There Are No Stupid Questions, Only Stupid People

From time to time, just to do an internet pulse check, I tab through my own stats to see what's bringing people here.

Sometimes it's surprising, or a I find a new blog, or I see someone has thoughtfully given me a shout out and there's a spike in page views.

And then there's today's little moment of mirth for moi.

Because one of the categories I find the most interesting is to see what keywords and searches dumped people on my little island in the Matrix.

One of this week's snort-worthy queries to the gods of Google and Bing was:
"how can you fight your ncclex score".

So if you end up here in general, or at this post because I put NCLEX in it, allow me to give you a leg up on this difficult and pressing question, especially for would-be nurses.

Here is the seldom-revealed-in-such-clarity, Top Secret:Codeword Access Sooper-Dooper Guaranteed Method to crack this deal wide open, and solve your NCLEX problem.

DON'T BE A DUMBASS. Study. Learn. Succeed.

I'm pretty sure I covered both study and test-taking strategies for your boards in the middle of 3 essays towards the new grads, a few weeks back.

So, sportsfans, in case you figure your state nursing board is going to jump back once you sic your lawyer, J. Noble Daggett on them, and cough up a passing board score because the sun was in your eyes that day, allow me to offer you a great deal on a barely used bridge right next to some beachfront property in New Mexico. Just send me your credit card number, bank account information, social security number and your ATM PIN, and I'll get right back to you.

(If that sarcasm went over your head, go back to beautician school, or perhaps consider a career in either food service or janitorial endeavors.)

You aren't going to "fight" your NCLEX score, as a rule. And in case no one ever let you in on this tip, let me let the cat out of the bag:

Your patients don't come with four handy multiple choice options tattooed on their chests.
That means you have to use Mr. Brain to come up with actual thoughts, and then behave appropriately and arrive at a rational course of action, based on what you see.

Y'know, pretty much how 99.9998% of the rest of life works.

So if you've somehow arrived at your nursing boards, and bungled them, either regroup and do better, or go home. But abandon any thought of arguing your way to a passing score if you didn't earn one. If you flunked your boards, let me be the first one to encourage you to try again. And if that amount of integrity and honesty with yourself eludes you, let me be the first one to say I'm really glad you're not a nurse, and I hope you never get to be one without undergoing a successful brain and character double transplant, if a donor match becomes available.

Because if test-taking kicks your ass, in a situation where you have oodles of time to successfully pick one of four letters on a keyboard, in an ideal test environment, the last place I want you to be placed is at a patient's bedside when some serious crap is going down. Try to remember that your kindergarten teacher lied to you, you aren't the most special snowflake, and if you can't hack the easy stuff to get this gig, you sure as shooting aren't going to be able to handle the life-and-death stuff day in and day out for twenty to forty years.

So please, either perform a Valsalva Maneuver (look it up!) until you hear a loud popping sound, and your head breaks suction from where you had it stuck, or pursue another career endeavor.

But thank you, whoever you are, for providing me the chance to mock your anonymous and unintended flash of honesty, once I found your jam-smeared fingerprints all over the NCLEX cookie jar. But please, pull your pants up from around your ankles, and decide if you're serious about this profession, or just comedy relief.

Take Pity On The Newbs

As Whitecoat's blog has reminded me, it's July.

Which, for those of you in teaching hospitals, means the new kids have been rolled out from med school and internships, and so Summertime Santa has delivered your shiny new batch of ER residents. The ones with about 5 minutes' experience, at this point.
Counting the time to get their name badges from security.

There will come a time to begin lovingly screwing with them a bit, but for now, handle them gently, like baby chicks and newborn bunnies. Everyone is new at some point. The Golden Rule applies.

I remember when I had a whole year of the ER under my belt at Seventh Circle Of Hell Hospital, when I had the unknown-to-me realization that "OMG, I know MORE than the DOCTOR!?!"

Because I experienced, on a lovely summer night one July, the dawning of comprehension of that fact courtesy of just such a larval example of the ER doc.

I'd been a nurse for most of a decade at that point, and done pre-hospital work for even longer, but my time in the big-time ER was just about at my first anniversary, so this was a new experience for me too. (Remember what I said about everyone being new at some point? There you go.)

So imagine my growing astonishment at finding a brand new ER resident, fresh out of his wrapping, as it became apparent he was staring at the patient chart in front of him, blank except for a Chief Complaint and curt but clear triage notes, evidently hoping for all the world that the very page would suddenly gain the power of speech, and exclaim to Dr. Freshmeat what in the wide world he should do.

As I ambled up to him, thinking perhaps there were some order I should note, I became aware that the entire chart was blank.

"Has the doctor seen the patient yet?" I asked.

"I'm the doctor." he said, and we introduced ourselves.

"So, first day?"

"First hour. I'm wondering what to do."

Honesty like that generally demands mercy, and he was a decent-seeming guy.

"Well Doc, usually with chest pain patients, besides the 12-lead EKG he already has, we do a stat chest x-ray, basic metabolic panel, CBC, and cardiac enzymes, repeated up to times 4, to rule out an MI." Because I'm not a genius, but after doing the same thing 500 times, I'd start to notice certain patterns...

"Great! Thanks!"

And he begins to scribble furiously in the orders block.

So figuring he's still got to actually see the guy, I move one bed down my area, just as the Head Attending, Dr. Doneitall, walks up to supervise Dr. Freshmeat, and ensure he hasn't killed anyone by 6:15PM.

"Dr. Freshmeat, tell me about your patient."
"He's got new onset chest pain, he has a negative initial 12-lead, so I'm ordering a stat chest X-ray, BMP, CBC, and serial EKGs and cardiac enzymes to rule out MI."
"Outstanding. Strong work. Carry on."

Which praise, at Seventh Circle Of Hell, from Dr. Doneitall, is the equivalent of Babe Ruth telling you you're a great baseball player. Especially to someone in his first hour in the ER.

Whereupon Dr. Freshmeat, behind Dr. Doneitall's turned back, whips around to me, throws me two thumbs up and a monstrous stage wink, and mouths "THANKS, DUDE!"

Because I just slowpitched him that hanging curve and he parked it in the bleachers. He just needed the initial nudge to help the textbook answers pop out of his forehead and flow onto the chart. Words cannot express how easy it was to work with Dr. Freshmeat the rest of his residency, and he did indeed grow into an excellent ER doc.

My other experience, growing after that night, was that I could generally run rings around the first-year residents, the second-years could keep up with me, and the third-year residents could bury me in orders in about 20 minutes that would kick my @$$ all night, and would, until they started to hone in on horses instead of zebras, and abandoned the shotgun approach to diagnostic work. It helped when they had the mentoring attendings, instead of the anal-retentive ones.

So unless they're total dicks from the get-go, cut the new kids some slack.
Keep an eye on them, shove them in the right direction from time to time, and help them to succeed, and it'll generally pay off. If not for you, for their patients for the next 30 years.

You can always screw around with them after a few months go by, just about the time they start to get a little cocky.

Diagnosis Of The Week

Your child is sick.
We know this because you've dragged the little troll here, under the general precept that "If Momma ain't happy, ain't nobody happy."

Okay, well played.

But you know what undercuts any shred of compassion we would otherwise have for someone who's visited us so often that your registration now consists of the clerk typing "F12", and your entire life history is instantly uploaded to the sign in paperwork?

It's that you brought your other 5 kids, and signed yourself in as well.

Crack medical professionals that we are, we know that the correct diagnosis is not "Mass Casualty Incident", "Attempted Mass Murder", nor even "Multiple Food Poisoning" (though your aunt's two-week old casserole has almost reached the status of agar as a culture medium in microbiology circles).

No, gentle reader, the correct diagnosis of this ailment is "Family Plan".

Now, we understand that the economy is tough, so it's hard to resist bringing your entire brood, because babysitters cost money, whereas to you, the ER is free. And we know we have better cable than you, and more video consoles. We also know it's hard to resist the free $5 universal remotes in the rooms, despite the docs having replaced them three times, and having sash-chained them to the walls, along with the free crayons we buy by the bucket, rather than see your spawn reduced to actually waiting quietly while the TV plays.

But what boggles our collective minds is that you frequently show up with both parents, grandmama, and your 7 kids, when you, we, and every person in triage can tell that there's only one sick kid among the bunch (if that, but I'm giving you the benefit of the doubt).

Allow me to be so unfeeling as to suggest that next time, 1 parent brings one kid in your 1 car, and the other stays at home with the other 11 not-sick kids. Sociologists have a name for this: they call it "parenting".

I know I'm being unfeeling, because, really, how could I possibly know at a single glance, before a single vital sign is taken, that all 17 of your offspring don't each have Dengue Fever? It could very well be exactly that, and who am I to assume otherwise? And I apologize for thinking that you brought them all because you cleverly noted that since the doctor's already in the room, why not let him do 25 full physical assessments instead of wasting his precious time with one actually minimally sick child?

Clearly, yours is the superior outlook on the proper role of the ER in your life.

So the next time your big yellow bus rolls up, and you, your spouse, his brother and sister-in-law, their 9 kids, your grandmother, and 32 of your kids tumble out of the Clowncarnucopia of Fail, I'm not going to bother to explain to you why, on a 5-level triage system, where 1 is dying, and 5 is minimally acute, you're all the only "6"s on the tracker, and the entire Western Hemisphere will be evaluated first (including the guy who signed in with lycanthropy), before I even consider shuffling you along to the clinic side.

And thanks for bringing your entire village all the way here, because nothing says reasonable health care usage like seeing the entire chorus of Les Miserables descend on my desk simultaneously, grab an entire bucket of pens and sign in forms, occupy every seat in the waiting room, and turn a busy waiting room into a school field trip for the entire district, while they run around, scream and yell, and eat half of 117 bags of Flaming Hot Cheetos, while scattering the other half of each bag all over every horizontal surface as a sacrificial offering to the Mayan God Of Faux Corn Products.

The only thing rolling in my favor is that the day they authorize a minimal $5 co-pay for your nonsense, one of these trips will wipe out your EBT card balance for the month, and you'll have to sell the Mercedes.

But until then, you're on notice: the next time you pull this crap, I'm not telling the Fast Track Doc we have a Family Plan.
One more visit from the Bratty Bunch, and I'm upgrading you to a Flash Mob.
And on my 5-point triage scale, that's a 32.
Be warned.

Raging Bull&#!^

Okay, first, read this tale over at Dr. Whitecoat's blog.

Just for reference, I may have mentioned this subject before.

And I may, perhaps, keep bringing it up until any assault on any health care provider gets you an instant non-negotiable 24-hour stay in the Graybar Motel, just like wife-beaters and drunk drivers.

One, because that's not too much to expect, and
Two, because it's f***ing the way it should be.

We have, in the referenced tale, a perfectly reasonable description of an incident that happens with tedious regularity, especially in emergency departments, but in fact, throughout healthcare, and we yawn at a situation where someone committed criminal battery on the nurse, then multiple staff members, but had to rise to actually assaulting and battering a police officer - a man with multiple backup officers right next to him, and a tazer, bulletproof vest, service pistol, and 50+ rounds of ammunition on him, as opposed to someone in cotton hospital pajamas with just an ID tag for armorplate - before anything like a certainty of a trip to jail, rather than merely being tenderly escorted onto the street, was contemplated.

How do I feel about that? Thanks for asking.
IT'S BULLSHIT!!!
My apologies if I was too subtle there.

To be fair, the story wasn't the first one Whitecoat has referenced; tales of ED violence around the country and around the world are a regular feature on his blog, because they're so easy to find, again and again and again. This one just frosted me, because of the tacit acknowledgement that "that's just the way it is".

When we, as a work unit, as a hospital, as a profession, as an entire segment of society, agree to let ourselves get kicked in the crotch daily, as though it was okay, guess what's going to happen to you and I tomorrow?

If you guessed "get kicked in the crotch again", congratulations.

Enough is enough.
Start rattling cages, and get the monkeys working for you for a change, instead of sucking up to their Press-Ganey score whores.

Or start making plans to bury your friends.
Because if you think the nutbags who keep shooting up Gun Free Zones at schools aren't going to figure out very soon it'll work at hospitals too, you're certifiably insane.

Not The Fashion Police

From time to time, as noted earlier, some folks come to my house, and one way or another, wind up strapped to a gurney, dressed in a patient gown, under close observation every minute, until we can find a nice soft room for them in the psych unit so someone with the patience of Job and the compassion of Dr. Schweitzer can sort them out, and help them get the voices out of their head.

We do an excellent job, but sometimes, there's just too many crazies, and not enough watchers.

So when you get someone settled in, rotate them off the restraints, get all the prelims done to grease the skids for their departure to our/somebody else's psych eval unit, sometimes they've become such model citizens that the need for being tied to the bed rails has long since passed, and can't be justified.

And then Mr. Murphy punches in, and that split second the minder is busy dealing with one of the unstable campers, one of the calmer ones notes the merest sliver of a chance for freedom, and bolts for it, leaving the minder with nothing to show for a last desperate effort but a handful of patient gown with no patient inside it.

When you're the one who sees someone sans obligatory hospital gown, or anything else, go flying past you, out the front door, over parked cars and parking attendants, bushes, hedges, parking meters, and fire hydrants like a gazelle on crack, it's probably better that you noted the patient is now running in nothing but a smile up the nearest freeway onramp, rather than attempting to replicate her feats of Olympic steeplechase prowess into the dead of night.

Now, I know at that hour, human response and higher brain function aren't at their peak, even when you've been on the nightshift for, seemingly, your entire adult natural life.

But when you pick up the phone, and report the incident to the local Patrolers of Highways, you expect a certain level of...well, not competence, which they have, but more like...perspicacity, which they might sometimes lack. Just a bit.

You would then be forgiven, after telling them a naked crazy woman is running down their freeway, and asking for a wee bit of assistance in corralling said waif, and returning her to the land of Milk and Geodon, when they ask in reply, "Could you give us a physical description?" and your jaw hits the floor.

But when you ask, in a voice dripping with sarcasm and pathos, heard plaintively across the entire waiting room, "Officer Notthesharpestpencilinthebox, just exactly how many naked women do you figure you're going to find running down the freeway at 3AM???" and this reduces both the security chief and your charge nurse to hysterical giggling tears for 10 minutes afterwards, it makes the entire shift almost worthwhile.