"I'll take "Words That Rhyme With 'truck' for $1000, Alex..."
Pediatric codes are the worst. Like somewhere between merely horrific, going all the way to hellish. We're talking three-pages-of-code-notes-charting hellish.
Always.
ALWAYS.
Every time I do one or see one, I pray it's the last one I'll ever do.
EDNurseasaurus had a post about MA and staffing ratios, and a very typical shift in any ER in the country. I may have covered this on this blog before, but it bears repeating:
CA calling.
1) I started in the pre-ratio days.
On but one memorable night in Busiest ER On The Planet (no, really!), I was the third nurse in triage.
My assignment:
Everyone coming in on ambulances too weak/fragile/fall-prone to put in a chair.
Everyone seen, treated, admitted, but not needing a monitored bed, so pulled out so we could hot-stack new patients in their old rooms, and the pre-admitees moved to the hallways.
All the traumas downgraded from trauma monitoring, and in the back hallway.
The fresh chest pains who needed to be moved to the EKG tech booth, then back to the triaged-but-no-bed-open pit.
Move the admits to the floor after calling report, when beds become available: no tech. 18 floors.
Get food/water/urinals/bedpans/blankets/pain meds/barf basins for any and all of the above.
Discharge anyone seen, treated, and released in my flock.
Total body count tonight, just for me: 79. Seventy. Nine.
I shit you not.
As I received report from day shift, thinking he was kidding me, and then finding out he was serious, I did some napkin math: at 5 minutes apiece for vitals, that's 12 an hour. 6 + hours to get from A to Z, and start with A again.
"Yeah, that sounds about right." he confirms.
He only tells me the highlights on the 10 sickest ones. The other 69 are either unknown, stable, or GOK: God Only Knows.
I look at his vital signs updates. In our 1-2 hour standard-of-care ER, they are listed every q6+ hours.
Spot-on.
In the pre-EMR world, I spend over an hour just finding the charts, locating the bodies that match the charts, and writing down a list of the names on everyone's favorite ER scratch paper, a brown paper hand towel. (*Bookmark this note.)
I locate a portable vital sign machine, and except for full-arrest traumas, it takes the entire staff, including Trauma and ER Chief Attendings, about 3 minutes to realize I have the right of way at all times, owing to my demeanor, size, and attitude, and they'd better GTFO of my path, or be run over like the extra in the chariot race in Ben Hur.
Come 7AM, I have six patients left. No one died, everyone got to the floor/a room/discharged/whatever.
Last year, going through my papers, I found the *paper towel, with all 79 names. It went home in my cargo pocket, and I was hoping JCAHO would stop and ask me about the place.
As if. They took one look at the place after 5PM, pronounced "Privacy issues must be challenging for you." and were never seen in the ER again.
2) A few years later, CA (i.e. nurses in CA) put nursing ratios on the ballot. It sailed passed voter acclaim, over the fear-mongering b.s. of penny-pinching corporate sh*tweasels.
For ER:
Normal: 4:1
Critical 2:1
Super-critical trainwreck 1:1
If I have one ICU player, I can have 2 normals as well, for 3 total
And obviously, if TSHTF, and there's a train wreck, plane crash, 7.0 earthquake, you're gonna get what you get, and suck it up.
It's still too much sometimes, but is one helluva lot better than nothing.
And any place busy, you're getting patients shoved up your butt as fast as you D/C the last one, with about 60 seconds to strip and flip the gurney, shpritz it with cootie-cide, and slap a fresh sheet on it.
I've taken up my ICU player, only to return to two fresh untouched normies or another ICU player before I even get back with the empty bed.
That's everywhere, all the time.
Ratios? Hell yeah!
Next stop: mandatory ancillary staff: EMTs/CNAs, etc.
If I and another nurse split a tech, that tech, for 1/4 to 1/3 of my hourly rate, doubles my output and productivity and, can do all the stupid but important stuff you don't need a license to do: vitals, blankets, water, code brown-yellow/ transport to x-ray/CT/U/S, the M/S floor, doing EKGs, D/C'ing IVs on patients for D/C, running samples to the lab, etc.
Paying me $40/hr to spend twenty minutes looking for a fricking tube system transport container to tube my samples to the lab is cost-ineffective b.s., and keeps me from doing patient care. And I spend three hours out of twelve a night doing that. So I point out regularly to manglement that they're paying me $120/shift to play hide-and-seek with $40 worth of plastic, while lawsuits are waiting because I couldn't care for $50K patients. (Whereupon, they look at me as if I've grown another head.)
We could have enough techs to speed throughput for a thirty-something bed ER, for the price of one additional nurse, and there'd only be 1200 ambulance company EMTs who'd leap at a chance for 12 hour shifts instead of 24, benefits, and a chance for tuition reimbursement to become RNs/PAs/MDs, so of course fully staffing techs is not a staffing priority, because they could fix it in about 5 seconds, forever, and have a 100-person float pool to ensure we'd never be short techs, even with 10 psychs needing sitters.
But they'd have to pay money for that, while simultaneously cutting wait times, admit times, and sending patient satisfaction scores to the moon, so, not a priority for the clipboard commandos and the Good Idea Fairies who haven't been at a bedside since the Johnson Administration. (I'm not sure whether it was Lyndon's or Andrew's.)
I feel ya, sister.
MA should vote "Yes". So should the other 48 states.
Some time back, on absolutely my second shift ever at Shoestring General. I'm at the back end, getting the hang of yet another EMR, and doing pretty well with all my patients, but then again even though I'm new here, I have more ER time than everyone else on the shift combined, except the charge nurse.
So things are busy, but steady, except for Baby Huey*. This particular Not My Patient Tonight is on a 72-hour psych hold, for being off his meds, and playing in traffic. Literally. Boom: danger to self, on a hold per PD, instantly. So he's goofy, but not violent, and not all there mentally. with his very own 95# sitter to tend to keeping an eye on him. Which is sort of a disparity right there.
Physically, he could play inside tackle anywhere from Oklahoma U. to the Cleveland Browns. Call it 6'5", and somewhere north of 275#. But he's pretty soft-spoken, and re-directable when he starts to mentally drift. So it's cool.
Until about 0445AM, when he's told for the nineteenth time that he cannot leave, because psych hold, and finally, through the voices in his head, the penny drops.
I'm standing behind the desk at main station when he wanders out into the hallway.
"Baby Huey, you need to stay in your room please" says his sitter. "You have to stay here tonight."
"No, no, no! Gotta go now!" (direct quote) saith Huey. Who then proceeds to take a running start at the lobby door, barefoot, in just a hospital gown. BOOM!
He hits that thing like Dick Butkus hitting a slow QB, and that door swings through 180° so fast and hard it sounds like a cannon when it hits the outside wall. Thank a merciful god there's no one on the other side, or they'd have been launched like a high pop fly past center field, and generally towards Hawaii in low earth orbit.
Before we can even pursue, the waiting room confuses him, so instead of exiting, he heads down the main corridor to the rest of the hospital, where he encounters a series of locked - we're talking electronically and mechanically - double exit doors.
Slap-slap-slap-slap-slap-BOOM!
Slap-slap-slap-slap-slap-BOOM!
Slap-slap-slap-slap-slap-BOOM!
We're just getting to the lobby, and he's already three doors down, having crashed through them like the opening scene of Get Smart, but at warp speed.
Locked doors? No problem. He's hitting them so hard, the metal jambs are flying loose and taking chunks out of the drywall when the pieces coming off finally land. If any of the 90# Filipina nurses on the floors were walking by, they'd be little crumpled lumps embedded into the opposite wall, but amazingly, he hits no one. Or else they're diving behind counters like the running of the bulls in Pamplona.
We're rounding the corner just in time to see him blow through three more doors, flying through med/surg, telemetry, and surgical wards, now under a full head of steam, and with his southern exposure flapping in the breeze as the gown parts. He even eats it a couple of times, taking a couple of big faceplant tumbles, but before anyone can complete the tackle, he's back on his feet, legs churning for the end zone. Our slower guys just follow the trail of staff with shell-shocked looks lining the halls after the parade's gone by.
Finally, he runs out of hospital, and he hits an emergency exit in similar fashion, booming through it as well, and bursts out into free oxygen of the pre-dawn air on the backside of the hospital building. And runs smack into a nine foot expanded metal fence he can't climb.
By the time we get to the exit, he's pivoted, found the locked exit gate, and can't figure out the latch, but no matter. Up the fence he goes, using the pushbar as a footing to climb up.
Four of us from the ER, joined by two more guys from the wards he blasted through, are all in hot pursuit, and his momentary vertical attempt allows us to catch up to him. Now we've got him for sure.
Before he can get over, two of us grab his gown, and start to pull him back inside, before he's out on the side streets.
So he shimmies out of the gown, and crashes, now butt naked, the eight feet to the sidewalk outside. We got the empty gown, and he's gotten to the street.
Not being crazy or confused, we open the gate, and hurriedly try to form a loose circle around him.
He takes tumbles, but gets up, and continues to head away from the hospital. We circle him, but if anyone gets too close, he bolts. We're trying to herd him back towards home base, but he's not having it. Oh, and he's screaming and babbling incoherently as we pass through slumbering suburbia.
It's still dark, and early morning, but people are starting to hit their morning commute on the local streets, and we're trying to keep him (and us) from getting run over.
Cars approach, and we keep one eye on Baby Huey, while waving traffic to go a different way. Seeing six guys in scrubs chasing a huge naked screaming guy down the middle of residential streets at 5AM, they get the hint, and drive away in any other direction.
We keep trying to at least make Huey turn and head into the quiet residential side streets, but like a moth to a flame, he's headed for the bright lights of the main drag, a busy boulevard with morning traffic getting heavier by the minute in the pre-rush hour darkness.
Meanwhile, one of my compadres is keeping the ER advised of our progress on his cell phone, and they're relaying it to the local PD. We hope.
We keep trying to direct the one-man stampede towards safer paths, but he's just not going to go along.
We're about 50 yards from the boulevard, and traffic flying past in clots with each green light, and he looks like he's getting ready to bolt through traffic.
And finally, fortune smiles on us. As Baby Huey is half walking, half-trotting, he gets to a curb next to the corner lot, about twenty feet from multiple passing cars, and then Hallelujah! there's some sprinkler water runoff in the gutter. He hits it barefoot, slips, eats it hard, and he's down!
"Dogpile him! Now!" I yell, and four nurses and two techs all pile on Huey simultaneously, before he can manage to struggle up on his feet again. Everybody gets at least a limb, and I throw my ponderous bulk right on top of him, holding on, and laying there like a big human sandbag to keep him on the ground.
Now it's a stand-off. He can't get up, but we can't get off, or do anything more than throw our body weight on all his limbs. So we're just one big half-naked 14-legged mess on the pavement, looking like six guys at the rodeo, all trying to ride the same bull at the same time.
We dare not turn loose of him for a single moment, or we'll be doing this again somewhere else. If he makes it through traffic, now only a bare couple of yards away from where we're all playing on the ground.
A couple of early risers and even homeless people at the kwikie mart across the street see the ruckus, and ask if we need help.
"Yes! Call 9-1-1! Now!!!" we shout, holding on to the bull for far longer than the eight seconds in a proper rodeo. We're too busy to do much but maintain the situation.
"This was *not* in the job description!"
Finally, after something between one and five minutes, which feels like an hour, a black-and-white pulls into the intersection across the street. One of us risks letting go with one hand and starts waving frantically. We're rewarded with flashing lights, and the growl of a Dodge Charger coming right towards our melee at full throttle.
A squeal of brakes, and Officer Tackleberry comes flying out and lands on top of the huddle. It still isn't close to enough, but it helps. A bit.
"Hey, guys. How's it going?" he asks with a big grin. "We've got to stop meeting like this." I wisecrack right back at him. We all giggle a bit, and the wrestling match continues.
As Tackleberry calls on his radio for more back-up, we try to get better control of Baby Huey's arms, and start s-l-o-w-l-y moving them to where Ofcr. Tackleberry can get a handcuff on a wrist. It finally gets there, and the first cuff goes on with a satisfying cl-click. But we can't get Baby Huey's other ponderously large arm anywhere near close enough for the second half of that act. But we're still holding him down with all our might, and he's tiring, ever so slightly.
Tackleberry reaches for his second set of handcuffs, just as his sergeant rolls up, and joins the festivities. Finally, we manage to get a cuff on wrist #2, then click the empty cuffs in each set together for the win. While Tackleberry and Sgt. Dooright do cop stuff with the locking mechanisms, we concentrate on keeping Huey from kicking anyone, and keeping his head protected from the pavement, because he's now trying to beat his way through the asphalt, forehead first.
Finally, a fire engine and a paramedic ambulance arrive. They throw a blanket under Huey's head, and it takes six hospital workers, both cops, and four of six firefighters to roll, lift, and place Huey gently on the ambulance gurney, velcro his limbs to it, buckle him in, and lift the whole package up and into the ambulance for the return trip to our ER, several blocks away.
A couple of our guys ride in the ambulance with the paramedic, and everyone who came in a vehicle drives to the ER.
The other four of us hoof it on foot back home, exchanging high fives and fist bumps, amazed that we finally wrangled our wayward guy without anyone getting seriously hurt, including Huey.
We beat the medics and PD to the ER by a couple of minutes, and then do the whole thing in reverse to get him into the ER from the ambulance. Per doctor's orders, we've already got a sedative ready for injection, which is given to Huey on the stretcher.
Once it kicks in, and he's too groggy to resist, it once again takes ten+ people to detach him, lift, and move him to our hospital gurney, and secure him until he's fully out.
And tell the story you just read to those left behind to mind the store, while we were out and about on the Great Crazy Patient Hunt.
Once things calm down, we pull some extra labs on our psych guy. The doc's worried there might be some controlled substances on board, but we also do basic blood chemistry.
The reward is finding out that Baby Huey was probably wandering the streets for days, and not drinking enough water. And no drugs on board, just plain nuts, but he's in pretty severe rhabdomyolisis. Which means his body, without any food to eat, is eating itself, and overloading his kidneys with toxins from muscle breakdown to very near the point of organ failure.
Baby Huey's not just batshit crazy and off his meds; he's very, very sick. We get multiple IVs going and start blasting him with the fluids he hasn't bothered to drink for days. Instead of going to psych placement, he needs to go to ICU that morning. I catch up on all my other patients, and now I inherit care of Huey, who's waiting for the next ICU bed. We squeeze in a full debrief for the night house supervisor, and a multipage multi-person incident report, in between patient care. Huey spends a week in the ICU, calm as a lamb, getting his psych meds every day, along with the meals and water he'd skipped in the tsunami of crazy he was living running around on the streets for days. He gets everything else he needs, until he's medically cleared for a psych hospital to pick up the ball. (They don't do medical problems, and we don't do crazy, so he has to be in great health everywhere but between his ears before they'll take him.)
So in a group effort, police, fire, EMS, the ER, and ICU save his life so he can come back to planet earth.
He could easily have been hit by a car and injured or killed. He might have caused a crash that hurt additional people. The police, alone, even at 2 or 3 or 5 to 1 on him, wouldn't have been able to taze him or wrangle and wrestle him into submission. They might have ended up killing him given his strength and aggression. It would have made wide news release, and given them a black eye in ripples outward that would have lasted for months. And if we'd just let him go to catch another time, he probably would have had organ failure and died before he was found.
Instead, he was as fixed as we could make him before going to the psych hospital. On my way out, I passed three guys from building engineering trying to put the Humpty Dumpty broken doors along all the main corridor back into operation.
We thanked the other wards whose people tagged along for the final victory. I sent a personal letter of thanks to police and fire departments, and made sure they got to senior supervisory levels ("Dear Chief..."), not just a verbal attaboy from a shift supervisor, because they seldom hear the rest of the story, or get thanked by anyone for what they do every day.
They had our backs, and we had theirs, and instead of a tragedy, or multiple tragedies, we all saved a guy's life, and unknown other lives, in what turned into just another wild and funny story from an hour out of way too many years in the ER.
I could hardly wait to see what Night Three was going to be like. But I'm pretty sure when I went home the next morning they liked my work so far.
*{Not his real name. Or hers. Or xe's. In fact, maybe none of this ever happened, and I just hallucinated it all. Duh. HIPPA, bitchez.}
Almost actual size, but it's not this new and shiny here.
New gig at Shoestring Hospital, in Teeny Weeny ER.
Small, hella-busy, still same old fun.
Except for (wait for it) all the ancillary BS hoops to jump through to start. Wait, it gets better.
So busy and short-handed, your contract started yesterday. (What's that? You never signed one? Don't worry, we'll get around to that...in a coupla months. Maybe.) But here's your log-in to complete the same 42 online modules (on my time and nickel, apparently) before you start. Because the ones you just did for our sister hospital in the same system don't count, because the left hand and the right hand in this fucktarded corporate lash-up don't talk to each other.
How...special.
So, after pounding my head against the monitor for three weeks trying to follow their instructions, it turns out they assigned me no account, so couldn't log-in to the education site, which helpdesk line is so secret, no one in the entire hospital knows it or has ever heard of it, until we reach the threats-of-suspension stage, and it will suddenly leave them exactly as short-staffed as they were before I started, and suddenly shit gets real for them.
Whereupon they "suddenly" discover the secret helpdesk number, and I then find out all the courses they assigned to me in the first place three weeks ago were the wrong ones, and not the ones they've been telling me that I haven't completed, because I couldn't log in, and they never assigned the right ones in the first place.
Because they're all a bunch of chronically and blisteringly incompetent fuckups.
This is my shocked face. I didn't name this place Shoestring Hospital and Teeny Weeny ER for nothing, and Incompetence is one of the core values here.
If I did nursing like they do administration, the dead bodies would be piled up around here like firewood. (And, in all likelihood, they soon will be anyways. But that's another ten stories.)
This will be a short contract. If they ever give me one to sign before I finish it.
And they wonder why they can't find anyone besides brand new grads desperate for a job to become full-time staff? And why they all leave after 366 days?
Note I am not referring to drug ODs, nor to intoxication to the point of cessation of breathing. It is solely in reference to plain old intoxication. Something which used to occasion a visit to the local constabulary's drunk tank. Which, long and short of it, is where the problem reared its ugly head.
Because, gentle reader, despite a multiplicity of job skills, police officers, sheriff's deputies, and whatnot are many things, and jacks of a host of trades. But "licensed medical practitioner" is not any of them (and I'm okay with that, and about to tell you why).
Y'see, back in the day, Ofcrs. Reed and Malloy used to load drunks in the back of the squad car, and tote them to the drunk tank. Which was fine for drunks. The problem arose because people with head injuries after car crashes, and people having strokes, and people with diabetic-induced blood sugars of 20 all look exactly like drunks when apprehended. But unlike garden variety drunkaholics, they unhelpfully tend to die a lot overnight when placed in a large drunk tank holding cell. This causes consternation for the officers, annoyance for their families, runaway profits for said families' personal injury attorneys, and great aggravation and heartburn at the offices of the legally responsible municipalities concerned.
So the word has gone out, from city council to city attorney to chief of police to watch commander to desk sergeant to every Ofcr. Reed and Malloy and Deputy Fife:
Take all drunks to the E.R. And I get that, boys and girls, I truly do. You don't have a CT scanner in your car, nor any medical training but the barest state minimums, so to preclude killing people by mistake, you bring them to those of us qualified to tell a drunk from a guy who took too much insulin and not enough dinner before he plowed into 3 cars and staggered into your arms.
Well and good it is, dulce et decorum.
But where all of you ministers of street justice screw the pooch, is that once you leave the few medical emergencies, and the overwhelming vastness of public wastrels, in our hands, or handed off to us by way of the local fire guys, whom you also had to wake up and drag into this mess, is that you, having happily washed your hands legally of them, don't return and take them to jail, nor even issue a summons for public intoxication, once it's medically certain they're simply drunken @$$holes in desperate need of a stay in the Greybar Motel.
Let me make it clear, lest I put it too mildly, that in every ED I've worked in, and on every night of every year of this century, that amounts to between 2 and 20 m*****f*****s every shift, in perpetuity. I'm sure you don't miss dealing with them, having happily palmed their vomiting, urinating, diarrhea, abusive and obnoxious behavior, and even their assaultive escapades, onto mainly a bunch of overworked nurses, techs, and doctors in scrubs. I'm sure your desk sergeants and watch commanders think that's a splendid thing. I'm sure your city minders don't miss the wrongful death lawsuits. And I know for goddamned certain (ask me how, I triple dog dare you) that the sonofabitches in the city attorney's office have never criminally prosecuted so much as one intoxicated drunk for any of the literal dozens to hundreds of techs, nurses, or doctors that are assaulted and battered daily and nightly in any place hereabouts, just like they don't statewide, or probably in any state.
And as another monumental douchebag opined in a similar vein, "What difference, at this point, does it make?"
Well Sparky, it means that sooner or later, you or yours is going to come in the door with your wife, or kid, or parent, having a heart attack or stroke (or, if God is just, it'll be you yourself, and better yet, your chief), and I'll just be too busy to get to you right away, because I and ten or twelve of my colleagues, without bulletproof vests, batons, tasers, or pepper spray, are doing the wild hog rodeo with some out-of-control 300-visit-a-year @$$hole that should have been doing six months in county for multiple arrests for intoxication that you never bothered to make, because policy; or because the loss of $500K per offender, year in and year out for this happy horseshit caused staff members to burn out and leave, and budget cuts due to those ongoing financial losses have left filling the job impossible.
And then your kid, your wife, your parent, or you, are going to sit in the waiting room, and maybe even die. Sucks to be you on that day, huh?
Or, long before it gets to that point, some one of you with two wits to rub together, could be proactive, and start taking the repeat offenders off the menu, and let some judge set them to filling potholes in the summer, and shoveling snow in the winter, for six months at a stretch, and while we might see them once in six months, after a couple such bed-and-breakfast arrangements with the county, either they'd decide on another life trajectory, or we'd have the best-maintained roads in decades.
Maybe think about that the next time you're sure we'll have time for you when you crash your unit, or take a bullet fighting crime. It'd be a real shame to find out the last bed in the ED was filled by Roscoe the Sterno Bum, for the 200th time this year so far, a half an hour before you rolled in on a stretcher, wouldn't it?
It never ceases to baffle me how people who would never lip off at the DMV, or when getting dinner at a restaurant, or while standing in line at Starbucks, or anywhere else, think that when they show up at the hospital, the rules of civility and decency have suddenly magically disappeared - for them.
Dear fuckweasels: Thought For The Rest Of Your Life Didja ever lip off at a restaurant, and show that dumb waiter who's the boss? Didja ever notice afterwards that your food all tasted like spit??!!! WORD!
Take a lesson: some of us won't be badgered by your rude assholerry, and will not only give you worse than you send, and that right in front of your friends and family, we're big enough to make it stick, including sideways up your ass in the parking lot if you think you can go there.
And nota bene: your friend/relative in the bed is the patient. They have an actual reason for being here. Your presence is a mere courtesy, and a revocable one at that. The minute, no, the second dealing with a knobjob like you interferes in the slightest way with patient care in my room, I don't care if you're the Pope's uncle, your ass is out, for good, permanently. I will make you persona non grata, with no visiting privileges, and I'll happily swear out the restraining order in the morning to make that a permanent situation. Test me, I triple dog dare you.
If you shut down your mouth long enough to engage your eyes and ears, you might also notice that your friend is 1) Getting damned good care 2) Not very happy when you're being an obnoxious litter box nugget 3) Eager to forget he/she knows you when you bring your Inner Jackass, and let him/her out to play in front of God and everybody.
So instead of "advocating for your friend"*, realize that you're just another pain in my ass, because all you're really doing is demonstrating your impotence to do anything more helpful than dropping a hand grenade into the outhouse just to watch the shit fly.
My cure for your problem is sending you to Siberia, forever, and if you want to go double or nothing, you can find out what the bail is on Monday morning for disturbing the peace, trespassing, and/or assault and making terroristic threats. See if the judge thinks it's as funny then as you do now. Especially if you blow a point-anything on the jail breathalyzer. BTW, I document the antics of lunatics for a living; good luck with "your side" of things after I file my totally accurate notes of the encounter in a legal document, for the permanent record, right after it all happens, while you're still hitching up your trousers and looking for that missing piece of your hindquarters, sobering up in a holding cell, or trying to get someone to go good for your bond.
Or just cowboy up, and realize that if we're taking care of a friend or family member who's having a heart attack, a stroke, or bleeding out, fucking with us while we're doing our jobs probably isn't in their best interests either.
So do yourself and your buddy a great big favor: sit your ignorant ass down, or go get yourself a nice steaming hot cup of STFU, while people smarter than you do the job they're being paid to do, instead of dealing with dumbasses like you interfering with other peoples' care.
Momma may have pinned your diapers up on the family refrigerator and told you they were art since you were two years old, but now that you're only acting like a two year old, the rest of us can see your handiwork for exactly what it is, and reality is about to slap you real hard right in the back of the head. With a sock full of quarters.
*(After 20 years of this BS, it's no longer anecdotal evidence: 99.98% of these Special Snowflake Wannabe Patient Advocate douchenozzles are the visitors, not the patients. If you like watching Wheel Of Fortune for hours, and reading old dental hygiene magazines, keep bucking for Permanent Waiting Room Flourescent Light Therapy, proud soldiers of the Dumbass Army.)
So this week, after spending the weekend at St. Sisyphus (if you're hazy on mythology, look it up) see if you can spot the hidden trend:
--- 20-something dude, too drunk to skateboard, so he walks into traffic, gets hit by car, ambulance ride to ED, elopes (forgets skateboard), brought back by PD from his home a few blocks away, found drunk off his ass and returned for trauma work-up, alcohol level 240 --- guy who jumps off second level of building, breaks fall with face, blood alcohol level >300 --- guy who's drunk goes out to get more beer, falls down on head, comes home, family notices he's way more dopey than when he left, and he full on seizes in ED due to a massive brain bleed, alcohol level 180 --- guy comes into ED claiming to have been shot in face, actually has minor trauma from getting bounced from club after acting like an a-hole, blood alcohol level 250 --- homeless guy takes all his daily psych meds and drinking beer, passes out, does faceplant on concrete, alcohol level 225 --- drunk chick falls in parking lot, breaks fall with face, alcohol level 225 --- way underage coed waiting in line to get into illegal rave, passes out before she even gets in, blood alcohol level 270
And that's just a random HIPPA-compliant mix-and-match sample of the week's actual patients, with descriptions/sexes/etc. scrambled at whim.
If you guessed the common factor was an overdose of braincell-killing Judgement Juice, buy yourself another round. These aren't lifetime problem drinkers, these are simply young jackasses whom society needs to stop rescuing. (Seriously, let's just let a few of them go under, to drive the point home.) A couple of those are going to be effed up for life already, and then, surprise surprise, will probably drown their problems in alcohol for another 40 years. Just to pile on, this is the week after Spring Break, which brought out hitherto unheard-of levels of alcohol-induced assholery, judging strictly by a few media stories from around the country. So my sample were merely the Everyday Drunkholes.
I shouldn't complain, because Budweiser et al will be paying for my mortgage and cruise vacation tickets at this rate, and it's barely April.
But when you can afford to get so f****d up you can't walk straight and not play in traffic without a keeper, but you can't afford health insurance or a hospital bill despite the government handing you that shit on a platter, it's time to bring back galleys, where you could work off your hospital bill by rowing at wages of 10 cents a mile, or by being chained between two poles on a street corner, and letting people kick you in the junk for $1 a kick.
Ill be the guy in line with a wad of singles bigger than a pole dancer's on Monday morning, and wearing a pair of steel-toed boots.
And either solution would keep those a-holes from procreating anytime soon, which would be a net plus for society. But the next time some soopergenius bitches that their hospital bill listed a Tylenol for $65, remind them how much it costs to subsidize these ignorant jackasses who rang up a $40,000 trauma bill at the hospital while on welfare and food stamps, or while still living in momma's basement. Then tell them to STFU.
Over on the right sidebar, you'll see a fairly short blogroll of medical/nursing blogs I regularly visit.
It's short because for whatever reason, nursing and medical bloggers simply don't last. They burn out, run out of words, time, or motivation, and then they quietly die on the vine one day. I've only been at this for about a year and a half, and I've already buried three of them, and a few more over there are on life support waiting for someone to pull the plug.
But under the heading of "A Picture Is Worth A Thousand Words" is one over on Tumbler that just seems to keep going and going like the Energizer Bunny:
If you want to understand nursing without getting a degree, and being elbow-deep in someone else's really vile bodily fluids on a holiday weekend at 3AM, go there.
The recipe is simple: Take one Universal Nursing Truth, illustrate it with a short looped .gif/clip from somewhere in the culture - TV, movies, etc. - that didn't start out to have anything to do with nursing (but does in the right context), and get an essay on nursing that only takes about 1-3 seconds to grasp.
The results are, in a word, brilliant. And more often than not, require a Beverage Alert, to avoid hot, cold, or carbonated fluids shooting out your nose. I have lightened my mental load and killed a bit of time surfing that blog for a little humor when things quiet down on a busy shift. (Don't tell the hospital IT guys, that makes them crazy!)
I bring this up because the second current offering is Ebola-related. I missed it when it was new, because things have been a little busy at the keyboard lately. But since no small number of folks are tuning in here to stay current on the topic, it's appropriate.
The site also chalks up "likes". There are 702 for this particular offering, so far. As most of the visitors there are probably nurses, like myself, make of that informal poll what you will.
And the WSWCN blog deserves a long-overdue shout out anyways, so it might as well be for this.
My best guesstimate is that I've directly cared for 50,000 patients. Probably more if we count the ones I've triaged - seeing 70-80 a night instead of 20-30. Nothing special there, my co-worker for a good chunk of the last 10 years had been a nurse literally since Eisenhower was president (for you youngsters for whom that rings a bell, look it up.) so she probably saw a number much closer to half a million.
And I certainly haven't kept a tally on this, but I'd say I've personally zipped about 100 people into their last sleeping bag for transfer to the Eternal Care Unit.
I bring it up because I was reading a completely separate story, regarding the grisly task of recovering the victims of an airplane explosion, and unbidden I was simply overwhelmed with the thought of the ones I've dealt with.
I don't care where you are, as much as we try to not let it happen, people die in the E.D. (Dammit. It still generally pisses me off.) For some it was a welcome friend, for many a blessing, and far too many a rude surprise courtesy of physics, ballistics, and man's inhumanity to man. I thank a merciful deity that none of them have been children. As a student I watched a futile but understandably prolonged full code on an 8 or 9 year old girl found at the bottom of a pool, long after there was any hope but the outcome expected, but thankfully, I didn't have to deal with that aftermath. Small mercies are always welcome.
Amidst a full code, there's things to be done, orders to chart, algorithms to run through, so you're busy, and amongst friends. The subject of the exercise isn't in any condition to respond, so you tend ( or at least I do) not to focus on them as much as on the rhythm on the monitor, the presence or absence of a pulse, and doing your part in the multi-person ballet at the bedside.
But one way or another, I seem to end up being the one doing aftercare, obviously on my own patients, but a lot of times on others' as well. Sometimes with the other nurse(s), or a tech, and even a couple of students from time to time. But a lot of the time, just getting it done by myself. Part of it is the amount of time on the job, and wanting to share a colleague's load, and to a certain extent, I'm pretty sure it creeps the youngsters out more than they want to admit, particularly when they're still kind of new to the job.
Of course we aren't perfect, and some nights, it's just that person's time. A number had their time come and go at some abysmally-run convalescent home, warehoused by distant family, or an uncaring system, and we just get to deal with the end result of low wages and minimal/minimally functional staff, taking care of way too many chronically sick patients. Other times it's someone set free from the ravages of metastasized cancer. And on more occasions than I'd like to recall, it's a traumatically rude unhinging of the mechanism of life.
It still doesn't happen a lot, maybe once a month on average. Then there was the night we had six in a shift. As Edmund Blackadder once said, "I'm thinking of a phrase that rhymes with 'clucking bell'..." But any way I look at it, even as rare as it is, the mileage and the years on the night shift adds up; I just didn't expect to be one of the go-to people for "final prep".
I've just been thinking about it, because it's there now, and it's probably going to rattle around in my head awhile until I get it out, so I'd rather write about it than just mull it over. And it's not like there are a lot of people you can talk this over with one-on-one, at least not if you ever want to hear from them again.
I don't know why it matters to me, but the best way I've found to deal with it at the time is to talk to them as I clean them up, especially if there are family members a few doors down just getting the news. I do it some for them, and the patient, and some for me. It seems like it's the least I can do to acknowledge and maintain a little human dignity for somebody who's getting tags tied to a toe, some of the tubes out, some of them left in, and getting stripped just as naked as the day they were born, before zipping them in for their last ride down the hall to the morgue freezer.
Later on, there'll be time to talk with family members, when they have any. And definitely time to talk to the coroner, the organ donation line, perhaps the local PD, and to try to find a personal physician. I'm not a big fan of waking doctors up, especially for this kind of call, but it always seems to happen between midnight and 4 AM. And no transfer, not even to ECU, is going to happen until all the paperwork is finished, all the boxes checked, and the charting done. At least I don't have to call a floor report first.
But before that, and after the drama ends, I figure the least I can do is think, or say out loud, "Sorry you're here tonight. Hope it doesn't hurt any more, or where you are.", as opposed to thinking of them as so much inanimate hamburger. When you're dealing with what's left behind after their personal train has left the station, it's hard not to wonder about that, right? It's not like I'm doing comedy routines, or expecting any answer. But we take care of people, and when you do that, you talk to them, because it helps them to cope with what's just happened. Or, in this case, it helps me.
New Year's Day Seventh Circle Of Hell Hospital 0300 hours - Once upon a time
It's been a pleasant, and even abnormally q-word night. Every section of Main ER has open beds, so nobody's stressing. Homeless Hangout, AKA triage pit, is blissfully unoccupied. Someone, one of the clerks likely, has a battered boombox streaming out soft Christmas and seasonal music, in open defiance of policies. Good for her.
Then the Batphone rings. City paramedics bringing a GSW victim in, in full arrest. Virtually the entire staff, having nothing better to do, swings into action. The Trauma Team is roused from their lair, and assemble too. At 0302, in the softly jumbled glow of the flashing red and yellow lightbars on the outside wall, one of our gurneys comes in, bustled there by a beefy wave of firefighters, the smallest of them atop the victim doing chest compressions that would amply circulate King Kong.
Three nurses swarm IVs, getting both antecubitals and a hand, and saline and Ringer's go pouring in, while blood type and crossmatch, labs, blood sugar, and hemoglobin tests get drawn and run stat. In about 60 seconds, the monitor leads are attached, there's an ET tube in place, along with a foley catheter, and a femoral stick by the younger resident and med student team.
As I'm crawling through, over, and under the humanity to take over bagging, they're preparing a chest cutdown while the code progresses through the steps like a machine.
In fact, it ends up being bilateral chest cutdowns, because blood is pouring out of this guy. He's essentially being cut in half from both sides to try and cross-clamp the aorta, trying to save his heart and brain until better work in surgery can save his life. And, failing that, it's good practice for young surgeons, since he's effectively dead anyway, despite the twothree four units of O negative pouring into (and out of) his chest cavity even before he's cracked open.
The Chief Attending for Trauma calls it in about 60 seconds after that. "This guy is done. My left and right index fingertips are touching through the entry and exit holes in his left ventricle. Non-salvageable."
Mr. Unlucky has been well and truly 10-ringed, right through the heart.
Before anybody can even peel gloves off, triage nurses bustle another delivery from the ambulance ramp, this one delivered by Homeboy Ambulance: two dudes in a Chevy saying "Our homie got shot." It's now 0308.
And judging by the amount of blood coming off and out of him, yes, he has indeed.
Contestant Number One in tonight's game of You Bet Your Life is literally pushed, still on the gurney and gutted like a fish, to one side, to give everyone a chance to pivot 180 degrees and start work on Number Two. Helpfully, they're all warmed up, and this one actually has a pulse and respirations, albeit with several more bullet holes in him than our unfortunate first contestant.
He looks good for stabilization, and the Trauma Team are excited to have someone they can actually have a chance of saving. As the arrangements for the surgical suite are being made, and he's being rigged for transport, the Batphone has gone off again. Another gunshot wound to the chest, another full arrest, inbound and 1 minute out.
At 0312 they arrive, pushing Contestant Two and his transport team aside, and wedging Contestant One, now with a sheet - rapidly becoming blood-tinged red - pulled over the body from head to toe, firmly along the far wall of the trauma bay.
Vulture's Row, the overhead observation area, now has a number of paramedics, cops, EMTs, etc., arrayed along it equal to the number of doctors and nurses working on the now third victim.
As we're doing the third version of IVs, ET tubes, central lines, foleys, blood tests, hanging O negative blood, CPR, and yet another chest cutdown, there comes the unmistakable voice of tonight's Queen Of Triage:
"There's another car on the landing all shot up, there's more gunshot victims inside, and I can still see the gunsmoke in the car!"
I stay in main trauma, while another bunch hustles outside to scoop up whatever Homeboy Ambulance Number Two has deposited on our doorstep.
Just as Contestant Number Two gets hustled out to surgery, they're calling the code on Contestant Number Three, despite his chest cut-down. No chance, and no blood left in him. But then Contestant Number Four is wheeled in, turning out to have unfortunately stopped bullets to the abdomen and leg after they passed through her car door. Another guy in the car caught one in the arm, and is taken to a side treatment room. Most of the blood on the other occupants was from Number Four, but that's not apparent to us right away.
As most everyone shifts to the newest thing to play with, the two corpses sit along opposite walls, draining out every drop of blood, until we have time and staff to deal with the dead instead of the living. Everyone at this point is treading deliberately, as the floor is quite literally three quarters of an inch deep in the approximately six or seven gallons of blood and additional blood products which have drained all the way to the floor, and now cover the surface of the entire 20 by 35 foot trauma bay, not counting a huge liver-sized clot and numerous smaller coagulations plopped and strewn hither and yon in all the fuss. Every step makes the never-forgotten "shhhhwuck! squish! shhhhwuck! squish!" sounds of rubber-soled shoes pulled out of and placed back into the coagulating ocean of blood with which the entire bay is now carpeted.
It's 0315.
Contestant Number Four is stable, conscious and coherent, and apparently the bullets that hit her didn't hit vital organs or vessels. Fortunately there's no free fluid showing on the bedside ultrasound, and she's not in any distress except pain and shock at being in car full of people shot up by other folks.
Paramedics shuffle back to their firehouses, cops are everywhere, and we separate the belongings and blood-soaked clothing into piles for "evidence" versus "hazmat garbage", and a seemingly endless number of phone calls to coroner, relatives, and organ donation banks begins.
We begin mopping up, rather literally, filling large Roughneck trashcans full of oxygen and IV tubing, trash, and debris from three chest cutdowns, three intubations, three central lines, twelve IVs, four foley catheterizations, and four remaining units of O Negative blood from partial transfusions. Housekeeping is using the wall suction to try and tame the tsunami of blood, before they get down to the tile, and then bleach-disinfecting everything to the bloody grout. Body bags come out, tags are tied to toes and affixed to belongings, and a stream of labels are made for the pages of charts, documents, and other office work of sending someone to the Eternal Care Unit. Twice over.
It's now incredibly only 0320.
Sometime later, before sunrise signifies the impending end of shift, trauma surgery calls to let us know we're batting .500 for the night, 2 out of 4.
The two failures are now coroner's cases, bagged in white plastic zippered shrouds in refrigerators across the street, and the floor looks like none of it ever happened. The only traces left are the spreading ripples on the souls of those who were there, or friends and relatives who are just finding out about how the New Year started for those four people - none of them over thirty years old - this morning, after embarking on a New Year's Eve that certainly must have started for each of them so full of promise. Clearly, being around for the beginning of a day is no guarantee you'll see its end.
So much for the quiet New Year's Eve shift that wasn't. I hatelovehate love this job.
Why, specifically with nursing, do the most unprofessional, disorganized, dysfunctional, mildly retarded, socially inept @$$holes unfailingly become middle management? Is this Affirmative Action for jackasses, or are they hiring the handicapped because they're fun to watch, or is it just that senior management can't, in my father's memorable turn of phrase, actually and reliably "tell $#!^ from Shine-ola"? I confess to feeling uncharacteristically baffled.
Do an experiment: think of the co-workers you'd least like to work with, and the ones you'd be most inclined to fire for their shenanigans if you were King or Queen For A Day, (or for students, the ones you consider deadweight on clinical and lunchmeat during lectures), and for any position you stay in more than 5 years, keep track of how many of them become charge nurses, nurse managers, and clinical coordinators.
If you find someone who's so gratingly annoying the whole department wants to smother them with a pillow, congratulations, you've just met your future supervisor. If they want to fill the pillowcase full of IV pumps and beat them with it, you may have identified a future CNO.
I bring this up because, surprising me not a whit, yet another terminal management failure has been inflicted upon my work unit. She's a legend in her own mind, and clearly, at some point, she was allegedly a decent nurse.The problem comes in that when handed any slight amount of authority, she defaults to Genghis Khan-like management techniques, that probably didn't even work for Genghis, back in the day.
Which leads not only experienced me, but utter newbies on the staff to recognize in 0.02 seconds, that she's scared spitless because she's too insecure to shut her piehole and work with people, actually listening to them and MANAGING them, because she clearly lacks the wisdom, experience, competence, self-confidence, or basic 3rd-grade-level human coping skills to not dictatorially try to micromanage everyone like they were Barbie dolls at her tea party 24/7/365.
That style didn't even cut it in the Marine Corps among fresh recruits with room temp IQs, so it sure as hell isn't going to cut it with trained degreed professionals and experienced support staff.
I mention it because it's a wee bit off-putting.
And a corollary, which I'm sure shows up somewhere on a managerial training curriculum is that when you hire and promote the least competent people, it not only destroys morale and lowers productivity, it also demonstrates to everyone down to the janitorial level that you have your own head so far up your @$$ that you can't tell the difference between someone who's good and someone who sucks, and that you're - theoretically, at least - the very supergeniuses who sign the checks and direct the affairs of the entire facility. Which scares the hell out of we, the employed.
So somewhere in the Rules For Big Wheels, there has to be written the caveats: 1) Don't pull your pants down in front of the entire staff every day by hiring management morons 2) Try and demonstrate some basic level of bare competence unless you like the sound of laughter behind your back pretty much in perpetuity.
At this point, I've seen upwards of a dozen various management folks come through, and go out the other door. I could count the keepers on my thumbs. (And one of those two handed the promotion back to them after a year to go back to bedside care, because it was corroding his mind and destroying his soul, not to mention starting to hurt his marriage because of how it was affecting him.)
And as these personnel decisions are invariably made by the same people who make clinical decisions for the hospital, one is left to wonder how, other than bare good fortune, we don't kill people like the Black Plague going through Europe in the Middle Ages.
In my tenure at Seventh Circle Of Hell Hospital, it was observed on more than one occasion that we didn't see 3000 patients a week; actually, we saw 150 patients 20 times apiece. Which came far closer to the truth than anyone wanted to admit.
But King of the Cockroaches (as many refer to the patients who refuse to die, despite massive doses of radiation) was everyone's favorite, Mr. Shipley. And when I say everyone, I mean, everyone within 100 miles.
No mere gainsaying and hyperbole this, because on countless occasions, I personally witnessed paramedics from 3 cities away, who hadn't worked our area in years, or even decades, observe no more of him than Mr. Shipley's Santa-white mane of hair poking out from under an ambulance blanket as he lay waiting in the hallway for a room, who then kicked the gurney as they went past, and greeted him by name. And they all knew to take his cane away from him, because when sober he was the nicest guy you'd ever meet, but when he was drunk (about 90% of every waking moment) he was a mean mofo of a drunkaholic to deal with, not above whacking you with his county-supplied walking stick.
His modus operandi was stupid simple. He would get drunk, on whatever. He would fall down. His drinking buddies on Waste Of Skin Row would call 9-1-1, and report he was having a seizure. He would be picked up by paramedics. He would be brought to the hospital. He would receive multi-thousand dollars' worth of full-court work up, including head CT, all while roundly m*****f****** everyone around. He would sober up somewhat, along a blood alcohol continuum from 700 to the low 200s. He would be admitted. He would elope. Then he would get drunk, on whatever, and begin the cycle anew.
One July, a new resident guilty of nothing but unsupervised greenness, ill-advisedly called medical records, and requested Mr. Shipley's medical file. About 15 minutes later, two file clerks rolled up with two mini-shopping carts, and dumped the equivalent of four Manhattan telephone directories on the resident's desk. It was seriously a stack 3-4 feet tall.
"That's everything for this year, doc. If you want anything more, I'm going to have to call in some help to haul it all upstairs."
Conservative guesstimates put Shipley's recidivism in the ER at upwards of 250 visits/year. One week, I worked 5 12-hour shifts, but he beat me, arriving there 6 times. I discharged him one early morning and he was back in the ER before I was, on the same day. Assuming a generously low rate of $2K/visit, you figure it out.
Even at Califrutopian real estate prices, it would have been cheaper for the County to buy Shipley a modest house, and have enough left over to employ both round-the-clock bartenders, and nurses, plus all the distilled consumables he required, with change back from what his medical care was costing annually(and been able to resell the house, someday). And Shipley was merely one of hundreds in our little slice of paradise by the Pacific.
I only half-mockingly proposed that instead of my third shift every week, they instead purchase a 40-pass. party bus, a paper shredder, and a couple of cases of 40 ouncers and other stuff. I outlined that I'd drive around downtown picking up our favorite derelicts, get them on the bus with free beer and booze, and deliver them, suitably lubricated, to a different city west of the Rockies every week. After helpfully shredding all their personal IDs and paperwork. Portland, Salt Lake City, Denver, Albuquerque, whatever.
There was some slight risk that those cities' constables might have figured out what was going on, when 40 bums they'd previously not seen arrived, all claiming to be from the greater SoCal area, and all without a shred of documentation in proof thereof. But such was a minor irritation, because 1) They might send the bums back to us, but we'd still have gained a few days respite from their predations on our medical resources. 2) They might retaliate by sending us their bums, but at least we'd get new faces, and perhaps set up a Bum Exchange Program among the various metropolii, which might also broaden the horizons of the bums in question, and give everyone new folks to play with. 3) Most likely, once they realized they weren't in Kansas anymore (or rather, were in Kansas, but wanted to be in L.A.) the bums would avoid the cops, and set out to return homeward. And pass a liquor store on the way. And that, quite simply, would be the end of that Grand Scheme.
I could never get the Head Wheels to go for my plan, but they were suitably impressed that I'd thought it through so thoroughly.
Leaving us, day in and day out, stuck in the clutches of the federal EMTALA act, mandating that we have to lather, rinse, and repeat, for everyone, despite the futility and wastefulness of the effort. Next time your grandmother has to wait in the waiting room, or her ambulance gets diverted three hospitals away for her heart attack, be sure afterwards to take pen in hand, and thank your congressman. And please remember, you're picking up the check.
I, like 50,000 other emergency nurses, am pretty damn good at my job.
Which makes losing someone just that much harder to deal with, most times.
I'm not talking about when the 89-year-old senile hypertensive diabetic post-CVA Parkinson's patient with metastasized brain CA comes in as a full code, in full arrest, and with no family closer than 2,000 miles away, if any can even be found. Those are times when, instead of recording what's being done, I want to kneel down next to their ears and whisper "Walk towards the light." as the compressions continue.
I know hospice and ICU nurses who do exactly that, without apology, to let patients who've struggled in excruciating pain beyond any reasonable expectation for so long, know that they just want them to relax and let go of the rope, and they tell them it's okay to go.
And for them, and us, it is okay that they go.
But when an acutely sick patient comes in, and it's someone too young in our mortal estimation to be ready to check out, and our efforts fail, it really really sucks. Deep down inside, where we put the things we feel too much. It makes you feel want-to-cry sad, not-a-Catholic-and-still-feel-like-you-need-confession guilty, and how-did-this-happen inadequate. And if you're anybody but me, for whom a Dr. Pepper is a hypercaffeinated binge and alcohol is only for mouthwash and Nyquil, you probably have an urge to knock back an adult beverage or two. It's hard on our egos and humbles the sober estimation of our own skills and abilities against an implacable universe, it's tragic for the family, especially when they're standing right there, and obviously it's generally quite a shock for the patient.
Like Captain Kirk, I don't believe in the Kobayashi Maru scenario, the unwinnable test. It's an affront to our skills, looks bad, feels bad, and dammit it just ain't fair. We win so many times we forget sometimes we don't. So helpfully, reality delivers a nice cruel stinging gobsmack, just to keep us honest with ourselves.
There's a scene in The Guardian when movie Coast Guard rescue swimmer Ashton Kutcher asks Kevin Costner what his number, i.e. how many people he's saved, is. Costner, playing a 20-year veteran rescuer, tells him it's 22. Then he tells him that's how many people he lost over the years, which number, he says, is the only one he ever kept track of.
I can totally relate to that mentality. (In fact, I wish the guy who wrote it would get out of my head.)
As much time as we spend with the whiners, the crazies, the system abusers, and all the walking minor wounded, the battle we...alright, that *I* fight, is really mainly against Death itself. I say this fully appreciating that his batting average is 1.000. But by and large, not on my watch.
So when a guy not old enough for social security comes in the last 30 minutes of shift with severe abdominal pain, and you get his IV, draw the labs, and get him medicated, comfortable, and off to CT in mere minutes, glad he's feeling better and relieved that you aren't leaving any messes for day shift to clean up, nothing takes the wind out of your sails like the doc telling you just before hand off that he thinks the guy is ripping a Triple A.
Except coming back to get report from the same nurse you handed off to the same night of the day you went home, and finding out after he got his CT, and with his family standing all around the bedside, the ones who thanked you for easing his pain that morning, he finished ripping that AAA, bled out internally and died in about 3 minutes, an hour after you went home.
Maybe it's just me. Perhaps I've only worked in terrible places with terrible people. But I don't think so. Maybe it's just that I'm a big, bad former Marine, and when one's only tool is a hammer, all their problems look like nails. Except I'm average sized, with a middle-aged donut (despite my brain's insistence that I'm still young), thus not really physically intimidating to anyone except perhaps Warwick Davis, a hobbit, or my cat. So in looking back at my anything-but-extraordinary career in the ER, I'm frankly rather astounded at what a throw-down knockdown hog-wrassling time it's been.
I've been spit on and at, punched, kicked, slapped, choked, hit in the head, clawed, gouged, bitten, urinated on, pelted with any number of objects and body fluids, dog-piled, injured to the point of temporary disability twice, one of which was potentially permanent and career-ending (and thankfully fully recovered from), assaulted, battered, and of course verbally abused, cursed at and threatened almost daily.
I've broken up fights, disarmed lunatics, and made at least as many tackles in my career lifetime as Dick Butkus did in any one year he played, and no disrespect to Mr. Butkus, but I did mine while wearing less pads and no helmet.
I've seen co-workers stalked, threatened with death, punched in the eyes, nose, mouth, and throat, had their heads yanked back by the hair, bitten so hard they had teeth marks a week later, had faces scratched, legs and knees twisted, need ice packs, Ace wraps, and stitches, been kicked in the groin, and had IV poles, power cords, chairs, instrument trays, canes, shoes, full and empty urinals and bedpans, and just about anything else you could imagine wielded, swung, or thrown at them, time after dozens of times.
Total number of patients or visitors arrested for assault or battery, let alone actually charged with violence against us, or prosecuted for same, in all that time: zero.
Is it just me, or is there something more than a little f*****d up with that ratio?
Police have bullet-resistant vests, pepper spray, tasers, batons, and guns. And numerous other cops one radio call away.
If we're really, really lucky, the hospital, one time in a thousand, might file a restraining order against somebody, once they've gone apeshit enough to get charged and booked into jail anywhere else in society. And hand to God, had anything like this happened to me at home, I'd have been well within commonsense rights and responses to have blown a few heads off.
So Houston, WTF? Saying this is a problem is like saying the explosion of Mt. St. Helens was unsettling. It's telling the astronauts on the last Challenger ride that things would be a little bumpy.
Whose fault is this?
Society in general, for thinking that walking into the ER is carte blanche for doing what the jacktards with Ph.Ds, and too many with Nursing Ph.Ds, call "acting out". What the police call it when it happens anywhere else is aggravated assault and mayhem, so let's quite pussyfooting around and using psychobabble happytalk instead of precise clinical language. Five year olds "act out". Adults are being criminally violent.
Hospital management, from relief charge nurses to CEOs and every worthless waste of skin and oxygen thief in between, for collectively and reflexively shrugging, and adopting the "Tough Shit, You Knew The Job Was Tough When You Took It" philosophy, which is a remarkably callous, spineless, gutless, and self-serving crock of a well-known substance when employee safety (not to mention the safety of everyone else in the hospital) is what's at stake. Coal miners in Appalachia get more respect from management than staff workers do in hospitals. In the words of one former military commander, "F*** You. Strong message follows." Those penny-pinching short-sighted bastards have never had anyone's backs except their own buttcheeks, mainly because that's where they store their heads on this issue, 365 days a year, plus an extra day during leap years. I'm remarkably well-read, and I've got pretty comprehensive recollection of my nursing school days, and I can't seem to recall reading in either the state penal code nor any textbook of nursing that the job of healthcare workers is to get the shit kicked out of them, literally, day in and day out until they either quit, retire, or die, yet I've seen and experienced that is the reality.
The police, for taking a "So what do you want US to do?" attitude, as if suddenly the laws of the city and state magically don't apply inside a hospital like they do at Fred's Bar & Grill. (For the record, Officer, I want you to do to them what you would if it had been a "brother officer" they'd kicked, punched, spit on, or tried to choke out. Because if you don't, Hear Me God, I'm going to treat you like them, every time you and your brethren in blue enter my ER. Think about that long and hard when you just can't feel me about cuffing Mister Douchebag and filling out those nasty reports.) And a lot of that is because of the city and district attorneys who are too gutless and chickenshit to prosecute, in their entire careers, one case of violence against health care workers anywhere I've lived, worked, driven by or flown over since I Australian rappelled out of the womb on the end of an umbilical cord. As Casey Stengel said time after time, "You could look it up."
And lastly - not mostly, not substantially, not firstly, but certainly lastly - us. Those of us who put up with being treated like punching bags, as though getting jacked up is some mark of special blessing, machismo, or street cred. Or because we didn't know any better, or because supposedly older and wiser colleagues told us, explicitly or implicitly "That's just the way it is." As Bruce Hornsby's song should have taught you, "Aw, but don't you believe it."
It's bullshit, boys and girls. For the love of Jesus, Buddha, or the Flying Spaghetti Monster, stop acting like the dumbass battered wives and girlfriends you diss and scream at, strap a 2x4 to your spines, and stop putting up with being whomped on like it was some freshman hazing or dumbass rite of passage.
It's assault, battery, mayhem, and attempted murder. Swear out the complaints, press the charges, and if necessary make the citizen's arrests required, and don't take no for an answer, or tolerate getting undermined by higher-ups. When you feed the pigeons, you get more pigeons, and more pigeon crap. When you appease the bullies, you encourage more bullying. (And yes, you worthless wankers, I mean every one of you in a supervisory position who doesn't kick abusive people out the door on their fat whining asses, in 100% of cases, with zero tolerance, with security and if necessary a police escort.)
Or someday when one or fourteen of your co-workers, God forbid, finally gets a window blown in them by somebody with a 'tude and a firearm, because of all the times you didn't stand up and scream "ENOUGH!", it's going to be too goddamned late to tell yourself, or their families and kids, that you're really sorry you couldn't find the will, the wisdom, or the sense given to the dumbest jackass on the planet, with any number of legs, to act to end things before they went that far.
I'm not expecting to speed-dial 9-1-1 for every insaniac. That's what Geodon, Ativan, Haldol, hard restraints, and big security guards are for. And I get that both those on booze, PCP, meth, and those stricken with Alzheimers' or otherwise altered may be a handful. Those are patients, and we'll deal with them.
But the ones who are AOX4 and just aggressive, hostile @$$holes, including spouses, parents, family, and friends in about a 10:1 ratio to the actual patient seeking care, need to be confronted with a simple common-sense standard: you attack those trying to help, you leave in handcuffs, and you never get to come back to us again.
I want the law in 50 states and every U.S. territory to be blessedly simple, straightforward, and unconfusing: any threatened assault or actual battery on anyone in healthcare, from an EMT at the side of the freeway to so much as a custodial person at a hospital or a clerk in the doctor's office, is a straight out-and-out non-negotiable felony, and with the same mandatory 24 hour no-bail no-release jail time as spousal abuse. From Bangor to Guam, from the Bering Sea to the Canal Zone. And yes, that goes for drunks and drugheads. If we can charge them for manslaughter behind the wheel, we can damn skippy charge them for felony battery in the hospital or ambulance, and the quickest way to take the fun out of things is for The Man to deliver the smackdown. And any continued verbal abuse or threat of violence whatsoever gets you kicked out so fast it takes your clothes a minute to catch up to your sphincter when you get ejected, and you get a restraining order filed the next morning in perpetuity. To hell with "Three Strikes", let's try the "One Strike" policy, and see how it works. And post it in big red letters on signs right next to the cutesy "Patients Rights" plaques, at every entrance to every hospital: "Any assault, battery, or threat of same by anyone against any employee here, for any reason, will result in immediate arrest and prosecution. Any verbal abuse will result in immediate and permanent ejection from the premises. There will be no exceptions under any circumstances and no second chances."
It's ridiculous that flight attendants serving Diet Cokes are given more protection from obnoxious businessmen under the law than the doctor, nurse, or tech working to save a life in the ER or at an accident scene working with drunks, drug addicts, certified lunatics, and world-class violent jerks, but they are.
None of us should have to lift weights and work for a martial arts black belt, or seriously consider wearing shin guards and knee pads, a cup, and possibly even a bulletproof vest under our scrubs just to do our jobs. Or to soberly weigh whether we'd rather carry pepper spray, a taser, or even a pistol hidden on our persons, breaking ethics, hospital policy, and possibly even state law, in preference to being one of the half-dozen pictures in the paper when some sub-human ghoul decides hospitals are the new place to go on a shooting rampage with no one who can shoot back.
There's a way to reverse things before it goes that far. (And if we don't, it's going to go that far, mark my words and note the date.)
It's far past time to stop mollycoddling the f*cktards, and start applying a little tough love. Generally, by giving them steel bracelets, and a 24 hour time out at the Graybar Motel, until the day comes when you're more likely to see icebergs off Miami Beach than hear about a healthcare worker getting roughed up.
Can I get an "Amen"? And how many of the yapping pointyheads constantly carping about "getting nursing the respect it deserves" will help make such a policy reality, and how many will instead stare blankly like you've just grown another head, cough, shrug, and move on to studying the latest JCAHO Happygas, rather than saddle up for this fight? Watch closely, and look and see who your real friends are when your own safety is under discussion, ladies and gentlemen.
