Baby Nurse - Another Successful Launch!

 

Just finished clinical rotations with another about-to-graduate nursing student (my second so far) who wants to work the E.D. Since they were joined at the hip with moi, the designated utility infielder of my stomping grounds, they tagged along for shifts in triage, trauma, and multiple shifts with pairs of critical ICU holds camping in the ED. Final shift bonus for training purposes: a full arrest.

We don't normally throw that at our actual licensed new grad RNs until a month or so into their ED preceptorship, but this not-yet-graduated nursing student took to all of this like a duck to water with minimal guidance and supervision. Huzzah.

My earlier one is now in their 15th month here, and about 8 months out of training wheels, and is doing great.

I'm not going to be doing this job forever, and it's satisfying to pass on some of what I know before I either start forgetting it, or become too mentally or physically decrepit to pay it forward. I'm still pretty pissed at what the Idiots In Charge did with my first new grad RN (who recycled in-hospital despite the Mean Girls in the ED to become a fantastic ICU nurse, after some horrible co-workers hamfistedly and short-sightedly crashed their quest to work the ED), but starting out some nursing students right, who will, to a 95% certainty, knock out all their certs (ACLS, PALS, NIH) before applying to HR for an opening in the ED and get fast-tracked to starting here takes some of the butthurt sting out of that earlier cardinal sin. Not all of it, but some.

I'll recommend my latest padawan to my director for hiring (I'm only one voice), but with current turnover, they'll probably be picked up after passing the NCLEX and knocking out the pre-requisite certs.

{New grad tip: Get all the crap (certs/cards/classes) your wished-for department/specialty requires before you send in a resume and apply. That moves you from Florence Nightingale Wannabee, in a stack of 1000 resumes from the same, which will sit in HR until they've exhausted all the great candidates, and move your application into the basket with the 10 other smart and motivated applicants who have all their crap together first, whom HR can and will interview and hire for next week, or the very next new grad class. Write this tip on your hand with a Sharpie, lest ye forget! Or wonder why no one has called you 3 months after you graduated, while you're still serving lattes as a barista. Your choice, kids.}

It's almost like I know what I'm doing, and the bosses' boss keeps funneling some good rookie prospects to me to impart some wee few tricks of the trade.

Sadly, their completion means I'll now be doing all my work again, instead of supervising a bright young acolyte at those tasks.

>Le sigh<. First-world problems.

Still worth it.

Now We Are Ten

 

Sonofagun. Past it, in fact. As of early last month.

Didn't even notice in all the hubbub of normal life.

We are also damned near the last and only ER nursing blog that's not happygas and rah-rah pablum still in existence. Shrtstormtrooper, God love her, keeps plugging away on her blog, and more regularly, we confess, than we have on this one. But she sounds about ready to throw in the towel on the ER, and make a mental health move to something less soul-crushing. Time will tell.

We didn't realize ten years' time would get us the Sole Survivor crown in this endeavor, and as we said, we haven't been nearly as prolific or consistent dropping in over here as we have at our other endeavor.

Part of that is because after the first year or two, you've seen almost everything you're ever going to see in the ER, for 95% of patients. A sprained knee or appendicitis is exactly like every other one. (Thank heavens.)

The other 5% is unbelievably hilarious, jaw-droppingly horrific, or mind-bogglingly weird (sometimes all of the above).

But we've got, according to the Social Security Administration, probably another decade of shoveling coal down here in the boiler room before we can think about docking this battleship and getting off. And if we hit the Powerball tomorrow, while we love the job, and most of our co-workers, we'd leave skid marks out of the parking lot, and send the night shift a prepaid food truck every night for a month as a goodbye present, and never think about it again, unless writing a book or a script.

And sleep soundly every night, and walk around with a smile on my face every day afterwards.

But we took care of another...seventeen patients just last week, directly, and saved at least three of them from dying that day. And that part never gets old, no matter how tired we are of the drunks, addicts, and drug-seeking @$$holes who waste our time and effort, society's money, and their own lives.

So we're not going anywhere, anytime soon. Including online.

Just disappointed currently, because of having a preceptee/new grad for a couple of months, who was learning the gig ahead of schedule (95% her, and 5% us), and then was taken away and farmed out to good nurses and bad for the next two months, and is now struggling, hesitant, had her confidence shot, needing extra time in orientation training, and may possibly crash and burn, because manglement does what it does deaf and blindfolded, and can't figure out why they keep losing 90% of their new grad trainees, when they keep turning them over to nurses who couldn't teach their way out of a wet paper bag, let alone imbue a new grad with the skills to do this job. We could teach a motivated monkey to do it well, but we're not somebody's bestie, and thus not liable to get that opportunity again.

That absolutely and quite simply sucks.

And it's unethical, unlawful, and sadly against hospital policy to take the guilty jackholes into the supply room and do some one-on-one wall-to-wall counselling, to teach them the error of their ways.

That's a notable pity as well.

Because I like my job, and I'd like to download some wee quantity of what I know and learned in the last nearly thirty years doing it, before it's too late. But I don't love that enough to ride that concern right over the cliff.

And the Flying @$$holes always self-select for more Flying @$$holes, and can't figure out why better quality people always end up leaving, or not getting on their team in the first place. 

Said every staff member at every hospital since Florence Nightingale was a new grad.

At any rate, since noticing the recently passed blogiversary, we are entitled to a party and some cake. And many happy returns of the day.

Best wishes to all who drop by here, and a commendation to those who continue to fight the good fight, in the professions and careers that matter, to the highest extent humanly possible in this lifetime.

What do you do at work? I save lives. 

You too? Pretty effing awesome resume, right there.

In Vino Veritas

  

When we get new patients in the E.D., there are a host of questions asked, most appropriate, but a certain non-negotiable number we have to ask, which have no wild bearing on anything related to why you came in tonight, because some Good Idea Fairy has decided that Problem X is this year's Important Thing.

This year's focus, it has been decreed, is suicide, and thoughts of self-harm.

How braindead stupidly are we following that rule? Every patient. Every complaint. 

Sprained wrist. Ingrown toenail. Yes, even toddlers.

What made my night last night, was when one of the 17 drunks and ODs a night came in, and dutiful nurse receiving the patient is going through his list of things to know, and mines this gem:

"So, have you ever felt like killing yourself, or have you ever had any thing that made you feel like you wanted to harm yourself?"

Whereupon, Patient Jack Daniels replies, "Well, I was married once..."

The paramedics cracked up. It was all I could do to not fall out of my chair laughing.

All This, And They Pay Us!

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.}

The Show That Never Ends

So, with the entire hospital full and packed to the rafters this week, X number of E.D. beds, and 4X number of waiting room patients all friggin' night, I walk into my shift after clocking in early, because of the page of a violent patient in the E.D.

Four hard restraints, three assaulted staff members, two police responses, one bite mark, and a cuckoo in a bare room later, and that issue is settled while the meds kick in.

Oh, and no points for guessing who's getting that patient as part of their assignment.
So as the night wears on, Fate has firmly tattooed her heelprints on my backside, because I'm getting my ass thoroughly kicked, and even though we're closed, we get a call we can't turn away, for a STEMI inbound in 5 minutes.

And I'm also doing the critical beds tonight.

FML.

That'll be me in the white tonight.

 

So our patient arrives, with the paramedics having done damn near everything (mad props, guys), he's got a STEMI on the field 12-lead, tombstones on the 3-lead monitor, and a STEMI on our 12-lead. And a classic CP presentation. So we're pretty sure it's a heart attack. We dotted all the "I"s and crossed all the "T"s, and we're just waiting for the cath lab doc's arrival to move him over, when the little stinker patient codes. Fifteen seconds of compressions and one defibrillation later, he's back, with the wife biting her fingers off watching, and off he goes to cath lab, finally.

Where it turns out he's got one coronary artery 99% occluded, and another distal one that's at 90%, both of which they stent.

So as I leave, the family is in the ICU waiting room, and I've already talked to his ICU nurse, where the patient is smiling and joking with the nurses, and liable to get a few more decades with his family, after getting to the hospital just in time.

Because everyone from the paramedics to the E.D. to the cath lab to the ICU are badass rockstars, on their "A" game.
And I get to leave the family with smiles, instead of tears.

That'll be me as I walk to the parking lot that morning end of shift.

Expecto Patronum

It sucks coming in to the shift after the Christmas weekend, with the ER jammed, and the overflowing lobby looking like the tiger cage at the circus, at feeding time, and the triage nurse feeling like a staked lamb. It's even worse when every time you get a critical patient out of the ER, you get rewarded with another sick patient, even before you get back from passing along the last admit.

It starts getting better when you get everyone out, either discharged home or admitted, and it's really turned the corner when all your beds are empty, and the lobby has been cleaned out too.

Even when it doesn't happen until 6 AM.

Now all you have to do is make that last hour, hoping that nothing will go sidewa

"TWEEEEEEEEEEEEEEE...Medic Six...three minutes out...witnessed full arrest...CPR in progress...intubating..."

Leaving just enough time to clear the decks for action stations and grab the crash cart, because as the one with no patients, guess who's getting the run...?

And everyone shows up, just ahead of The Guy, the purpose of the exercise.
Including the uninvited party crasher.

I really hate that guy.

He tries his best, too. We get a pulse back, lose it, get it back, lose it, get it back, lose it.
The ET tube gets dislodged; the doc re-places it. We go through code drugs like Charlie Sheen at a cocaine lab. Everyone is on their game though. The guy comes in a deathly shade of purple, and we manage to turn him pink and warm with compressions and bagging. Lines go in like clockwork, IV, IO, central line, NG tube, foley cath. A pile of debris and detritus forms around the perimeter of the room, in inverse proportion to how our guy is doing. Apparently you need to fill a garbage bag to save a life, and we're doing our bit in spades on both counts.

Finally, the efforts start paying off, the pulse comes back for good, blood pressure and oxygen sats stabilize, and we start thinning out the garbage piles just ahead of the arrival of the family that last saw their husband/father/brother/uncle being loaded into an ambulance in the dark half an hour ago.

Sometimes, with some patients, the end is a welcome release from terminal pathology, but not this time.

And with an extra little push from timing, a short transport time, and rockstars on arrival, this guy got the A-Team.
And I love it when a plan comes together.

Oh, and f**k you, Death.
Not on my shift.
Not this time.

"How the hell do you not get burnt out doing this?"

I really, really enjoy my job.  (When I get to do it. The three dozen things a shift that have jack and squat to do with actually caring for patients still suck my soul out.)

There's always bad shifts, even bad weeks, but when I catch myself getting overly grumpy about it, I make a mental game out of kicking its @$$.

Life really is 10% what happens to you, and 90% how you decide to feel about it. I realized it's a lot more fun going through life as the cat than as the litter box.

And when it's time for time off, GTHO and have fun. (Also, if you never go away, they never miss you. Really.) At least one county away by car is great; if it involves a plane ride somewhere else, so much the better. This year I'm picking off the 27 states I've never been to - and probably finally getting the (online, now!) BSN they swore I couldn't live without as a nurse - by 1995 (snort!). Next year, I'm either doing countries, or destinations. I want to see what a full passport looks like.

But after a week, 10-14 days tops, I start getting twitchy to get back to work. I've never not had a job (except during part of college) since I was 13.  That's mumblemumble an awfully long time, so force of habit there as much as anything else I suppose. Total days, lifetime, on any sort of state unemployment, zero. Trabajo. Period.

BTW, assuming someone does 3x12hr shifts weekly, if you pick up 1 extra shift/wk at a different facility, you network, see how other people do things, have a fallback job when your main gig craps out on you (and they will!), and you have about 20-25% after taxes of your annual pay in your hand as your Better Life slush fund if you simply put it in a jar every payday. I highly recommend it for anyone with 5+ yrs. experience. That's vacation, retirement, a down payment on a mortgage, or a new car, in return for one extra set of clean scrubs every laundry day. Times the rest of your career, that's one helluva better place to be in. Wish I'd started doing it ten years sooner.

One other thing: if you have an ounce of discipline, keep a shift log.
E.g., I'm about to embark on a 13-week contract. Or, 39 shifts. Potentially, as many as 65. Whatever.
But if you'd like to put what you do in perspective, start a little tally:
Say, something like : 4 GSWs, 19 MVCs, 42 MIs, 23 CVAs, 37 hot appys, 59 fractures, 107 psychs, 317 FDGBs, 81 peds, 126 admits, and a little boy with a toy soldier up his nose.
1423 doctor's orders implemented, 917 meds passed with no errors, 182 IVs started, 12 NG tubes, 56 foley caths, 918 phone calls, and 2 teddy bears successfully returned home with their smiling owners.
It lets you see just what an actual difference you make, and it's a metric fuckton more persuasive than the jacked up ratings on annual evaluations if you want to point out what you've actually done for your facility, if you're there long enough for an annual evaluation and raise discussion.
Trust me on that.

Like that slush fund, consider the tally another way of paying yourself first.

Gift Wrapped

You had a heart attack a couple of years back.
Undeterred, you're still smoking every day.

But you had chest pain the other night.
So you came to the ED.
No, not by paramedic ambulance called to your house, with all the latest technology and pharmaceutical wonders at their fingertips right there in your in your living room.
(Too easy, right?)
Instead, you waited a few hours - to make sure this was really something - then had your wife run a few red lights driving you in to see us.
Then you came in, went to the bathroom, and then waited to register to be seen.
Without telling anyone why you were here.

Of course, your full arrest in the waiting room a minute later kind of let the cat out of the bag.
Lucky for you it was late at night, during the slow time, and we all came running.
And somebody jumped on chest compressions for you in about 10 seconds.
And kept on doing it until we got you onto a gurney and into the code room.

And you were in V-fib, of course.
So we zapped you a couple of times, cranked on your rib cage for a few cycles in between, and pumped you full of code drugs, sunk an ET tube on the first try, and got a pulse back.
(Did it sting? Do you remember any of this now? Just wondering...)

And then we shipped you off to the cath lab, and then they sent you to the ICU.
Who fixed you, and sent you home again.

As much fun as we had, we hope next time you'll call 9-1-1. First.
And not risk your wife plowing into a vanload of innocents when she's running red lights on the way to the ED.
Or you arresting in the passenger seat 10 minutes away.
Or dropping somewhere between the cars in the farthest reaches of the parking lot, and us playing hide-and-seek in the dark after your wife runs inside and tells us about it.

So maybe it's time to lose 50 pounds and ditch the Marlboros for good, eh?
Because you did nearly everything wrong, and evidently God's not done with you. Yet.
Congrats, man.

Happy New Year.
Enjoy it.
Oh, and you're welcome.

The Real Thing

One interesting bit of apocrypha, is that the way they teach (or used to teach) bank tellers to distinguish counterfeit bills is by giving them the real bills to handle. After handling actual currency, the failings of counterfeit bills are immediately evident. Why this is germane may become evident as you read on.

For a wee decade or so, I took my prior job at Callous Bastard Hospital for granted. I was staff, I aced the interview, and I was senior in time served to most of the people there except the doctors I worked with. I also knew my job, both generally, and specifically with regard to that facility, and I was damned good at it.

But as my shifts were pre-ordained by scheduling fiat, I could guarantee several weeks in advance when and how much I'd work, and by dint of seniority had carved out a schedule that was about as sacred as it's possible to get. I could pick up extra days, but Uncle's confiscatory withholding made that option a fool's errand.

I also didn't notice, being the frog in the frying pan, how The Powers That Be had consciously and unconsciously (mostly the former) made the place progressively more of a hellhole to work in, by short-staffing, under-equipping, micromanaging, nannying, neutering, hamstringing, and generally undercutting everyone trying to do excellent work, mainly because Managerial Head Up The Ass Syndrome On Crack (times) Who Gives A Fuck About Actual Results As Long As We Meet Our Overlords' Asinine Goals.

The end result was that when I was set adrift with about as much concern as scraping mushrooms off the lawn, I was both depressed, because I felt like I'd failed to do something, and unaccountably relieved at not having to go to work there.

Flash forward to working a registry gig: I can't tell you how many days' work I'll get next week, next month or next year. I've been in quite a number of local E.D.s, all new to me before. I've been universally asked to return/stay/apply for a permanent position at most of them. I know I can work 9 days a week forever if I choose to. As it is, I've been pulling 5- and 6-day weeks with 12 hour shifts, pretty much non-stop since I started this in January. And I've noticed a few things.

1. You can tell a bad hospital in about one shift, after you've worked in a couple of good ones.*
2. I look forward to going to work now pretty much every day.
3. I've been told more times by patients and their families in the last 10 weeks (something like 50x) that "You really love your job, don't you?", than the total number of times I heard that in the prior 10+ years.
4. I'm smiling at work, even when it sucks whale turds, most of the time.
5. Measuring myself against the yardstick at a dozen other hospitals, I'm damned good at what I do, and I always was.
6. I really do like my job. A lot. And it isn't about the paycheck.
7. And oh, by the way, my paychecks have doubled.

So thanks for canning me, Callous Bastard Hospital. I got rid of everything I didn't like, I've maxxed out my income, and I've increased my personal job satisfaction tenfold, simply by not working for you. And now your staff is leaving in droves, and you're begging for people to replace them. Funny old world, i'n'it?

Among the few things you can change frequently in your life are your underwear, your location, and your attitude. If something in life isn't right, it's probably because you've skipped one or more of those three for too long.

And when life give you lemons, freeze them.
Because when you throw them back, they'll hurt more.





* I learned this lesson with film and television productions. But I expected most of them to suck. Realizing the principle applies universally To Everything was a real "Doh!" moment.

Over there someplace --->>>
there should be a new addition to the blogroll:

Hogwarts' School of Grid-Down Medicine.

AKA providing medical help for you and yours, when you're all there is, or is likely going to be, for any number of reasons.

Doc Grouch, Ivymike, and myself had it suggested upon us courtesy of Concerned American over at WRSA.
We promptly all fell all over ourselves thinking what a great idea it was. Doc Grouch and Mike did just about all the work of launching it.
My input was some tinkering, and then I got a vacation, and then my return to reality, as previously noted, has been a bit...bumpy lately.
Thus any credit due to me for it so far is right about nil, so I'm not being immodest to tell you the site looks great, and there's stuff there you should read, learn, and pay attention to, if you think big shiny white hospitals and endless streams of Government Bux to pay for visits there will not last forever, in all places and times, for the rest of your life.
In other words, if you have any grasp on medical and sociological realities, let alone an awareness of the frequency of life's normal allotment of natural disasters.

Doc and Ivymike have done great things there thus far.

As my situation stabilizes, and I get back to regular posting, I'll have more of a share carrying my end of the log, along with Doc Grouch, IvyMike, and anyone else we can cobble together to keep it a going concern, and improve it.

Start at the beginning, read the posts, do the homework.

Our goal is not online medical school. (There are probably laws against that anyways.)
It is that everyone with the time and inclination be provided with the guidance, resources, and gentling prodding (of a solid boot in the ass, metaphorically) to be as prepared as they may choose to be to deal with medical emergencies anywhere, with what's in your pockets, or even better, with the prudently-stocked contents of your home version of Somewhere General Hospital. And anyplace on that spectrum between those two. Guided by what we have invested and reaped from a combined goodly number of decades each and all trudging through the corridors practicing our medical arts.

Go.
Pay attention.
Learn stuff.
Practice it.
Save Lives.

Potentially even those that mean the most to you personally, at a time when you may be their best, or only, chance.


(And though Life's been kicking my butt a tad lately, I'm kicking back, and I'll shortly be back with more Shepherd stories - from a host of new assignments, and a number that have been kicking around for awhile, as well as seeing what Ebola is doing these days besides killing people as efficiently as ever. So whatever you've been coming here for will return in short order, once things settle down a bit for me. thanks for your patience.)

A Little Link-Love: Represent!

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:

                                                     What Should We Call Nursing?

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.

Enjoy.

Just A Day, Just An Ordinary Day

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 two three 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 hate love hate love this job.

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.

Sour Trout

The title is one of the best and funniest sign-ins I've ever seen as a triage nurse, and I only wish I'd written the first 500 like that down, because I could write a book, and retire on the royalties. Or at least get a nice week on Maui.

In case you, unlike just about any ER nurse worth their salt, can't tell what the chief complaint is, it's "sore throat", approximated lovingly and with due diligence by someone whose English skills are somewhat lacking, which is about half my patients hereabouts.

And while that one isn't bad to read, it isn't the first time I've run across it.

Once upon a time, as a tender apprentice in the program at Seventh Circle Of Hell Hospital, where they took six months of class and clinical to push larval ER nurses out of their little Playdoh Fun Factory Mold, I ran across the same chief complaint.

Helpfully, they would do our classes two days a week, and run us through 3 days a week of clinical, on training wheels, with experienced nurses nearby. Which was good, because while I'd been a nurse for half a dozen years and worked without a safety net outside the hospital, their particular brand of patient experience was truly a priceless way to learn, by which I mean the place was ghastly in terms of volume, acuity, and overall suckiness. But hey, once you've played at the Palace, you can work anywhere, right?

So one day found me as the nurse in the back half, treatment, of the walk-in ward. The great part about this area was that everything would walk up, from hangnails to full-on heart attacks. We only kept the minor stuff, but in the pre-ratio days, that meant 8 hopefully minor patients for me, and 50 people waiting for the other nurse out front bringing them back.

And on this particular day, I not only had a brand-spanking new ER resident right out of internship, but the good fortune and favor of the Gods of Emergency Medicine had also helpfully provided me with Dr. DoneItAll. Dr. DoneItAll was able to open up his wallet and tumble out a cascade of about 200 cards, certs, training, and a like number of boards, peer-reviewed articles, etc. covering just about everything. Including probably radiation treatment in the Arctic for the hyperbaric chamber patient, come to think of it. On top of which, he was a really outstanding ED physician, excellent teacher, and a helluva nice guy to boot, which made him not just tolerable, but a genuine delight to work with.

And to help me in my monkey-see, monkey-do days of learning the business of emergency nursing, just the day before, the lectures had helpfully covered the main details regarding eye, ear, nose, and throat complaints we needed to pay attention for.

Thus when my patient presented with fever, sore throat, swollen neck, painful swallowing, drooling, and told me "I habb a sour trout" in the most classic I-have-a-hot-potato-on-my-tongue voice I could have hoped for, I wasted no time in stepping out to go tug on Dr. DoneItAll's sleeve, and inform him "You need to see the patient in Cubicle 2 NOW, please."
And, without questioning me, he stepped in, did about a 30-second physical exam, and stepped out.

"Peritonsillar abscess. Pt. to EENT Emergency, STAT."

And turned to me and said "Nice catch. Strong work."
Which, at Seventh Circle Of Hell, was the equivalent of hitting a home run.

But it's always nice when Fate lobs a nice slow breaking ball right out over the plate for you to smack over the fence in the first place. If only they were all that easy.

You Rock

Besides the expected doctors, nurses, and techs, the ER needs/wants/demands/begs and pleads for the support of numerous other departments and services in the hospital, and mostly we get it.

Some of them are average, some are horrible (I promise, I'll get to you another time), and some absolutely shine.

In this last case, the bunch of folks I've almost always had the best experience with has been radiology. Every last blooming one of them, from x-ray, to CT, to ultrasound.

I haven't gone soft, and there's been an occasional stinker or two, but so seldom as to be noteworthy when it happens. And I wish a couple of them could remember that when they bring somebody back, they can plug in all the wires they disconnected to take them away. But that's small potatoes in the long run.

I've had x-ray techs wait patiently for me to finish a tough stick and lab draw without a peep, tell me about a patient who needed more attention, and save me/the docs/the unit secretaries from ordering or getting the wrong x-rays, on the wrong body part(s), on the wrong patient more times than I can remember.

I've had CT techs who should be wearing the ER equivalent of a chestful of attaboy medals for the most phenomenal service and support I've ever seen. And save a life or two, above and beyond the call of duty.

And ultrasound techs who were so good they whisked my patients away, brought them back, and had the results sitting on the doc's desk before I checked on when they were going to take my patient, and long before Doc Crabbypants started whining about it.

They've expedited care on children, and adults who act like children, gotten in the game without getting in the way, they've caught little old ladies before they fell, and helped dogpile the homicidal whackjobs who tried to attack us, gotten every picture and scan we needed, no matter how difficult, and did it all without pissing and moaning, mostly just a simple shrug, and usually a smile.

Take a bow, boys and girls, because you and what you bring to the party are the biggest difference between all medicine before Pierre and Marie Curie, and after.
And you really, really deserve a gold medal.

Trust Your Gut

On this particular night, I was in triage, my home away from home.

Do this stuff long enough, and you realize that for no discernable reason, patients with the same chief complaint all show up on the same night. Some nights you get two main flavors, others it's just one.

On this one, it was one, and the one flavor of the night was chest pain.

Four hours into the night, and we'd already triaged eight legitimate chest pain patients. The last one, in fact, was a hot STEMI (ST Elevation Myocardial Infarction - a big fat heart attack in layman's terms) soon to be headed for the cath lab. Once I got him in the room and the fire drill of getting him ready to go began, I headed back to triage to start on the next patient.

Looking at the computer tracker, I saw that the newest sign in was a 40 y.o. M with abdominal pain, nausea/vomitting. Bummer, but nothing special during the height of flu season. I already had 15 pts. on deck waiting to get back, and 5 or 6 waiting to come in for vitals and a quick look, but a lot of them were overwhelmingly likely to be of the "you aren't dying any faster than the rest of the human race" complaints. So I decided to stick my head out the door and eyeball the new guy, who I was sure wouldn't be having a fun night, just to make sure he was okay.

I looked towards the front, and saw who it had to be, guy in his PJs, trashcan between his knees, and looking thoroughly miserable. But something about the look on his face made me say "Let's bring this one in for a closer look".

I walked out, grabbed his wheelchair handles, and told him I just wanted to talk for a minute, and check on him. His female entourage (fiancee, I later learned) was 39 weeks pregnant and ready to pop any day, but that was ancillary to everything at this point.

I piloted this guy inside the screening area, hooked him up to the vitals machine, and while it cooked, I ran through the 60 second OPQRST about his pain (epigastric) - {Perk!}, he'd been feeling miserable at home since shortly after dinner, hadn't been sick prior, no history/no meds/no allergies. His pulse is slightly tachy, but nothing radical, ditto for the BP, but then I've just watched him do a couple of gloriously painful dry heaves on the trip inside, and he's a little diaphoretic. Nothing inconsistent with the Food Court Two-Step, and he's probably just eaten something that his body wants out ASAP.

But he's 40. And his pain is epigastric. So it could be gut, or it could be cardiac. So even though the chest pain team is running like one-legged butt-kickers, including with the STEMI I just took them, I still page for an EKG, just to be safe, for me, for him, for the lawyers.

I get him on the table and prepped just as the harried EKG tech zips in with the "You've got a lot of nerve" look on his face, but this guy fits the profile, so I'm not abusing the privelege, and we run a 12-lead.

"Abnormal EKG".

No elevations, but it's funky, according to the $5K electronic chipset brain in the box.

So I roll the gurney he's on back to another open room with full monitoring, because it was empty 90 seconds ago when I took the STEMI to the room across from it.

As the nurse in that section looks at me, I do the clutching-my-chest pantomine for "chest pain". His jaw drops. "You've gotta be kidding me! Another one?"

"Sorry man, he's legit. I don't order them, I just deliver them."

I see the cardiologist on call has arrived to see his guy with the STEMI, and he AND the ER doc both look at the fresh 12-lead from my latest, which I hand them as I roll past to the room.

I hear the cardiologist, one of our finest, say to the ER doc as the both look over the 12-lead printout, "That looks okay, he's stable to wait. We'll be ready for the STEMI in about 5 minutes, as soon as my team's all in."

I'm thinking that's pretty spiffy, since it's only been about 20 minutes since the page went out. Even when we're getting beat up, we shine.

My partner has triage under control, and I know my co-worker's getting hammered, but them's the breaks. Another nurse is floating, and I ask her to grab an IV set-up, while the chest pain tech and I get this guy into the empty room with a quick swap of full gurney for the empty one already there, and I start hooking him to the room monitor.

The float nurse comes in with a ready-made draw kit, and grabs the guy's right arm, while I'm sticking EKG leads on and firing up the room monitor. The guy's talking to us, and his very pregnant girlfriend takes a seat at the foot of the bed. As the tourniquet's going on his arm to pop up a vein, I'm snapping the last of the 3-leads onto the patches. The other nurse calls the guy's name. Then again, loudly. I glance over and see he's clutching her hand as she's trying to stick the IV.

Just as I look back at the monitor, I see his eyes roll back in his head, and he goes from sinus rhythm to full-on bag-of-worms classic ventricular fibrillation. His girlfriend's screaming gets everyone's attention outside rather nicely.

"Code Blue Room 6!" I yell over the other nurse's back and out the door To Whom It May Concern. Then I drop the cannula I had prepped, and swap it for a bag valve mask at 15 liters. The crash cart and even more nurses are at the bedside before I've even finished dialing the liters up, and we stick the pads on him in maybe 20 seconds. His girlfriend looks for all the world like she's going to deliver right now, and I nod to the tech to gently move her out of the already too small room.

The ED doc bustles in as she goes out, the crash cart nurse has the defib charging, we're all clear, and we shock him.

No change. Still v-fib.

The doc says to up the charge as one of the other nurses is already spinning the dial, and in seconds we're ready again. "Clear!"

Zap Number Two...resolves into a beautiful sinus rhythm, and I'm happy to confirm between bag squeezes that he has both carotid and radial pulses just like both monitors show.

Meanwhile the other nurse finished getting the IV we wanted, and drawing a full rainbow of tubes for the labs he's going to need. Most everyone else goes back about their business elsewhere. With nothing else to do, I grabbed the Code Record, documented everything we did for the 65 seconds it lasted, and just as I and the other nurse are signing it, the patient pops back fully conscious and says, "What happened?!"

"Hey pardner, you left us for a little while. Glad you're back. But I think it's safe to say we're keeping you tonight."

Then I went to the inside wait area, and told a much-relieved lady her date was back around as I walked her back to his bedside.

I passed the zone nurse, told him we saved his patient for him to work up, no charge, then headed back to triage.

The guy had another shaky few minutes later, no codes though, but as he was waiting to go to the Cath Lab next, they hooked him up to a nitroglycerin drip. That's when it hit me, as I was passing his room coming and going with other patients from triage for the rest of the department.

He was pink. Slab of ham PINK.

This was remarkable, because while I hadn't consciously noticed it, when he'd arrived he was somewhere between white and gray, by comparison to how he looked at the moment. My frontal lobe hadn't caught it, but some part of my brain had, and that had to have been what caught my notice.

The zone nurse told me later, "I'll never question your triage calls again!"

The patient, it later turned out, had a 95% posterior cardiac artery occlusion, with no ST elevations noted anywhere. If the fiancee hadn't pushed him into coming, he'd have died at home. And if I hadn't gotten him back to a room when I did, he'd have coded on the waiting room floor, with probably a much worse outcome.

His fiancee's pregnancy was the other shoe to a pending but not yet final divorce, which explained why the dude was having a heart attack. Look up divorce, marriage, and having a baby on the life stress scale, then combine the scores.

And learn to trust your gut even when you can't put your finger on why.

Of course, we got 3 more chest pains after that.