that this entire time, Skinny's been yelling "BITCH TRY TO KILL ME!!!" repeatedly and at the top of his lungs. While the full arrest is getting worked on by a dozen people 10 feet away.

Being face to face with Officer Kong, in between bounces I casually ask him, "Say, how do you think that new plan to cut back on security officers to only 2 people at night is going to work out?" (Which really is somebody's genius idea.)

So now I have to deal with Officer Kong laughing out loud to the point of shaking as we're both riding this tiny rodeo bull long past the obligatory 8 seconds.

Finally, several other officers arrive, hard leather restraints in hand, and we strap three of Skinny's four extremities to the gurney. For the broken leg, which he's flung every which way, we settle for wrapping his legs with a sheet and knotting it under the gurney to prevent its movement without binding it directly.

So as the CNA prairie dogs her head out from wherever she went and hid, and finally takes Skinny to Ortho, Officer Kong asks me what Skinny was on.

"Well, he swears it was just marijuana, but after the needle on my BS Detector buried itself past the red zone, I'm going with PCP. Ya think?"

Tuesday, March 12, 2013

Flawless Brilliant Logic

"So, why are you here in the ER tonight?"

"Because my baby she have feeber."

"Yes, 101.2. How long has she had a fever?"

"Oh, since maybe one hower."

And then, after the 4,000,000 time I've heard this, I just snapped. Grabbed the vitals machine, and clubbed her head into a fine pink stew until Security pulled me off her.

"Ma'am, just curious, but how much is your co-pay for ER visits? This has no effect on getting seen, I was just wondering."

"Is ten dollars."

"Okay, so here's the thing. If you want to be seen, we'll get you in, but we're swamped during flu season, and the wait even for the fast track peds clinic right now is about 4 hours. You understand that you could walk over to that drugstore across the street, buy yourself a bottle of children's acetaminophen liquid with the same $10 bill, get $4 in change back, and save 4 hours of waiting time that you'll never get back, right?"

"Oh jess, but for $10 I get to see El Doctor."

And then I realized I'd been thoroughly destroyed and outmaneuvered by Stephen Hawking-level logic by someone that, judging by her sign in sheet, is illiterate in at least two languages. Where else could someone whose uninsured husband may sell oranges at the freeway exit get to see world-class board certified emergency pediatricans for the bargain price of just 10 bucks?!?

Certainly not in Zacatecas, Calcutta, or Timbuktu. Just here, home of Broken Substandard Healthcare So Beyond Help That Only The Government Can Fix It.

And then I just snapped. Grabbed the vitals machine, and clubbed my own head into a fine pink stew until Security pulled it from my twitching fingers.




And then my alarm went off, and it was time to suit up and get to work.

Monday, March 11, 2013

63

I really have been a Shepherd of Gurneys, from way back.

I came by the job naturally.
Y'see, way back in the misty dawn of Time Before Nursing Ratios here in sunny Califrutopia, I really was given my own personal flock. While gainfully employed as full-time ER staff at the Busiest ER On The Planet(TM), I was assigned as the official third nurse in triage, which meant I was the one in charge of all patients either
a) too sick to sit in chairs, thus on gurneys, but not sick enough to get a room yet, or
b) admitted, too sick to go home, but not sick enough to require a room and constant monitorring, and no bed available upstairs, thus pulled out in the hallway.

And on this particular far-from-extraordinary day, that meant I was personally responsible for some 63 patients. Really. No $#!^, 63 people. (This was in addition to the department's normal load of full rooms, full waiting rooms, and ambulances with critical/trauma patients q 5 minutes, 24/7/forever.) Shepherd Of The Gurneys.

Which meant I had to do vital signs per protocol. Plus attend to requests for pain meds, water/juice/crackers, urinals/bed pans, and of course, should beds be ready upstairs, call report and transport them to the floor (tech help? As if...) and move the pending ones as yet untouched by physician hands into available rooms, based on the flow of acuity in this sea of humanity.

The sicker ones were in a "parking lot" right behind the other triage nurses, and the balance, some 50 or so, were distributed up and down the hallways all around the department.

If you remember the scene in Gone With The Wind where the camera pulls back to reveal Scarlett amongst the acres of Confederate wounded at the Atlanta train station, you're on the right track.

If we allow for a blazing speed of 5 minutes per person to find them, do their vitals, and attend briefly to any personal needs, that means it would take me over 5 hours to get from A to Z and back to A. Not accounting for new arrivals, admissions departures, and such petty things as potty breaks and perhaps wolfing down a sandwich for moi.

So the first thing I did, which took most of the first hour, was simply record a personal census of the names and locations of my people, and arrange their charts into some semblance of order. When I looked at them, I noted, unsurprisingly, that the guy I took over from, with the same assignment, had posted regular vitals on them at just about exactly 5 hours and change intervals, just as I'd calculated would be the case. So much for Q 2 hour vital signs. Making sure my supervisor was aware of the situation got me the Universal Management Salute, shrugged shoulders, and wasted 60 seconds. After that, it was off to the races.

I vitaled like a monkey on crack, and everyone other than paramedics coming in with full arrests learned in about 5 minutes to get the hell out of my way for the balance of the shift, whether I was getting morphine, a bedpan, or pushing a patient-laden gurney to the floor. Miraculously, I got every admitted patient upstairs, eventually; took in another ten or twenty new arrivals, and slotted everyone into a bed, as time wore on. No one died, no one waited for pain meds, and I actually got relieved for just enough time to, in fact, wolf down a sandwich and go pee once in 12 1/2 hours. I think there were less than 5 patients left the next morning to hand off.

Meanwhile, even at Hell Central, they had enough money in the budget to allow for extra facilities staff to strip and rewax the floors, because JCAHO was coming soon.

Not enough money for more staff, mind you, but enough to pay for two months of extra maintenance, floor repairs, fresh curtains, and another dozen items of senseless frippery to foolishly placate the officious clipboard jacktards and make them feel important prepare for the triannual certification by sucking up, asskissing, and rearranging the deckchairs on the Titanic tidying up the department.

Why yes, Emperor Nero, your fiddle solo was masterful! Shame about the capitol, eh?

Having survived Ordeal By Fire, I kept the scrap I'd used and carried, containing the original names plus additions, to that night's assignment list. I carried it every day hoping and praying that when we were being surveyed by the Brainless Minions of Stupid Shit that exemplify JCAHO on its best day, one of them would have the nerve to start asking me questions, or try to tell me how to do my job better. O please let that happen.

Yeah, and monkeys will fly outta my butt, too.
The JCAHO geniuses don't like talking to staff, especially night staff, at busy ERs, probably because just like everyone else, they don't like getting their asses handed back to them on the end of a pitchfork with some pithy comments for seasoning.

In doing some cleaning and de-cluttering recently, I came across a certain well-preserved scrap covered with names from not really that long ago, looking exactly like it did the last time I shoved it into a scrub pocket on my appointed rounds that night.

I wasn't Supernurse, and the nurse I took over from did the same job I did. My only takeaway, then as well as now, was that if you keep sending nurses in the emergency medical system up on that kind of high-wire, one day gravity's going to kick in, and the results aren't going to be pretty. We're people, particularly well-trained and schooled specialists with critical skills, knowledge, strength, and enthusiasm like you wouldn't believe.

But if you keep driving the car at 140MPH all the time, when something breaks, there's going to come a reckoning for ignoring the laws of nature. You can ignore reality, but you can't ignore the consequences of ignoring reality.

If you can't deliver smaller flocks, you damned sure better start getting more shepherds, and taking better care of the ones you have.

Nota bene.


Sunday, March 10, 2013

Diagnosis Of The Week

Once upon a time, prior to entering nursing school, using the time-honored "try before you buy" approach, I took patient care out for a test spin. While doing volunteer patient care with some of the best medical professionals (paid or unpaid) I've ever been privileged to work with, we had occasion to do a lot of community events.

One especially notable one was an annual two-day air show which always drew upwards of 500,000 visitors for the two days. Because jets are cool, and entry was free.

The plus for us was, with that many bodies, we were going to get business. The minus for the city involved was, with that many bodies, there was no way they were getting an ambulance into the site, and even if they did, it would create more problems than it solved. So for everything from sore feet to heart attacks, we were it.

Mind you, were were up to the task, both from a personnel stand-point, to the fact that we essentially set up a 20-bed treatment area in the former airfield fire station, which became Airshow ER for those two days every summer.

But bureaucracies run on paperwork, so every year, after things wound down, the local supervisor of constables would come around, and get the low-down on the numbers and categories of patients we'd treated, for everyone from the airport manager to the mayor, and 27 agencies in between the two.

So one year, Fearless Leader is giving Lieutenant Doright the annual tally of victimology: 

"We watered 20,000 cups worth of participants;
 had 852 people needing sunscreen;
6 difficulty breathings, resolved;
2 chest pains, both transported by city fire; 
3 diabetic emergencies;
8 pedestrian-versus-airplanes..."

"Sorry, I thought the planes were parked. Did they run over the...?"
"Oh no, sorry, what happens is, the people are walking around the parked planes with missile racks hanging down and sharp wings and such, and not paying attention as they gawk, and they bonk into them headfirst.
 Where was I?...
okay, 11 foot injuries;
412 heat-related complaints, all recovered after treatment;
and 4 elderly patients FDGB."
"Sorry, what's an FDGB. I've got 20 years on the street, and I've never heard that one before from the city paramedics."

"Fall Down. Go BOOM!"
"Gotcha. Don't take this personally, but I think you guys enjoy this business too much." 



Dear Readers, from that day to this, one of my solemn healthcare missions in life is to make FDGB as commonly used and accepted as SOB, GSW, AAA, and countless other acronyms in the medical field. I didn't invent it, it's in the Public Domain, in fact it's even made it into the Urban Dictionary after 20+ years usage, but it accurately summarizes any number of medical runs and sign-ins that you'll see in the course of your career.

So I humbly request that you join me in proudly using FDGB, every time it applies.

Friday, March 8, 2013

Dear Management

I hate to intrude upon your endless pursuit of JCAHO's infantile good graces, higher Press Ganey scores from the whining bastard drugseekers to whom you send surveys, and various other manifestations of professional career masturbation you indulge in, but some happy few of us are busy trying to save a few lives around here.

I wouldn't interrupt you playing with your org charts, fapping to your brilliant cost-saving moves, or the other various and sundry versions of Office Happy Time that must certainly fill your days in your office between surfing for web porn or planning your next vacation, or, please sweet Jesu! your pending retirement, unless this was something kind of important.

Now, I realize I'm only one of those lowly peasants who still works at the bedside, because somehow, when I enterred the profession of nursing, it was with some vague idea that actually caring for people in need would be involved. And I'm sorry I can't muster the enthusiasm for the Happy Gas they're sniffing in academia enough to want to put up with whatever artsy fartsy Theory Of How We're Really Really Important they're pushing, so that I could write you a scholarly article you might actually read, if not comprehend, but it seems I'm too busy doing what matters for the people who matter, and they're called PATIENTS.

In case you haven't bothered to, you know, come by the department and see what actually goes on (and judging by the fact that even after several years' employment here, most days you have trouble picking me out of a crowd, you don't) we're a little busier lately. A solid 10% busier, year over year, across the last decade, means we're now seeing double the volume with virtually the same number of staff. I haven't checked with personnel, but last I looked, I'm not getting paid twice as much as then. So in lieu of upping my salary, a few other suggestions come to mind.

1) You could, without requiring dynamite up your @$$ or a horrible headline in the local newspaper, come around at night, on weekends, and during holdays, and these not being your office hours, you could brush the cobwebs off a set of scrubs, put them on, and lend a hand. Not every night, weekend, or holiday - I'm not asking you to be chained to an oar. But once a month, just pull half a shift during the times and days you're not usually around. We get that all that Invisible Leadership you think you're providing must be important to someone in the hospital, even if we can't for the life of us figure out to whom, or what it is. But actually being around once in awhile would educate you about the place you're supposedly in charge of 100 times better than a stack of memos would, and some of your minions might actually get some idea that you give a damn for something, or even someone, like perhaps them. If the selfish motivation that it would better equip you to do your job is what you need to make the effort, I say whatever turns your crank. Just do it.

2) A secondary effect of this would be you'd get to actually see a lot of people who're overwhelmingly just names on a staffing matrix to you. (Of course, to be fair, the hellhole of employment your studied disinterest has created has also made the merry-go-round of getting hired and moving on as soon as possible a little tough for learning names before they're already out the door. So you might even slow down that revolving door too, but let's not go all crazy yet.) Which sudden notice on your part might lead to a view of who does what that's a little less inclined towards the relentless brown-nosers, once you see who's a doer, versus just a showboat.

3) These first two might even lead you to, once again, without dynamite shoved up your @$$, know who deserves a heartfelt "Thank You" for exceptional performance, and 5 seconds of recognition during shift change report, which won't cost you more than the 5 cents to spit an Attaboy/Attagirl out of your printer, and handing it to that person. The secondary and tertiary effects this would have on individual and group morale, as well as helping hone your subordinate managers' rather elastic idea of accurate performance reviews, without embarassing them, would be breathtaking. So for a few hours' time and a few cents a month, you could get better workers, better supervision, and better performance. Sorry to have to tell you what I learned in about 15 seconds, in a job where life and death was in the job description, at the tender age of 22, but it seems what they cover for Marine combat leaders for 240 years evidently hasn't filtered down to hospital management at your level.

4) Some other things you might notice are how constantly short-handed we are. Miraculously so on weekends and holidays. One hole in the schedule is a problem. Nine is a catastrophe. Don't yap about "nursing shortage" because there isn't one where we're concerned. What there is, is a shortage of hospitals willing to spend the time and effort to hire people, and do the commonsense things that every other business does to reward and retain the good ones, and discipline or weed out the bad ones. And when the holes in the schedule are techs, you have absolutely no excuse. I could put an ad in the paper today, and by morning there'd be 5000 ambulance company EMTs with skills, real-world experience, and a strong desire for regular shifts and the raise in pay that an ER job represents, lined up outside personnel to fill out an app. So not having droves of them in a ready pool for exactly the shortages we come up against nightly, shows that a little Surgilube up your hindquarters might help with the rectocranial impaction problem you seem to be suffering from regarding adequate recruiting, since forever, apparently. Just curious, but how much do you think it would improve satisfaction scores if we had enough people to take everyone to X-ray, ultrasound, CT, and upstairs when they're admitted, promptly, rather than 1/2 to 2 hours later, which increased flow-through times by cutting average ER stay-time in half? I'm just spitballing here, but it might actually save a life or two by not leaving sick people waiting outside unable to get in. Again, there seem to be some gaps in "How To Manage The ER 101" materials.

5) And speaking of materials, a little random visit now and then might make abundantly clear to you that as a 24//7/365 operation, it's a little beyond the pale to ask patients on a three day weekend to pee in their hands when we run out of urinals, because the waste of skin you hired to stock the supply room can't find his @$$ with both hands, a mirror, and an anatomical chart. We've also run out of, with regularity, things like bedpans, catheters, IV saline, IV needles, injection needles, blood culture tubes, IV tourniquets, and band-aids. But it's not like we need any of that stuff, right? And I'm not talking just once in a while, but this happens every frickin' week-end, since the Pope was in diapers. What would you ever do if there were an actual major disaster?? Given the annual operating budget, this situation is simply laziness, sloppiness, and slipshod stocking, not poverty. Does this guy have naked pictures of you with a donkey, or is he the CEO's nephew, or what??

So it's time for some tough love here. We know you like your job. We only ask that you actually do it. If you can fit it in your schedule.

Look at it like this: McDonald's sends their assistant managers, most of them younger than you by 20-30 years, to McDonald's University, and in mere days there they cover that the bulk of their job is two-fold:
Have enough staff to cook and serve the burgers, and
Have enough burgers for the staff to cook and serve.

Amazingly, an ER runs just about the same g**d****d simple way: just get us enough people to take care of the patients, and enough stuff to do the care, and we'll do everything else just fine. There's no worry about the customers coming in the door at Mickie Ds, and neither are we in any great worry about the 1 in 10 Trillion chance that tomorrow, no one will show up at the ER.

If you'd just take a chance, go out on a limb, and actually get the staff and equipment we need to do our jobs, and if, once in a blue moon, you'd actually say "thank you" to some of the people who're getting their butts kicked day in and day out to make your stats look good, and keep your travel agent in business, you'd be amazed at what a turnaround you'd see in the place you imagine you're the Kings and Queens of the Universe.

Sorry if that leaves a swollen purple bootprint on your ass, but sometimes it's the only way to break the suction and pop your head out of there.

Love and Kisses,
Everyone Who Works Here