Thursday, May 30, 2013

New grads Pt. III: Doing It

Day's going to come when you've passed your NCLEX, and gotten your first job. Sooner than you think. Once again, congratulations, and welcome to the major league.

If you thought you learned a lot before, try not to get your pants twisted too tight, but you ain't seen nothing yet. You're about to get the biggest education of your life, starting on Day One. It ends when you retire.

All your time in school, your prestigious diploma, and even that shiny new license after passing your boards document to any who care to admire them is that you are, now, certified by the state in which you live to be at least minimally qualified to do basic nursing, to the point that it's highly unlikely you'll kill anyone out of sheer ignorance, 80% of the time. And that's all it means, until you learn a whole lot more.

All three of the little epistles in this series are because all of you really are the future of nursing. I want you to succeed. Despite what you think, or how it may feel on some craptastic days (nights!), especially some in your very-near future, so do about 99% of your colleagues and co-workers.

So continuing in the spirit it's intended, a few final pointers as your embark upon the ultimate learning experience.

The aim of the exercise is helping people heal.
It's not getting you a bigger paycheck, lots of new friends, a date, a mate, or new toys. It isn't about stroking the doctors' egos, making your charge nurses happy, or being your co-workers' bitch. It's not even about making you better at what you do. All of those things will happen, if you do your part, and over time, more of the good ones than the bad ones. But the main one is that patients come first.

You're going to learn to hold your pee. Yes, literally. You're going to lose sleep, skip meals, stay late. You're going to be frustrated, offended, insulted, belittled, cursed, patronized, accused, and very likely even assaulted. Sometimes, all in the same day. It's a cruel world, and we're working at the nasty end of the stick. You will feel, and sometimes actually be, overwhelmed, helpless, angry, up to your eyeballs in other people's pee, poo, blood, and other body fluids that you'd really rather not care to acquaint yourself with, even by accident.

And you'll still be expected to do your job to the best of your ability, all day, every shift, forever. Welcome to the world of every one of your fellow nurses, and most of your coworkers. This is why it's called work. As Super Chicken reminded Fred, "You knew the job was tough when you took it."

The payoff, when you overcome all those additional hurdles, is that you'll get a lot of the other benefits this job isn't about. Which is still ancillary to the biggest payoff of all: your patients will get better in direct proportion to how well you do your job. And sometimes, they may, on occasion, say "Thank you."


People will bombard you with stuff verbally. Patients, coworkers, supervisors, families, bystanders, and busybodies. So unless you're deaf, it isn't going to be a quiet day, most any day. (And that's probably the last time you'll mention the "Q-word" within sight of your job, unless you want to find a voodoo doll with a remarkable resemblance to you, except full of pins, nailed to the staff lounge bulletin board.)

You're going to have to learn to hear it all, and separate the important stuff from the cacophony of background noise. Including from ringing phones and the callers they bring, overhead pages, dinging clanging buzzing PITA alarms, whining family members, and uncorralled children.

The biggest tip I can give is that when somebody who knows more than you tells you something, pay attention to them. It could be a doctor, another nurse, or the tech who's trying to tell you something. I repeat, pay attention to them. Listen to what they're trying to tell you. Remember that when you're just starting out, everybody knows more than you.

You've doubtless heard the phrase, "Nurses eat their young."
Uh, not so much.
There are a few soulless evil burnt-out bastards out there, and you'll learn who they are.
But mostly, nobody goes out of their way to set you up to fail, unless you go out of your way to ignore them when they try to help. Then, they'll happily watch you get crushed.
Some of them, nurses, doctors, techs, supervisors, patients, family members, and whoever else, have utterly abysmal people-skills, yet still have the patient's well-being and you doing your best well in mind. But every fish in the ocean isn't a shark, and every person you work with isn't a heartless jackhole.
Every one of YOU, however, are utter newbies, so until you aren't one, pay attention to the people who have been where you are, and know.
Grow a thicker skin if need be, and hear what they're saying to you.

The one time it's okay to run your mouth instead of your ears, when you're new, is asking.
Not questioning adversarially, but asking for information. How to do stuff, where things are, what the procedure is, the protocol, and ten million other things that you didn't have to know as a student. Because now, it's your deal.

A nurse is a computer with legs and arms.

If you're asking things, everyone knows you're thinking.
If you're asking the right things, you're thinking well.

It's also okay to ask for help. There are, of course, some unwritten rules.
Don't ask me to do something you can do yourself.
Don't ask me to give you information you could have gotten without asking. I'll tell you where to find it, and you can go look it up. If I don't know, I'll go with you, and then next time, we'll both know.
Don't ask for someone to do something like start a tough IV, or do an opposite gender cath for patient comfort, without doing something for them while they're busy doing your work.
Don't ask me how to do the same thing three times in the same week. Once is info, twice is reinforcement, and three times is you're an idiot.
Don't ask for help unless you give it at least as freely, if not more so.
Don't ask for information and then ignore it.

I, and we, all of us, want you to be the brightest and best nurse you can be, because we're going to need your help, and no one likes co-workers from the short bus. The only thing better than having a shift full of coworkers from top to bottom on the "A" team, is realizing you're on it, and earned your place there. Work with us, and we'll work with you. Screw us, and we'll screw you. Drag us down, and we'll carry you until you either learn to carry yourself, or we decide it's time to thin the herd. Believe me when I tell you that you don't want to see the bus from the underside.

You may be that one-in-a-million nurse who'll work at the same hospital from now until Social Security kicks in. But probably not. So get used to being the new kid on the first day of school, throughout your career. You'll change shifts, jobs, workplaces, and specialties, pretty much non-stop.

To survive and thrive that level of constant change, you're going to need at least a few people you trust.

You need at least one co-worker who's at your level, to tell you when your perceptions are dead-on, or if you're missing the forest for the trees. You're not everywhere, and neither are they, so other perspectives are going to help you fine tune your radar. And they have to be someone who you know has your back come hell or high water, like you have theirs.

You need someone at work that's older/smarter/more experienced, who you can go to for help, for wisdom and counsel, and to be a big brother/big sister/aunt/uncle. They will save your day, your career, and your sanity. Take your time, but when you think you've got one, hang on to them until hell freezes over, even if you move five states away. (In which case, find another one there, too.)

Have people who don't do anything remotely related to medical care. Someone who's a friend, who can tell you when you're not being you, or when you're in a bad place, bad mood, or bad job, without it being someone you might see at a staff meeting.

And take care of your relationships with significant others, spouses, kids, parents, and the rest of your family. They won't want to hear your awful hospital tales - that's what your co-worker friends are for. (Or, here's an idea, your blog!)

Love your family, be dedicated to your profession, loyal to your friends, a rock to your coworkers and colleagues, and a godsend to your patients.

And enjoy going to work. But don't love your job, because it'll never love you back.
Just get it done right.

You want to get to where work is work, and life outside is life outside. Both are important, for your patients, and your own sanity. Remember, no one's dying words were ever "If only I'd spent more time at work".

Do that, and before you know it, you'll be the one breaking in the rookies, and good at it.

Wednesday, May 29, 2013

New Grads Pt. II: NCLEX, and getting a job

So now you've finished school, but there's that one last hurdle between being an AAN (Almost A Nurse) and being an RN (Real Nurse): that damned NCLEX.

I'm going to give you the best strategy I know of for dealing with it:

(1) RELAX.
Seriously, just relax. Other than doctors and lawyers, you've just completed a more stressful program and course of knowledge than most people will ever deal with. (Seriously, any whiny undergrads or grad students from other disciplines, sorry, but you come up way short. Why? Because your homework during school didn't scream at you and shit the bed, literally, so spare us your puny protests. There are math geeks, and literature geeks, but there aren't any diarrhea geeks, so just accept your lesser status on this particular totem pole.)

And if you've made it this far, after fighting to pass your pre-reqs, then to get into your program, then to keep your instructors and clinical supervisors off your back and finish all your assignments and pass your tests and classes, you've got game, or they would've shown you the door long ago.

Besides, when you're relaxed, you both learn and perform better, and you're going to need to do both.

(2) LEARN.
Get one of the NCLEX prep manuals. Ideally, one with either a CD for your computer, or a code that lets you access their website, either of which gives you the chance to take sample NCLEX tests for practice and diagnostic purposes.

Take the sample NCLEX before you spend one minute on your manual. They should score you, and tell you where your strong areas are, and your weak areas.

Once you know this, review the NCLEX and your school notes and texts on your WEAK areas. Those are the ones you can improve the easiest, and they may simply be the areas you had the longest ago, and are rusty on. Or you had a crappy instructor for that subject. Or whatever. Just focus on building up your weak areas.

After you think you've done your job studying, retake another sample test, and see how you've evened things out. Lather, rinse, repeat.

By the time you take the actual NCLEX, you'll have done at least a couple of dry runs, so it won't be a shock to you.

(3) Prepare.
The current books tell you the average breakdown of what knowledge areas each test covers, and in what proportions. Get a grasp of that.
They'll also let you know how many questions, minimum and maximum, you'll answer, and how long you have to get it done.

A word on computer-adaptive testing, which hopefully is review for you.
I was going to be one of the last years of nurses that took the bad, evil, miserable old NCLEX: two days - 14 hours, 8 on Day One, and 6 on Day Two, of old-school SAT #2 pencil bubble filling, offered twice a year, en masse, to half the graduates each year, once in February, and once in August. If you booted your attempt, you were thrown back in the waiting pool for six months for another crack.

Now, you can just try again, and take it whenever. There are mandatory waiting periods if you blow it, and max numbers in a given time period, but you can schedule it whenever, and not have to take it with 4000 other students in a giant hall like the Bataan Death March of tests. So be happy you've got it so good.

I (oops) managed to stall after graduation, and thus ended up taking the first round of adaptive tests on computer instead. And it turns out, the results were the same for passing and failing for graduates who took the torture test, or the computer test.

Read what the current NCLEX review tells you, but when it was new, it worked like this: the computer has a bank of questions, from Level A, to B, to C, to D, to F. The first three questions didn't count against you. The computer takes your answers, and based on them, decides which questions to ask. It starts with a C-level question. If you get it right, you get a B-level question. If you get it right, you get A-level. If you get the first one wrong, you get a D-level question. If you get the D-level one wrong, you move to the F-level (nurse retard) questions.
After those first three, you're live. Get a certain minimum number right, cruise along at the A-level, and it stops after something like 70-80 questions, and you aced it! Get the first three, and every other one wrong, and stay on the F-level, and blow a minimum number, and after 70-80 questions, and it shuts off, and you flunk. Bounce along from level B to C to D to C to B to C to D, and it'll keep asking questions until you either climb up and hit enough A and B level questions to pass, or you max out after 200-something, or the max time limit, and you pass. Hit max time/max questions, and stick on the D level, and you fail. Hit it just right, and get enough C-level questions right and max out on questions or time, and you may just squeak by.

Odds are, you'll be zipping through the questions, it'll shut off after the minimum, and you'll know you either aced it or flunked it.

I was astonished when my test shut down after a little over half an hour, because I didn't think I'd gotten them all wrong, but I didn't think I'd gotten them all right.

I aced it.

I talked to a dozen classmates, and we all had the same panic reaction, and we all passed.

Other important points: You may be the person who'll be bouncing along at C level. Manage your time. Figure out how long you have per question for the max number of questions. It should work out to 30-40 seconds per question, worst case. So if you hit a question, don't freeze on it and try to puzzle it out for 10 minutes. It's multiple choice. Read the question carefully. If you can whittle out two obviously wrong answers, you now have a 50-50 blind chance: make your best guess, and move along. 30-40 seconds, in reality, is a looooooong time to think about four answers. Stay relaxed, read the question, understand what answer they're looking for, and pick the most correct answer. Then move on.

You'll probably do just fine.

Some other notes: In Califrutopia at least, your initial nursing license isn't good for 2 years, it's good for up to 2 years. Your license will expire, every time, on the last day of the month, the month after your birthday, every two years, forever.
So, for example, if you were born in July, your license will expire August 31, for your first, second, twelfth, and fifty-second time renewing it. Because that's how it is.

Okay, so who cares?

You. Because if you take your NCLEX in June, your first license will go past two birthdays, and expire August 31st, in thirteen months. If you schedule your NCLEX for August 1st, your first license will also expire after two birthdays, except that'll be twenty-five months. And you'll pay the same price for that first license. And after your first license, you have to start taking CEs. So do you want a license good for a little over 1 year, or a little over 2 years? Duh.

Unless you graduate in June, and your birthday's in January, in which case you don't want to wait 8 months to take your NCLEX. But if your b-day is close after or just before graduation, you oughta to know this. The state won't tell you this, so I just did.

Now, you studied, reviewed, got a good night's sleep the day before the NCLEX, aced it, and got your results. So how do you get hired?

(4) Act like you seriously want a job.

a) Nearly everybody everywhere expects you to have an ACLS card, along with CPR. Get it. If you're going to do peds, or ER, or anywhere kids may be in your patient pool, get a PALS card too. If you'll be dealing with neonates, get NRP.
(You know which you'll need because you already asked around before you graduated, because you seriously want a job.)

b) If there's anything else you need and can get, go do it.
IV/phlebotomy, 12-lead interpretation, Bulgarian sign language, etc.
If I'm the HR person, and you've got the 5 things I know you need, and everybody else has 2 or 3 or 4, all other things being equal, guess who I'm calling back first?

c) Whatever the dominant language in your area is, besides English, learn as much of it as you can. Spanish, Tagalog, Ukranian, whatever.
If you are or can become any level of functional in it, put it on your resume. Don't BS, but if you can stumble through your Tex-Mexican Spanglish enough to do a decent assessment, let them know you can take a stab at it. If you live in NY state, FL, or within 3 states of Mexico, learn Spanish, period. I don't have time to hear how unfair it is to you (it is) or how you wish we could boot them all out (we can't); deal with reality as it is, and learn to do your job better by learning to communicate, and make sure your job applications reflect your abilities.

d) Network like a monkey on crack!
Classmates, instructors, clinical coordinators, every charge nurse you worked for in clinicals, your neighbor's cousin the doctor/nurse/tech/financial clerk/lab tech/paramedic, or whatever. Anybody who can tell you where there might be a job is your new best friend.

e) Tailor resumes for different jobs
If you'd take a job in ortho or med/surg, have resumes for ortho for hospitals with ortho openings, and resumes for med/surg for hospitals with med/surg openings, etc.

f) Get the best job you can
If you can't find what you want, take something else, and be prepared to lateral across when you've made more in-house contacts, and racked up experience. Do a great job where you are, because that supervisor is going to be your new department/hospital's first interview call. Don't sabotage yourself.
And I realize you might be making more in tips serving cocktails, but get a medical job. Show you're serious, and they'll treat you like you are. (You can always pick up waitress gigs or whatever on the side, but a great review from the night manager at TGIFridays isn't going to be worth as much as good referral from the charge nurse where they hired you as a tech while you were waiting to take the NCLEX, right?)

g) Don't give up
I hated the Catch-22 "Can't get hired without experience, can't get experience without getting hired". I also managed to graduate at the one time in 20 years they were firing nurses nationwide instead of hiring them for sign-on bonuses. Many of you now can probably relate to that.
So I papered one entire wall of my apartment with the "Thanks for your interest, we'll keep your resume on file for a year, don't call us, we'll call you" letters. Really, an entire wall. Staying a little cranky amped up my determination to get what I'd worked for. And I got the job I wanted, in the specialty I wanted, with a training program, and without working in 5 specialties I hated while I held out, and did something else in nursing to pay the bills. Tough times don't last, but tough people do. (And 2 years later, when I shopped myself around, I was the one deciding who to call back when they were begging me to take the jobs they were trying to fill. The pendulum swings both ways, sooner or later.)

h) Don't burn bridges
You could get downsized, or need an extra part-time gig, or something perfect may open up somewhere else, or just want a change of scenery. Stay cordial and connected, and the world will always be your oyster.

Tuesday, May 28, 2013

New Grads Pt. I : Commencement

Today's missive, the first of three, is directed at those of you just-minted or imminently about to be so shiny new nurses.

First of all, congratulations on all your hard work. I know what you've gone through, and sacrificed, to get to this point. Pat yourselves on the back. You've definitely earned it.

For those of you not there yet, but approaching your turn: hang in there. Your day will come. And for frick's sake, hurry up! We can use the help!

Those of you about to be spawned as larval nurses, into whatever specialty, are going to need to know some things. Doubtless, you've heard them before, but in case I have any influence anywhere, you need to hear them again.

I titled this "Commencement", because you are at the bare beginning of nursing. In other words, despite a looming appointment with the NCLEX, and 2-4 years or more of pre-reqs, classes, clinicals, and drinking from a firehose of medical knowledge pointed at you since you began, in terms of your lifespan as a nurse, you're only now just coming out of your cocoon.

I can't tell you how many times I heard from older, experienced nurses, how long it would take me to know what the hell I was doing, and I would struggle to express how much it sincerely and royally pissed me off when they did that, but I can tell you all right now exactly how many times each incident pissed me off: that would be "twice".

Once when they told me so, and once when I found out they were right.

It really blows, IMHO, that we build up so much into getting potential nurses amped up about graduation. To me, it's like if we told Olympic high divers that the biggest day was the day they got to climb onto the ladder.

Because really, despite how much time, and mental and physical energy you've invested to get to where you are, that's where you are. You've studied the physics of diving, played on the trampoline, memorized the moves, done your exercises, splashed around in the shallow end of the pool with a lifeguard or ten nearby, but that's really all it amounts to.

You don't really learn how to do high dives until you jump off the board, and start doing the moves yourself.
You don't learn how to be a nurse until you jump off the board, and start doing the moves yourself either.

And from that first jump, if you pay attention to what you've been taught, and what you learn in the next few months, in order to actually start doing what you've set out to do, it's going to take every one of you, on average, at least one solid full-time year, and as much as two years, on your own, to be fully what you think of when you think of nurse.

If you aren't palm-sweaty scared shitless about that prospect, somewhere inside, whether you talk about it or not, you're a moron. Fear of screwing up, of killing your patient, or harming them, or just being a crap-headed idiot, is healthy, to a point. The point when it isn't is when it so rules your every waking thought that you can't function. Don't be that person.

But, as my brethren of the military persuasion say, "Embrace the suck". You're going to get help, and precepting, and watched, and managed. Some very well, and some of you, criminally poorly. I can't help you with that, because life isn't fair.

But even if you get the best preceptors in the world, who make sure you're competent at everything, and you check every box on every training sheet for everything they want you to know, they're all, sooner or later, going to reach the decision that it's time to push you out of the nest, and make you take a crack at flying on your own. And it's going to make you sweat, palpitate, hyperventilate, and maybe even shake and spaz out.

Welcome to the club.

If you aren't uncomfortable with what you're doing, you aren't learning anything. And for your first year-plus, you're going to be a sponge. And it's going to be just as hard on Day Two, and Day Twelve, and Day Two Hundred and Forty Three. Some of you may not make it past that. You'll quit. I wish you the best of luck with your future endeavors. And I really mean that. Think it over long and carefully beforehand, but if that's the answer, you have to make the right decision.

Some of you will decide, despite all you've endured, that nursing isn't what you want to do. To you, I want you to know something: if you really know that's true, and you get out of nursing, you are some of the bravest people I've ever met, and I salute you. And I mean that with every fiber of my being. I know what making that choice will cost you, but please believe me when I say that you're saving lives by making that choice, and saving your own soul. The people who stay in nursing long after they should have moved on are the biggest problem in the profession, bar none. Take what you've learned, and put it to good use somewhere else, and remember the people you learned with and worked with, and go with all my blessings. If you don't want to do this job, there's no paycheck on the planet that will ever keep you from being a bitter, miserable, pitiful excuse for a human being, and by not staying you're saving yourself, your coworkers, and your patients from ever having to deal with your evil twin. Vaya con Dios!

But most of you, the vast majority, will get through the tough times at the beginning, and the seemingly endless days (or, let's get serious newbies, nights) and somewhere down the road, you're going to wake up for your shift, and somewhere between rolling out of bed, putting on your scrubs, driving in, or getting report, you're going to realize, "Hey, after last week, there's nothing I can't deal with. I don't know it all, but I've got this!"

You're still going to be learning stuff, and you may occasionally get dropped in the deep end and be dog-paddling yourself to exhaustion, but you aren't going to wake up thinking you're going to wet your pants at work anymore, or wondering whether your co-workers will discover you're just a poser.

But the first step on your new journey, is coming to grips with the reality of that truth.
You, your instructors, your textbooks, and all the work you put into sucking the last drop of knowledge out them all, haven't made you, on this occasion, Nurse Badass.

But you've worked hard, you've trained hard, and you've learned well. You're like all those guys in the landing craft on D-Day, headed for a distant shore, as prepared as anyone could make you to that point, but there comes a point where the only thing to do for you is put you on the boats and head in.

So enjoy your graduation events, have fun as your family and friends hold their celebrations, and look forward with some pride at the paychecks you're about to get, because believe me when I tell you, you're going to earn every penny, every day.

And start psyching yourself up, because very very soon, it's time to hit the beach.

Sunday, May 26, 2013

Diagnosis Of the Week

Here you are, 24/7/365.

What you have is a shiny, red, painful, growing-like-a-goldfish-in-a-Doctor-Seuss-story bump, somewhere on your body. Your neck, arm, armpit, or some less public region.

What you think you have is how you sign in: "Spider bite".
What the doctor will tell you have is an "Abscess".

Thus, the correct diagnosis can only be "MRSA Spider bite".

Regular spider bites are relatively fairly rare.
For the entomologically tutored, the only venoumous spiders on the North American continent at least, are two:
Black Widows (lactrodectus mactans), and
Brown Recluses (loxosceles reclusa).

So unless you physically sighted one of the two above-named species at the scene of the crime, tiptoeing off with a guilty look on his or her multi-eyed face, and furthermore have, now and in your body, the signs and symptoms of insectoid envenomization with arachnid neurotoxin, please, stop blaming your little problems on spiders.

MRSA, carried not by the imaginary MRSA Spider, on the other hand, is a particularly disease-resistant strain of the bacterium Staph aureus, which someone you've come into contact with has given to or deposited upon you, and which may even now have colonized your body. We know this because you've been seen here for three other "spider bites" in the last six months. Laymen not medically trained often refer to this little factoid as a "clue", not a license to impugn the motives and culpability of every arachnoid in your world.

There's a way around this. Actually several.
1) Wash your nasty ass, ideally daily, and using not only fairly warm water, but also a decent scrub brush or cloth, and any number of personal hygiene products hitherto strange to you, most specifically soap. Lather, rinse, repeat.
2) Encourage the unheard of approach of similar behavior amongst your spawn, your clan, and your significant others.
3) Get a prescription for the antibiotics to kill the MRSA, and actually follow the directions and take the pills, on schedule, until they're all finished. I know how hard this is, but make an effort.
4) Do the same for every one of your spawn, clan, and significant others who have a similar history of recurrent "spider bites".
5) Scour your nasty hovel, with any number of bacteriocidic products, like Lysol, Pinesol, etc. Going as far as to actually burn your shanty to the ground is a bit extreme, but as I haven't seen your living conditions, I'm not going to rule it out immediately, sight unseen. Desperate circumstances may indeed demand desperate measures.
6) While you're at it, avail yourself of such radical notions as sweeping, vacuuming, throwing away garbage, and killing all bugs, rodents, and other vermin in your hovel. Clean out the places they live, and deprive them of the food they eat.

I know how hard it is to not live like a hobo in a third world roach motel, but think of it this way: an hour with a mop and a bucket of warm water, followed by a long hot shower, hurts a lot less than having our P.A. slash into that big nasty welt on your butt and dig around to get all the pus out. Your efforts, unlike ours, won't usually make you let out blood-curdling screams, and housework seldom, if ever, leaves lasting scars. Unlike an I&D.

It's your hide, and so is the choice.

But the needles and scalpels are all us, baby.

Monday, May 13, 2013

Mrs. Brown

Believe it when I tell you that when your pending ambulance run patient is preceded to the ER by a waiting police officer, it isn't going to be a good thing.

And police officers, not frequently given to exaggeration, will seldom capture the full magnitude of the situation with the short form of the story. Only the pain of actual experience will bring appreciation to you like the dawning of the sun. And by then, it's too late to run away. With years of experience, I've worked it out. And sometimes, I still wish I'd tried to run.

Mrs. Brown was absolutely one of those times.

Officer Taciturn's opening line, before her arrival, was attention-getting in its own right:
"When I opened the driver's door, the funk wave drove me back, and nearly knocked me unconscious."

And no, he wasn't referring to her George Clinton CD.

Then he backed up.

"I pulled her over when she blew through a red light. She was pulling out of a drive-through fast food place. So when I got up to the car, I was totally unprepared for the experience. She didn't have a license or registration. But she'd been living in her car for, she said, three years. Apparently, without leaving the driver's seat ever in that time. I mean living in her car."

Which was apparently the cue for the paramedics to arrive, along with a light task force, all eight of them maneuvering 500 pounds of woman into the ER, and to my open room.

I couldn't tell much about her, because they'd wrapped her in two of the big vinyl/Tyvek yellow hazmat patient blankets, and a couple of them were taking hits of air off their SCBAs as they trundled her along.

I can say that the wave of miasma emanating from her gurney cleared a path from the door to my zone.

The firefighters tenderly shifted her off the backboards they'd used, and slid the entire delivery onto our bed, with touching delicacy.

Then I found out it was because they didn't want to disturb any of the...contents, of the package.

The lead paramedic, a gentleman of long acquaintance, apologized for bringing her to us, and specifically to me. "I'm really sorry guy, but here she is. Mrs. Brown, chief complaint of sitting in her car for three years, unable to walk, and sitting in, as best as we could determine, over three years of fast food wrappers and mounded feces. Her welfare checks and whathaveyou are apparently direct deposit, and she goes to the only full-service gas station for miles to fill the tank, and eats every fast food drive up on the planet, so she never has to get out of the car. We would've done a more thorough exam, but she's AOX4, and our eyes were burning out of their sockets, so we just loaded her up and came in, once we got the extra help."

"Don't feel too bad, bud," chimed in Officer Taciturn, "the guys at the Impound Yard still have to inventory the vehicle contents. They're going to die when they see inside her car."

My tech came out, the patient's arms being accessible for BP and other vital signs. He was on the verge of launching his dinner, and excused himself quickly with the muttered benediction "Good luck!"

"Hey Maverick, what was that truck-driving school on TV? Truckmaster?"

I proactively gowned up, face-shielded up, and mentally made my peace with God before entering to do a head-to-toe physical assessment. She did, in fact, have toes, somewhere, in what can only be described as pounds and pounds of her own compost.

The doc, sight unseen, ordered baseline labs and a 12-lead EKG, which I drew. Then I started marshaling my resources for the inevitable decontamination this was going to require while the EKG tech had her turn in the pit.

The charge nurse, in a fabulously understanding act of compassion, discharged one of my patients for me, and moved the others to nurses with other assignments. And our chest pain nurse for the evening was underutilized, and rather than ducking it, selflessly elected to help me on my mission. Usually you don't see that kind of bravery outside of combat.

We arranged piles of towels, washcloths, and basins, and a separate linen and trash bin apiece, and made a deal with the tech I shared: he could stay outside, as long as he brought us all the basins of warm water we requested, until we finished. He said "Deal!" so fast I almost made sure I'd heard him by asking him to repeat it. Too late, because he'd already scampered off to the utility sink with a cart and half a box of empty wash basins. Normally I never delegate "Code Browns" to techs, but I will share them. But clearly, this wasn't normally. Now there was nothing left for it but wait for the chest pain nurse to gown up with me, and head back inside.

Into the Valley of Death rode the six hundred. Or actually, the two.

What made the most sense was to start at the head and work down each side to the knees, then do the other side, and finally tackle the lower legs and feet. I'm not Catholic, but if purgatory exists, the CP nurse and I each worked off at least twenty years' apiece for what we suffered during the next hour. We washed, rinsed, soaked, scrubbed, scraped, and chiseled excrement off that lady, from places on the human body I didn't think you could get poop into, until she was as clean as human hands could make her. We piled the discards, the original sheets, her shreds of clothes, and anything else into not the laundry hamper, but the hazmat burn bags.

Then had three different custodians and the night maintenance supervisor bring all the room freshener they could get. Each one questioned us in turn before entering, then went in, then wordlessly emerged and went straight to the wallphone to ask for more backup, which is how the super ended up showing up with a case of the stuff, and additional cleaning supplies.

Over an hour later, during which time happily nothing more serious showed up (or it did, but no one, and I mean no one, was going to disturb us for something as petty as a mere Code Blue), like the man in The Rime of the Ancient Mariner we emerged, sadder but wiser. And shortly afterwards, so did Mrs. Brown, smelling the closest to roses she had in three years, complete with sores and abscesses, but no longer encrusted to the hips in her own filth.

Report to the floor was a special treat, and the ward charge nurse brought us candy after they saw what they got, versus what they expected.

And yeah, it happened during Nurse Week of that particular year, too.

Tell me again what a wonderful, easy job we have, and that fabulous pay for what we have to do.

Friday, May 10, 2013

Victory Lap

Long before I even considered becoming a nurse, in fact before I was born, before most of you were born, back when John F. Kennedy was a shiny new president, Miss Daisy started her career as a nurse in the emergency room.

Back when ambulance drivers were usually morgue attendants, police officers, or drivers from the hospital, before the doctors were board-certified, before pulse oximetry, defibrillators, telemetric monitoring, ultrasound, CT, or CPR.

When an IV meant a needle, not a catheter, the IV bottles were glass, and so were the test tubes, and you spun your own labs, sterilized your own instruments, and sharpened your own needles between injections, she was taking care of the same cast of characters as you and me, except they all had short haircuts and narrow ties, and women wore dresses.
Including the nurses.

And dress, shoes, and those stupid caps came in any color you wanted to wear, as long as it was pristine blazing sterile white. Hospitals housed nurses in dorms (because calling them sharecropper houses on the plantation was a bit too close to home) and they had rules and a curfew.

I spent most of the last 10 years working alongside Miss Daisy in triage, at one of the busiest EDs in the country, and I'm here to tell you there isn't anything that gets by her any day of the week.

There may be some few of you out there so smart they never learned anything from anyone else, but instead figure it all out for themselves. That isn't me. From nursing instructors, Red Cross instructors, supervisors, charge nurses, co-workers, colleagues, tech, doctors, and anybody else, I've been the beneficiary of learning what they could pass along.

And that includes, in no small part, someone who's been a nurse in the emergency room for over 5 decades.

Nursing Tip: When the hospital House Supervisors refer to one of your co-workers as "Mom" in her presence, and they aren't related, you might want to pay attention to her.

I bring this up, because I found out today that after all that time, she's finally decided to retire from the boundless fun and good times that are the modern emergency department shift.

So wherever you are, there's a nurse or twelve that's probably helped you more times than you can count, and done it without cutting you off at the knees or embarassing you, when you asked for help, and paid attention to them.

My humble suggestion is that you don't wait until some misty day in the far-off future to pass along your appreciation for their help, their wisdom, and their example. They certainly deserve it, and you owe no less than giving your heartfelt thanks.

If it were up to me, Miss Daisy would get a parade through town. She certainly rates it.
As it is, I'm going to leave a polite suggestion that the CEO and VP of Nursing might want to get behind a little more than a gift card to Starbuck's for her on her last day. And then I think it's time for me to make a trip to the flower shop before I swing by the ED on my day off.

Thursday, May 9, 2013

Hot Baby

Hello again, motherfathers.

It's your turn today.
I realize that just because it's probably covered in "What To Expect: Baby's First Year" in half a dozen places, there's no excuse for thinking any of you parents have actually READ anything like that. Because that would just be silly, right?

So, baby has a fever.
How would you know? A rare device, known as a thermometer.
So maybe, just for the helluvit, buy one, read the directions, and learn how to use it.
And pay attention to why we do rectal temps on peds under 12 months, because it's the most accurate, not because we want to molest your child's diapers.
So if it's 101 or higher, it's really a fever. Not 99. not 99.9.

What to do, what to do??

Here's a Top Secret - Presidential/Codeword level solution, that's usually only available to highly skilled professionals, for treating the enormous medical emergency that is most fevers for children from 6 months to 6 years of age:


What's that? You say you have that at home? Well, let me fill in the gaps in your parental caregiving: it only works when you GIVE IT to your child. (!)

Easy there, have a seat, put your head between your knees, all that blood rushing to your head can give you a little rush at times, right? Take a deep breath, because now we're going to go full-tilt CRAZY:

You can even give it AGAIN, every 4 hours!!

OMG, who knew?!? I mean seriously, it isn't like it isn't written on the bottle, on the paper inside the box, and on the outside of the box. How would anyone find it that way, right? I mean, if it was REALLY IMPORTANT, clearly they'd have hired skywriters to come and fly over your house once a week, or even sent the Goodyear blimp over the neighborhood during cold and flu season.

But wait! There's MORE!!

I know this is news to many new parents, but fevers don't usually go away after one whole dose of Tylenol. But that's okay, motherfathers.

You can not only give it at home, and keep giving it at home, you can keep doing it for UP TO THREE DAYS!!

Contain yourselves. I KNOW how much wild fun it is to bring all three-four-five of your not-sick children, along with the one sick one, sign them all in "since you're here anyways", and sit around for a few hours with all the kids who might have RSV, flu, meningitis, whooping cough, not to mention all the suicidal adults, and the ones with blood spurting out of their heads (and then there are the patients like that, too!).

But instead of not-getting-a-babysitter, and parading the whole clan down to visit us for a not-being-sick waiting room TV party, you could actually take a stab at managing the lethal tropical disease "fever" at home for those three days, and see if it breaks on its own. And trust me, it won't hurt our feelings one bit.

Now to really blow your mind:
1) you can give accurate weight based doses, instead of age based doses of acetaminophen (Tylenol). Holy crap!
a) pay attention to your child's weight at each regular doctor's checkup, or >gasp!< get a bathroom scale of your very own, and then
b) follow the AAP doctor's recommendation of giving 10mg of Tylenol per kilogram your baby weighs!
So if kiddo weighs 8 kilos, that'd be the 0.8 line on the dropper in the Tylenol bottle.
If kiddo weighs 16 kilograms (35 pounds and change) that'd be two droppers full to the same 0.8 line!!
Wow! Math! It's like...Rocket Science!!!
2) if your child is over 6 months of age, and has no kidney or liver issues, or other concerns (your pediatrician can cover this in 30 seconds at a checkup)
you could ALSO give Children's IBUPROFEN liquid!
***Pay attention, read the label, the dosage and frequency is different than Tylenol.***
For instance, ibuprofen is every 6 hours, whereas Tylenol is every 4.
But hold on to your hats:
You could, for example, check for fever, and give Tylenol at 12.
Then check for fever, and if it's back, give ibuprofen at 3.
Then check for fever, and if it's back, give Tylenol at 6.
Then check for fever, and if it's back, give ibuprofen at 9.
Then repeat all of that again, every 12 hours, for three days, and only THEN come in to see us. And following that example, never overdose your child, but still keep them comfortable by treating them every 3 hours instead of every 4 or 6. It's a science miracle!

What's that? You say the fever keeps coming back?
If you give the medicine, and the fever doesn't go down a half hour later or so, THAT is a good reason to come in sooner.
If you give the medicine, the fever goes down, and comes back in 3-4 hours, THAT is called a normal fever. Which is why you keep checking, and keep medicating it. 'kay?

Now, at the other end, when the fever gets over 103, there's a few things you might try.

First, for mi amigos whose ethnicity saw their parents and ancestors originating from anywhere between, say, El Paso and Tierra Del Fuego, you could, as a suggestion, remove the t-shirt, pants, onesie, socks, booties, mittens, jacket, scarf, fur cap, four blankets, and the three rolls of Reynolds Wrap great grandmama burrito-wrapped your bebe inside. Wait about 5 minutes, then re-check your nino/nina.

If it's really over 103, it's time for a tepid (not hot, cold, or icewater frigid, just a wee bit comfortably cooler than body temp) bathtub trip. In WATER. Not alcohol, or any other thing. Please don't wait until your child's "Motherfather, I'm Freakin' ROASTING!" Febrile Seizure Attention-Getting Alarm goes off. Trust me on this.

Now, if you've done all this first (Thank you! Thank you!), and/or your child is less than a month or two old, it's Friday/Saturday/Sunday night, or a three-day holiday weekend, and/or your pediatrician is on vacation in Timbuktu, or your child had the febrile seizure, or is also throwing up the medicine and everything else for more than a day, or also has a screaming headache/stiff neck/can't stand the bright light, or is tugging their ear(s), or is being treated for any form of oncology problem, thanks, and come right on down to see us.

But don't think you have to torture your kid by not treating their fever, just so we'll "see it".
If you tell us your kid had a fever, we believe you. Having them come in screaming, and with lava shooting out of their heads, really isn't necessary to sell us on the idea that sometimes babies get sick.

All we ask is that you take a crack at handling the simple stuff, for your sanity, and ours.

Wednesday, May 8, 2013

You Put A What In Your Where?

Last time, we focused on new holes in your outside.

Today, we'll look at the other end of things, so to speak. That hole that came already installed when you came from the factory.

Sorry, yes, we're going there. Or rather, you've already gone there, or will someday. Ask me how I know...

See, the thing is, if you've seen something in the average supermarket or hardware store, the odds are that someone somewhere has tried to insert in someplace rather...awkward. And that probably includes ladders and paint buckets, though I have no actual experience with that patient. Yet.

But I'm still relatively young, so who knows.

I know you think it's terribly clever when you cryptically write "Personal problem" on your sign in sheet. But it's not, because we're going to ask for the details. And then, my charge nurse and 5 docs in back are going to call me and ask me what's going on with the sign in on the tracker. So pardon the entendre, but just put it out there.

We're not going to announce it over the outside PA or anything.

Back in the day, when x-rays were still on film instead of computerized digital miracles, we used to have an x-ray viewing room. When an x-ray tech said, "Hey, check this out" I thought nothing of it. But upon seeing over a foot of latex product from Doc Johnson waaaaay too far up someone's alimentary canal, I was glad I hadn't been drinking a cup of water or coffee. And I was really glad the lad involved was in another module, because I couldn't possibly have kept a straight face for two seconds.

Worse, the accomplice/girlfriend was there with him, and he/they had waited three days hoping things would work themselves out, to no avail. Surgical removal, sports fans.

Another time, one of our docs treated a gentleman who tried to plausibly maintain that he'd just happened to be changing a light bulb, naked, at 2 AM, slipped, and fallen in such a way that the intact lightbulb had boldy gone where no man had gone before. When no one over the age of 30 seconds was buying the story, he angrily proclaimed "So?! I'm not GAY or anything!"

My response is, no of course you aren't. And it wouldn't matter if you were.

What you are, is Curious George's stupid cousin, minus the prehensile tail.

And heaven help you when all bulbs are those spaghetti swirls, let alone if the glass used isn't up to spec. Yikes.

Don't think it's all guys though. (Actually, they're only about 90% of cases.) When you're a female who sits on a plastic chair, and everyone keeps looking for their cell phone going off on vibrate until they all realize it's you, well, welcome to the club.

The club of people with light bulbs up their keester, lost toys gone astray (they don't all end up on an island near the North Pole), or batteries up in your urethra (yes, really!), just among the more noteworthy exemplars.

So, as a PSA, a few tips:

1) I'm not judging your choice of playgrounds or toys, but if you end up in the ER, you're doing something (probably several things) wrong. I've heard rumors there are books and manuals, which you might wish to consult before your next excursion in the bedroom turns instead to a vist to one of our gurneys. "Trained professionals. Closed course. Do not attempt at home." isn't just for car commercials.

2) Whenever personal lubricants are involved, please kids, use a safety rope! Slippery things will get away from you, and you can't wish them back once they do.
And "Oops!" is not a safeword.

3) Before inserting anything anywhere, bust out a smidgen of logic, and mentally wargame out all the possible decision trees of what happens if your chosen implement(s) breaks, shatters, lodges, disappears, or what have you. Then work around those problems so they don't happen because they can't.

4) This is especially true if you're the accomplice: If your relationship isn't strong enough to withstand a possibly red-faced mutual trip to the ER despite following #1-3 above, then mayhap the original adventure might have been skipped as well, or at least kept a lot more on the vanilla side of the spectrum. Find something more fun to bond over than one of you waking up nauseated in post-op, when the surgeon returns your piece of errant property to you. Matter of fact, if you're going to blow $10,000 on a date, make it Paris or Tahiti, not Main Surgery.

Tuesday, May 7, 2013

Wound Care 101 For Dummies

For today, a few thoughts on that hole you made in your slipcover:

Prior to the dawn of the 20th century, and inoculations and antibiotics, "simple" cuts and scrapes that turned septic accounted for a respectable number of annual deaths.

So for your general fund of knowledge, if you cut, punctured, burned, got bitten by anything*, or otherwise screwed up the factory finish on your shiny pink carcass, unless you were bathing in Betadine at the time, it's infected.

Now, mind you, your ordinary immune system can handle quite a bit, but there's nothing quite as good as prevention when it comes to infections, which is 100 times better than treatment after you gave it a good head start. So let's cover the highly secret, only available to medical professionals, revealed in secret lectures during training, method to prevent a lot of trouble for you:

Go to the sink or shower, and wash out the wound. Using soap isn't a bad idea either.

If you have phisodermahexagoo, great, but plain old soap isn't bad either.
If you have a bottle of Betadine (Solution, NOT Scrub), and you aren't allergic to iodine, please, alternate that with the washing, i.e. water-betadine-water.

Quite literally, lather-rinse-repeat.

Every medical student learns "The solution to pollution is dilution.", right?
So keep washing, and washing, and washing, until it's really next-to-godliness clean.


Yeah, yeah, call the waaahmbulance, and get over it. The treatment for losing a pint of blood is...wait for it...a glass of orange juice and a cookie. That's how the Red Cross treats people who donate a full pint, 24/7/365. Unless you're spurting blood forcefully, you aren't going to lose a pint washing the wound.

While you're washing it, take note:
Is it all the way through the skin? (i.e. can you see some of your stuffing down inside there, like fat, muscle, tendons, bone, etc.)
If that answer is "Yes", you've already answered the "Do I need stitches/staples?" question.
Finish washing it out, cover it with clean gauze pads, and wrap it securely. You may need to apply firm pressure for several minutes, and elevate the part higher than your heart, to get the bleeding to stop. If we're talking arms, legs, or head lacerations, there isn't much likelihood that you can't control the bleeding, unless you have underlying issues like being a hemophiliac, or if you're taking aspirin or coumadin every day to decrease your risk for things like clots, strokes, and heart attacks. If that's you, take a few more minutes with the pressure and elevation.

Once things are stabilized, have someone take you to the ER.
If they don't stabilize, call 911 to take you to the ER.

And when you get there, one of the first ten questions we'll ask is "When was your last tetanus shot?"
If it was less than 5 years, you're good.
Between 5-10, or for larger wounds, you may get a booster.
If it was more than 10, OR YOU DON'T KNOW, you're getting a booster.
{Hint: Write "Tetanus booster", and the date, on a Post-it, and stick it to the back of your driver's license. Then you'll have it, without having to remember it.}

The description of someone who dies of tetanus (old term "lockjaw") is one I reread recently, from an early 1900s era description. Picture someone bent like a bow, with their head and heels touching the bed, and their body arched to the ceiling, as all their muscles go rigid (tetany) until they finally die from asphyxiation from paralysis of the muscles of breathing, fully conscious, dehydrated, hungry, and in incredible pain, with no possible cure, as they suffocate. That's what happens when you don't get your booster, if tetanus takes over. It doesn't live on rusty nails, it's everywhere. The spores sit dormant on everything forever, including in the dirt on your skin, and if they get in you, and make a home, and you don't have current immunity from inoculation, put your affairs in order.

Or stop crybabying, and take the shot.
I usually ask my patients: Shot? Or Horrible Death? Shot? Horrible Death?
I have yet to be turned down, although I've seen some godawful crybabying and whining.
Please don't be That Guy.
(Though if you're the 6' 275# Crip with four gunshot wounds, who's crying about a 1" needle like I was going to castrate you, I'll probably blog about you too, just like that giant pussy.)

That's it. They numb the area with a local anesthetic (another couple of shots) then when you can't feel it, they clean it out some more, make sure you didn't slice anything else more important, like tendons or blood vessels, they stitch or staple it closed, you get them out in a few days: problem solved.
Keep it clean, dry for a couple of days to let scabbing seal the holes, and watch for infection signs, then keep the follow-up appointment to take them out. This isn't rocket science.

Now, about all those other things you want to do.

Hydrogen peroxide: it bubbles up, and looks all sciency and high-tech.
Unfortunately, it only kills organic stuff, and only what it hits. It doesn't penetrate very well. And it stings, because it's killing healthy tissue. It's better than rubbing doggie poo in the wound, but it's not a good choice unless your only alternative is the doggie poo.
(Save it for getting the blood stains out of clothing - like scrubs; ask me how I know - carpeting, and upholstery. Like if you need to move the body before the cops get there.)

Alcohol: kills germs, if left in place for 10-15 minutes. During which time it's slightly more comfortable than pouring scalding lava on the wound, and that's once again because it's also killing healthy tissue. Save this for people you really, really loathe, and be sure to duck after you put it on, because they're going to swing at you - once they let go of the ceiling.

Merthiolate: (or, as Bill Engvall calls it, "monkey blood"). A tincture (weak solution) of iodine, popular with people from circa 1930-1960. If you're going to use iodine, don't dabble. Get Betadine, and go full strength. You're supposed to be doing first aid, not art class.

Everything else that's not water, betadine, or topical antibiotic ointment: probably belongs in the same category as doggie poo.
This includes butter, Crisco, dog spit (hey, ever notice that dogs eat their poo?), and most other magical witchdoctor concoctions your grandaunt, shaman, or witch doctor told you would work. The only exception is topical honey, provided it's covered with the same clean dressing afterwards, you're on a desert island, and there's no drug store or ER anywhere.

If your wound is superficial, not requiring stitches, your tetanus shot is up to date, and you decided to skip the ER visit, put some topical antibiotic ointment on the injury, dress it with a clean gauze and a good wrap, and change the dressing daily, watching for any signs of infection.
If you see any, come in anyways.
Ditto if you waited over 12 hours for something you knew needed stitches, but you're lazy or brain-challenged. We aren't going to stitch it up after half a day, but you may still want/need the tetanus booster or antibiotics, especially if you noticed it's growing red streaks up your arm/leg, or it's huge, hot, painful, and/or draining nasty pus.

For the other 90 million people who can't grasp this, we'll be ready and waiting to scrape the peanut butter, drywall spackle, axle grease, and every other wild thing out of the holes and treat the wound. For the few folks who read this and pay attention, thanks. This'll just be our little secret, 'kay? 

*("anything" includes, but is not limited to, power tools, power fools, people, dogs, cats, small pets, large pets, wild animals, fish, birds, reptiles, insects, velociraptors, vampires, werewolves, Bigfoot, and alien embryo implants bursting from your chest. Clear?)

Monday, May 6, 2013

Walking In Glory

I had intended to resume something more like regular posting this past weekend.
Life had other plans.

I don't generally blabber deeply personal details.

But this weekend, my beloved mother, described by more than one person outside our family as the Katie Elder of my clan, after nearly a 90-year run, and in declining health recently, passed quietly and quickly in her own bed, at home, relatively painlessly, and with family and friends at the bedside.

Rather than being overwhelmed with grief, I am thankful for the easiness of her passing, the ending of her struggle, and the fact that she went exactly as she wished, where she wished, and how she wished, without any fuss or fanfare, and without being a burden on anyone.

I know where she's spending Eternity, and she'd booked those reservations over a lifetime, so the only sadness involved on my part is that the suddenness didn't permit me to be there at the end, and thus the inability to say that final goodbye.

At some point, when things calm down, I may perhaps compose a proper tribute, but if you mixed equal parts June Cleaver, Granny from the Beverly Hillbillies, and Maureen O'Hara, you'd get Mom. She was tough as nails and feisty as kittens, and the red hair and Irish ancestry wasn't just for show.

She lived through three sons, long enough to see grandchildren and great-grandchildren, who if they do no more than live a life as well-regarded as she lived hers will be well-off indeed.