RN Staffing Ratios

h/t EDNurseasauras

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.

Vital signs - urinal - blanket - pain med - vital signs - jello - straw - blanket - vital signs - bedpan - water - report - transport - vital signs - accucheck - snack - vital signs.
Lather, rinse, repeat, 200X.

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.

Somewhere Else

It's happily rarer than people imagine, even in knife-and-gun-club trauma centers, but Death visits the ER.

Nobody's death comes easy, even the gang-banger who brought a knife to a gun fight, as his mother sobs agonal soul-shaking cries to the heavens. It's not my job to pass judgment, nor torture the living with the final sins of the dead. They'll be able to do that themselves anyways, and for months, soon enough.

I hate death with a passion when early, or some unbidden surprise visitor, and only when the awardee has lived at least their threescore and ten can I see it as a transition, while for only those dying in terminal pain is it the truly welcome arrival of a long wished-for friend.

The sudden, random, unexpected variety is waste beyond explanation, and the recipient of my quiet rage. Like Captain Kirk, I don't believe in the Kobayashi Maru scenario, and the ones you couldn't pull back are the hardest to bear, and the ones you remember long after the others happily fade from memory.

In Gene Hackman's line in Uncommon Valor, some faces never leave your mind's eye, but you make friends with them. Not to do so would drive anyone mad.

This very morning I was happy to be working on a critical patient, because it kept me too busy to deal with the one right next door, dying with no help nor hindrance from me, despite the earnest efforts of 20 others, and I was glad to be able to let others focus on that problem while I got my guy - awake, alert, and very much alive - ready for the cath lab and then ICU. It could have just as easily been the other way around.

I understand and pity the doctors, because they always get to make the notification, generally face-to-face, and they try to keep it simple and as subtle as a scalpel slicing your throat: "Your xxxx is dead. We tried everything we could. I'm very sorry for your loss."
And then understandably try to get back to work on the living, because there are always more live patients to see.

Dealing with the new patients in the room, the next of kin, family, friends, coroner, mortuary, etc., and calling to tell those unknowing to come in, but safely, and without revealing news over the phone, falls back on the nurse responsible for the man or woman or child they'll eventually have to disrobe, clean up, make less fearsome, and remove pads and tape, while leaving tubes and IVs and such in place, in case the coroner takes the case. Covering the patient for modesty, removing blood and worse; and then, after all the sobs are finally spent, zipping them exactly as naked as the day they entered the world into their final sleeping bag for that trip to the Eternal Care Unit. Tag on the toe, tag on the zipper, hands crossed, and please God, in the couple of hours' grace before rigor mortis starts to stiffen limbs and make it impossible to put grandma or auntie or son Jack into the bag without difficulty, and no limbs extended to other points of the compass than due south.

I've bagged some dozens, of all ages. Some mine, some as a favor to an overwhelmed co-worker. Gently and respectfully, sometimes with help, sometimes alone.

Mindful of the fact that fluids accumulate, muscles relax, and fluids follow gravity. Bad enough to handle the dead without getting slimed by them after their departure. Worst of all, the traumas, some where they've cut them open to reach the heart and stimulate it by hand, often to find the offending missile has penetrated the bullseye, and rendered further efforts more than futile, and sometimes after the patient has been sawn virtually in half from each side, with only the spine maintaining the semblance of a whole person.

I don't know what others do, but I tell you freely and honestly, I talk to them as if they were still there as they're being prepped for that last gurney ride. Maybe they still are there, or nearby, in some way known but to God. I have no idea how soon the bus gets there afterwards, or how quick the departure occurs. They may even still be alive inside there, seeing and hearing, trapped inside the body for a minute or few as things fade away after everything fails. It's simple respect for them afterwards, and it helps me to deal with what I'm doing. Quietly, but sincerely, knowing this is as close as I'll ever be to the doorway they've just entered until it's my turn to be zipped into the bag. They get the same compassion they'd merit if they were still breathing, because they're not carcasses.
Not yet.

I'd happily never have done it, but if not me, who? At least I know it'll be done properly, and with what measure of dignity I can accord someone who probably woke that day with no idea it would be their last.

I have my own suspicions as to what happens to them afterwards, but no one truly knows, nor but seldom is in any great hurry to find out, the trip being always a one-way turnstile.

At this point in my life, I still agree with the man who, when asked where he wanted to be when died, answered quite sincerely, "Somewhere else."

Qwitcherbitchin', Crybabies

Burning Platform has some whiny rant (and coming from me, that's really saying something) about a guy billed $426 for an $8 can of OTC pain spray.

Well, gee, no shit, Sherlock, and if you'd seen the report from MIT on the topic, or drove by Homeless Depot any time since 1986, you might have noticed those 200 Julios standing outside their branch in Greater Aztlan Assland, which heritage Mexican homeland apparently stretches all the way to Anchorage AKand Bangor ME. (Who knew?) And unlike whom, you have actual insurance.

Oh, and back awhile, your congressweasel voted in EMTALA, mainly in response to anesthesiologists passing gas for docs doing C-sections on pregnant migras who were crowning, and getting sued by them afterwards, but never actually getting, y'know, paid for their twelve years of higher-education services or their $1M expertise. Those bastards!! Doctors should work for free, amIright??
Occupy!

Short story long, if you show up at the ER, yours, mine, anybody's, you get to play, but you don't have to pay. At least, not up front. Unlike, say, your doctor's office, Urgent Care, or - waitaminute - every other commercial establishment in the flipping country, including the DMV and the Post Office.
Well-played, Fucktard Minions of Stupidity.

So, by the by, exactly how long d'ya suppose Mickey D's or Burger King would be open as a business anywhere, if tomorrow Congress passed the WAAH! My Tummy's Rumbling Active Hunger And Deadbeat Wimpy Act of 2018, dictating that anyone who wanted a hamburger now could get it now, solely on the promise to pay for it next Tuesday?

And if you worked at a business similarly burdened, how long would you have a job when that enterprise subsequently went tits-up, in about a New York minute??

And if the pharmacy at Wal-Mart had to hand that spray out for free, how much d'ya figure they'd start charging for kettle corn bags and underpants to subsidize that largesse? Say, somewhere around $426 dollars, just mebbe?

Anyways, they go on to knee-jerk call the price of the pain spray to government regulation and socialism(!), rather than all y'all getting the system you pissed and moaned for, and now finding out you're getting it good and hard.

Then, a couple of comments down, this nugget:

"Husbands bill was over $2000 to tell him his arm wasn’t broken.
Xrays were separate, about $50.
$256.00 for a tetanus shot.
For comparison, i can get a tetanus shot for a horse at tractor supply for $4.00
Tetanus boosters have been around for decades. Not like they’re rare or anything.
This is after sitting there for 4 hours among a couple dozen non English speaking persons."

Some people cannot put two and two together, and come up with the answer.
Let me help:

And that's why you're paying $256 for the shot.
You're paying for all the Julios and Marias and Wangs and Achmeds and Crazy Homeless Alcoholic Eddie guys with no insurance.

And of course they get a bill too (despite another idiot commenter suggesting we don't bill them).
Which we can't make them pay.
If they gave the right address.
If they gave the right name.

And also, because if your husband got an infection from poor injection technique, or they hit a nerve or blood vessel, or the sun was in your eyes, it was $256 to offset insurance premiums, because you'd then sue the hospital for a gazillion $$$. So you have a doctor ordering it, a pharmacist stocking it, and an RN giving it, rather than you grabbing a dose at Tractor Supply, and doing it yourself.

And of course, if he'd just gone to your doctor and gotten the booster himself, on time, months ago, it could have been had for maybe $20 co-pay, or even less than that, right?

Make your congressweasel pass tort reform, stop suing everybody for everything, build the frickin' Wall at the border, start throwing people back over it, get your annual checkups, and quit using the ER for drive-thru Urgent Care.  Now, how much of that is within the hospital or ER's control, and how much is within yours?

Otherwise, pony up. Walking in the door at any ER worth the name starts at about $1500.
If it was open, depending on day of the week/time of day, you could've gotten the same X-ray and treatment at any competent Urgent Care for a few hundred bucks.

People will price-shop for a ten dollar difference on a cell phone, but they won't use common sense about an ER bill of $2K vs. one at Urgent Care of $500.
Genius, right there.

(And if Urgent Care wasn't available for you, for any reason, then let's be reasonable. You had no choice about the ER, that injury hurt - a lot, and you wanted to know now. Fair enough. You want care now, you pay now.
We take cash, check, almost any insurance, and VISA/MC. Tell me they do things different at Burger King and Target when you want a Whopper or a pair of jeans.)

But don't bitch when you got the gold-plated care you demand, at prices your insurance company mostly pays, while you rarely see 10-20% of that cost.

This is the system you wanted, and now it's not so bitchin. I get that.
Now go fix it, as outlined.

I'd chat further, but I'm on duty at the ER tonight.
Where, if someone comes in with a heart attack, and we save their lives via the Cath Lab and first-world medicine that should be the envy of every Swinging Richard in human history since Adam, the only thing they'll remember afterwards, and go online to bitch about afterwards, is that the baby aspirins we gave them were billed at $20@.

So don't take this the wrong way, but as someone who couldn't have made two car payments in their life if they received $100 for every "thank you" heard from patients or families in 20 years of saving actual lives, if you complain about anything but gross negligence or egregious harmful malpractice, like having the wrong leg amputated, please, I beseech you most humbly and sincerely, go and fuck yourselves up the ass with a lit flamethrower, m'kay?

Because If I gave you that enema, I'd bill you for it at the price you deserve, and laugh while I did it.

Maybe when the shift is over, if I feel like it, I'll tell what you ought to be doing, and bitching about.
Knowing full well the odds of you taking such concentrated experiential wisdom is about as good as the odds of you listening to the discharge instructions you get.

Friday Fun

Way too true, at way too many hospitals.

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.}

Welcome To My World

h/t IOTW

IOTW links to a story called "Why it’s so hard to get mentally ill Californians into treatment"
(besides the obvious answer, which is because my fellow Californians keep electing them to office):

(EXCREMENTO, CA) For years, Diane Shinstock watched her adult son deteriorate on the streets.  Suffering from severe schizophrenia, he slept under stairwells and bushes, screamed at passersby and was arrested for throwing rocks at cars.Sometimes he refused the housing options he was offered. Sometimes he got kicked out of places for bad behavior.  Shinstock, who lives in Roseville and works on disability issues for the state of California, begged mental health officials to place him under conservatorship—essentially, depriving him of his personal liberty because he was so sick that he couldn’t provide for his most basic personal needs of food, clothing and shelter.
But county officials told her, she said, that under state law, her son could not be conserved; because he chose to live on the streets, he did not fit the criteria for “gravely disabled.”

RTWT.

This is my life, every day for 20 years in the ER, and every other ER, nationwide, especially so if the community is larger than 50K people, and if it doesn't snow there in the winter, multiply that by a factor of 10.

We didn't have 500,000 visits a year at the Busiest ER On The Planet™; we had 1000 regulars who came in 500 times apiece.

I've now been to...fourteen ERs in three counties in nearly twenty years doing this, and it's no different anywhere you go.

Schizophrenia is like heroin addiction: it's a social death sentence, and it's almost never getting any better. The worst part, for family, is that Suzy or John (mostly John, victims are about 1 1/2 times more likely to be male than female) is perfectly normal until late high school or early college, even honors students, and then that last bit of wiring in their heads doesn't go in right. It short-circuits, and they stop being normal, brighter-than-average kids and become, frankly, batshit crazy. I can only imagine the never-ending horror for parents of raising a child, getting them safely past all the normal hurdles of growing up, sending them to college, thinking things are okay, and then watching them completely melt down before your eyes.

Meds help, but only if someone with schizophrenia takes them.
The meds make them feel "weird" (which is what we who aren't schizo call "everyday life" 24/7/365/forever), but they seem fine. So they decide they're not sick, and don't need the meds. And become actually weird, hearing voices who aren't there, seeing people and things that aren't real, and end up in my patch, barking, frothing mad. So we re-medicate them, they get put on a psych hold, they get better, go home, and the cycle repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats. And repeats.

Frequently, after burning all bridges with family, friends, and everyone else, and being thrown out of every care facility in an entire time zone, for cause, they end up on the streets. Where they "self-medicate". I.e., with pot, meth, heroin, benzodiazepines, alcohol, bath salts, paint, glue, or pretty much any substance they can get into their hands, and their bodies.

In a lucid moment, a juvenile patient once confided to me, straight-up, that he got wasted because when he got The Voices In His Head drunk or stoned enough, he couldn't understand them or hear them any more. Pure medical genius, right there.

Oh, and The Voices? They never tell you "You look great!" "Everybody loves you!" "You're a wonderful human being!"

That would be too easy, right?

The Voices always say "You suck. Kill yourself. Everyone hates you. Why don't you die?"

Go watch A Beautiful Mind. Or every scene with Gollum in the LOTR movies. (No points for guessing which sections of those latter movies I will completely skip over, wholesale, in that entire trilogy, because it's too much like pulling a shift at work, except without getting paid.) There was even a great TV MOTW with James Garner as the sane brother, and James Woods as the nut, that they showed in nursing school, because the writers and actors got it so right.

The article tries to pin this mess on Reagan (color me shocked), for signing Lanterman-Petris-Short in CA in 1967. But every other state was doing the exact same thing, and in fact LPS was in the legislative pipeline and conceived under Democrat CA governor Pat Brown, Moonbeam's father, before Reagan was even thinking about politics.

The state - in fact every damned one of them - wanted to get rid of psych hospitals long before One Flew Over The Cuckoo's Nest (which was outdated tripe from 30 years earlier when the film was made, but why let facts interfere with a good screed, right?), simply because crazy people don't pay their bills, you do. So warehousing them in Bedlam was nothing but a money hole the size of the Grand Canyon, nationwide.

And the do-gooders got together with the penny-pinchers, and decided collectively that since psych hospitals were so terrible, understaffed, under-funded, and yet still too expensive, because staff needs salary and crazy people need food and medicine, why not just turn everyone so "unjustly imprisoned for life" out onto the street?
What could possibly go wrong?
"The state budget will save millions!"

Whereas instead, as we all experience daily, they're free to run into traffic, attack people, burglarize and rob and steal to get money for drugs/alcohol/whatever, crap on the streets, and generally validate every reason that we have for why we used to throw a net over them and lock them up for life.

Which we can't do, because you have to be a "danger to self, danger to others, or gravely disabled", the definition for which last means that if you are mentally with it enough to scrounge garbage to eat out of a dumpster, drape yourself in trash bags when it rains, and construct a cardboard pallet and hovel to sleep on and in, you're not "gravely disabled."
Just...eccentric, and living an "alternative lifestyle choice".
Don't believe me, ask the district attorney, the state bar association, and the Do-Gooders League Of America. This ain't a California thing, it's a U.S. of A. thing, coast-to-coast.

So they're free, and now everyone else has to lock their doors, put up bars, keep their kids inside, and pack heat, so that these literal lunatics can run wild and free.

Brilliant.

And the article shows that TPTB haven't figured it out, even after 50 years' time.

The do-gooders just want them to be free (and to hell with their best interests, or anyone else's).
The rent-seekers want more money, and no rules for them.
The families want somebody else to solve (and most importantly, pay for, their batshit crazy uncles, cousins, brothers, and sons).
And the police, the hospitals, and the courts are simply tired of dealing with their bullshit, and that of the interest groups who want it to continue more than they want what we have now to stop.

My bent is a libertarian approach.
After three trips to hospital on a 5150 for being off your meds, we throw a net over you.
We put you in a helicopter, and we drop you off on one of the Channel Islands currently inhabited mainly by goats.
Once a week, the helicopter flies over, and they kick out food bundles.
There are no trees, and the islands are 30-40 miles away, in waters best described as sub-arctic even in July; those people aren't swimming or floating back, ever.
If the family is all broken up over this, they can pay for private care. They can visit them on Shutter Island whenever they like. They can bring them food, clothes, or anything else to make their stay more pleasant. They can even bring doctors and medicine there to address any other needs. The whackjobs are now free to chase butterflies, run around naked, or even try to fly off the cliffs; I don't care.
I don't want them euthanized, or harmed in any way. I want them free. Over there.

What they aren't free to do, is continue to run around in traffic, assault people and each other, crap on your porch, or walk around in society off their meds.
Three strikes, and you're out.
Now they're free, and so are we.

The do-gooders have tried it their way. So have the penny-pinchers.
Now it's time to solve the problem.

Still Alive

Been having too much fun doing other things (including months - yes months - away from the E.D.!) to post here as much lately as formerly, but dropping in, I caught up with the three or four still-active blogs, put one oldie but goodie on life support, and buried three others that were cold, dead, and all shriveled up and dry.

I've also notched two more hospitals on my gunbelt, including a ferocious ghetto trauma center, working on two more hospitals (simultaneously!), and dipping my toes back into getting at least one full-time staff position.
Maybe.

I've mentioned it before, but there's a dearth of worthwhile blogs on nursing, especially for Emergency medicine, and the few worthy ones who pop up once in a blue moon simply almost never last.

I, OTOH, am pretty much terminally incapable of shutting up.
Just been cranking out too much content elsewhere.

So I'll try and put more time into things here, if only because by sheer survival, I'll eventually be the best, oldest, and last ER nursing blog still standing. And pretty much the only one.

As one doc I worked with used to note about the ERs nearby that had closed temporarily due to "patient saturation" (when ours never would, legendarily so), there's only one reason they did that:

"It's because they're weak."

Worth A Try

Important Safety Tip

 

F**king It Up By The Numbers

 

Today's tale of How Not To Do Your Jobs:

(PITTSBURGH) Eugene Wright of Meadville says police and medical workers got the wrong man when they transported him to the local hospital this summer and injected him with anti-psychotic drugs against his will, thinking he was someone else.
"The experience that I went through, this should never happen to anybody. It's very simple to check ID," said Mr. Wright, 63. "These people need to be held responsible."
Mr. Wright and his wife, Carolyn Wright, made their allegations in a federal lawsuit filed Wednesday against the police in Meadville, the Meadville Medical Center and a local crisis center, Stairways Behavioral Health.
Mr. Wright had the misfortune to have the same name as another Eugene Wright, a psychiatric patient who police said had issued threats at his doctor's office, his suit says.

RTWT.

Long story short: they did, in fact, have the wrong guy.
"But they were acting in good faith!"

Yeah, right up until that failure to look in his wallet, or call his employer or the ortho doc to confirm they had the right guy- or not. Times everyone from A to Z. No exercise of due dilligence equals gross negligence and depraved indifference to the consequences. And deserves a prison sentence.

So Innocent Bystander gets hauled away to the nuthouse.

And now, I'm the Pittsburgh D.A., by the power of the Internet.
What happens?

Officers Sh*thead and F**kstick are suspended without pay for battery, kidnapping, false arrest, false imprisonment, criminal conspiracy to do all of the above, and making terroristic threats. They deserve to be fired for cause, and referred for criminal prosecution.
The representative for Stairways who accompanied them gets charged with making a false report, criminal negligence, and accessory to all the charges against the Meadville PD.
Any nurse(s) who gave the medications has their license suspended, and is charged with criminal medical battery on a patient and gross professional negligence, along with false arrest and false imprisonment. Their license(s) gets revoked by their state board, and they get referred to criminal prosecution.
Ditto for the ordering MD at the hospital.
All of the above: the PD, the crisis center, the hospital, the nurse(s), the doctor, get civilly sued for the maximum penalty that a jury will accept. The chief of police, and the CEOs of both health facilities are also named as co-defendants civilly and criminally for gross incompetence and criminal negligence leading to battery, medical battery, kidnapping, false arrest, and false imprisonment.
Oh, and sue the orthopedic doctor and his staff for failing to make a complete report. They deserve some love in this too. 
The cardinal rule I've observed in a couple of decades in the E.D. is that the more you're arguing with someone, the exponentially greater the likelihood that they're right and you're not. Break the chain early, and double check, especially when it's as easy at it would have been here to sort it out with certainty.

It was the responsibility of the nurse treating that patient to make sure he/she had the right patient - not just the one the doctor pointed at, but that he was indeed the mental health case in question. When nothing more than an ID check and one phone call would have raised the question and undone the entire chain of errors here, there's no excuse, for anyone involved. Some criminal arrests and indictments would drive that home satisfactorily.

I don't have the medical record info here, but if the patient was not in any way an imminent danger to himself or others in the hospital, there was no reason whatsoever to administer ANY medications to him under any circumstances. If the record shows that he did nothing but raise the obviously valid legal and medical point that they had the wrong guy, and was not physically combative, they should be fired and sued just for that act. That's medical battery all by itself, even if he was the correct whackjob in question.

There should be five to ten people facing actual state and federal prison for this incident, and the plaintiff deserves a mid eight-figure payout to drive the point well home.
And then every staff member of the PD, crisis center, and hospital, down to admitting clerks, has to undergo mandatory training by the state, at their employers' expense, on properly validating the ID of a mental health patient in crisis adequately and properly.

When you have someone frothing and barking on scene, that problem is solved. But when you send your minions to round up people in the community, and end up kidnapping the innocent off the streets and hooking them up as psych cases, it needs to leave a mark, in both the criminal and civil divisions of the superior court, and at the federal level. (Posit this guy as someone with a valid CCW and carrying when the cops roll up, and let your mind wander how it turns out. One or more people dead, because a clerk had his/her head up their own ass. That's why everyone who screwed this pooch should be fired and criminally prosecuted, and not just sued into poverty.)

This is utterly unconscionable and inexcusable behavior at every level, and several people need a long, quiet time in a small gray cell - let alone some frequent group sex sessions in pound-you-in-the-ass-prison - to contemplate the responsibilities of their former jobs, and the rights of the people they're supposed to be serving.

After that, they can get jobs greeting people at f**king WalMart for all I care.
They're shitbags as human beings, and if it were my relative or yours involved, the full measure of justice in this kind of case would require baseball bats and some emergency dental and orthopedic surgery. Blowtorches and pliers might possibly be involved.