Tuesday, April 19, 2016

Why Nursing Is Stressful, Part 2

SCENE I 

[A hospital examination room. The PATIENT, a woman in her twenties wearing a hospital gown, lies on the stretcher. Her MOTHER is seated in a chair nearby. ]

[Enter a NURSE.]

Nurse: All right, miss. As the doctor explained, your CT scan showed that you have acute appendicitis, so you need to have surgery right away. The surgeon is on his way and everything will be ready soon. Do you have any questions?

Patient: Yeah. Can you bring me a turkey sandwich?

Nurse: No. Nothing by mouth before surgery.

Patient: What do you mean, "no?"

Nurse: Your stomach has to be empty. It's an important safety issue. You cannot have anything to eat or drink until after the surgery.

Patient: Then can I have some crackers?

Nurse: No. Nothing to eat or drink.

Patient: How about some orange juice?

Nurse: No. Nothing at all to eat or drink.

Patient's Mother:  What if I go get her something from McDonald's?

Nurse: Still no. That would still be eating, and as I just said, eating is what she cannot do. She must not eat or drink anything of any kind.

Patient: All right, I guess I'll just suck on ice chips.

Nurse: No ice either. Nothing at all.

Patient: What about just a snack?

Nurse: No! Nothing! Absolutely nothing to eat or drink at all. Nothing. No food, no drinks, no ice, nothing. Nothing. Your stomach has to be empty. It's a very important safety issue. If there is anything in your stomach, you could vomit during surgery, and the stomach acid can get into your lungs. That is extremely dangerous and can kill you. We want you to stay alive. So, you must not eat or drink anything at all, starting now, until after the surgery. Do you understand?

Patient: I guess.

Nurse: Could you repeat what I just said?

Patient: I won't eat or drink anything.

Nurse: Thank you. Now, I need to go check on something. I'll be back in a little while.

[Exit NURSE]


. . . 


SCENE II

[The same hospital room. The PATIENT is now sitting up, with her back to the door. The wall clock shows that THIRTY MINUTES have passed. 

[Enter the NURSE]

Nurse: Good news! The operating room is ready, so I'm going to take you to... wait. What are you doing?

[The PATIENT turns around. She is holding a McDonald's bag. Her mouth is full.]

Patient: [mumbling] Whup you meem?

Nurse: I said not to eat anything!

Patient: [mumbling] I'm nomp eeping amyfffig.

Nurse: Yes, you are! I am standing here looking right at you. Your mouth is full, and I can see the hamburger in your hand. It's right there.

[The PATIENT shoves the last piece of hamburger into her mouth, chews rapidly, and swallows.]

Patient: I said I'm not eating anything!

Nurse: Please wait here. I need to go call a surgeon and get yelled at.

Patient: But I said I didn't eat anything.

Nurse: You've got ketchup on your face.

[Exit NURSE]

Friday, March 18, 2016

Compassionate Delegation

One of my patients this week was a small baby with a high fever. Since she was too fussy to accept anything by mouth, the doctor prescribed a Tylenol suppository. I got the med from pharmacy, then went to the travelling float nurse who was working with me that night, and asked her to administer it to the patient.

She scoffed at me. "What's the matter? Scared of a little baby poop? You can't go trying to push off the scut work on me just because I'm from the float pool. I'm sure you've given suppositories before. Don't ask me to do your work for you."

I said, "No, of course not. That's not the issue. It's just that I wear size 8.5 gloves."

She thought about that for a minute. Then she went and gave the Tylenol.

Monday, July 6, 2015

Emergency Severity Index

How do we decide who gets to be seen first, anyway?

Like most EDs in this country, we use a triage system called the Emergency Severity Index. It's a set of rules that helps categorize patients and prioritize care. Many such systems exist, but this one is relatively modern and specialized. It was first developed in 2001 specifically for use in hospital emergency departments.

Under ESI rules, every arriving patient is assigned an acuity level from 1 to 5, with level 1 being the most urgently in need of care. Patients are not necessarily seen strictly in order of acuity, but the levels are used to prioritize care, so a patient having a heart attack needn't wait in line behind one with a papercut.

One of the main factors is that triage is fast. At the front desk we don't have the time for a complete head-to-toe assessment. The ESI level is assigned based on apparent immediacy of the problem and, for lower levels, the anticipated amount of resources required. (The presumption is that patients who need more complex care also need it sooner.) Here, "resource" means a process that takes special equipment or skilled intervention, like lab tests, x-rays, sutures, or the like.

The full ESI definition fills a book, but the categories can be generally summed up like so:

Level 1: Resuscitation - The patient is dying. Immediate life-sustaining intervention is necessary. Drop everything else and come a'running, because without help the patient's condition will be incompatible with life. Such a patient will usually (hopefully!) come in by ambulance with care already underway.
Examples: Cardiac arrest. Bullet wound to the chest. Brain injury. Traumatic limb amputation.

Level 2: Emergent - The patient should be seen immediately if at all possible. They are not trying to die at the moment, but are at high risk of having their condition degrade. Delay of care could present jeopardy to their life, limb, or major organ.
Examples: Cardiac chest pain. Eye injury. Acute asthma attack. Two-week-old infant with fever.

Level 3: Urgent - The patient is stable, and care will require two or more types of resource. These are people with vital signs in the normal range and who are not at high risk of immediate harm, but who need in-depth testing or treatment of some sort.
Examples: Abdominal pain. Displaced ankle fracture. Elderly patient with fever.

Level 4: Less Urgent - Also stable, with care expected to require only one type of resource. This is the one without an evocative description. It's just a middle ground between three and five.
Examples: Finger laceration. UTI. Sore throat. Abscess. Healthy adult patient with fever.

Level 5: Nonurgent - Stable, with no resources required except physical examination, routine care, oral or topical medication, and/or written prescriptions. This does not necessarily mean the patient is not sick! They might be miserably uncomfortable, but they are safe to wait an extended period of time for care if necessary.
Examples: Earache. Suture removal. Dental pain. Prescription refill. Work note request.

One thing to remember is that you can't tell just by looking. Lay people often seem confused at who gets up-triaged and brought in earlier, and patients sometimes complain about who got to go in before them, but we always have a reason. If two men present with back pain, one might go first if he recently had a high-risk spinal surgery. If two women complain of cough, one might go first because her pulse is very high and we suspect pulmonary embolism. If two kids have sore throats, one might have to skip the line because his tonsils are so big that his airway is at risk. There's always a reason.

Making triage calls requires significant book knowledge, a lot of professional judgement, and a little bit of intuition. It should always be run by an well-trained and experienced ED RN, because it's arguably the trickiest nursing assignment in the whole hospital.

Monday, June 22, 2015

Unclear On The Concept

One of my patients this weekend had special requirements before he would consent to be treated or admitted to the hospital. He instructed me at great length about all the difficulties of being a strict vegan, who will not eat or use any animal products of any kind, and how that will impact his care.

As we prepared to close his wound, he asked to see the label on the suture kit to make sure we weren't using silk thread. He also asked to read the ingredients on the antibiotic ointment to make sure it didn't contain lanolin. Later he had me call the food service department, on speakerphone, to confirm that our vegan meals are separately prepared and cannot cross-contaminate with any animal products.

He insisted we write in his chart that he will immediately sign out AMA and leave the hospital if his care products or meal tray were to contain anything at all non-vegan.

After all that was settled and documented, he asked for "a cup of coffee with 2% milk."

Monday, June 15, 2015

How Not To Be Seen Faster

Some people are always trying to skip to the head of the line in the ED waiting room. Last week in North Carolina, one patient who felt she had been waiting too long decided to set off the fire sprinkler system. This is not an effective way to be seen and treated sooner.

Other ineffective strategies include:
  • Shouting
  • Calling ahead
  • Coughing on me
  • Calling me names
  • Showing me money
  • Showing me a weapon
  • Showing me your boobs
  • Claiming you are a nurse
  • Claiming you are a physician
  • Claiming you are the hospital CEO
  • Offering me a ride in your new Cadillac
  • Offering me one of your McDonald's fries
  • Sitting in a wheelchair you don't actually need
  • Holding your breath while I measure your pulse ox
  • Telling me, "Write down 'unconscious' so I get seen first"
  • Telling me your buddies will "get" me if you're made to wait
  • Any sentence beginning with, "Now listen here, motherfucker"
None of these ever result in your being seen by the doc any faster. (Some of them will generate an immediate response, but only from a pack of several professionally looming young men with badges and crew cuts. Our hospital security officers are highly competent, intensely protective, and do not understand the phrase "just kidding.")

If you want to be seen first, all you have do is be the sickest person in the room. Manage that and you'll go straight to the head of the line.

Friday, May 22, 2015

This Will Hurt

A patient came to the front desk and said, "Nothing's really wrong with me but my wife made me come in. I took about eight Sudafed, and my chest feels a little funny."

No shit your chest feels funny. Your pulse is 211. Also, your fingernails are blue. Come sit right here while we stick these electrodes on you.

Have you ever heard of a Joule? No? Well, you're about to receive a hundred of them.

When you hear the word, "Clear!" you'll want to brace yourself.

Monday, May 11, 2015

I Need To Study More

When multiple patients arrive at once, we hand them little index cards and have them write down their reason for visiting. That helps us decide who gets to see the triage nurse first.

Today I picked up a registration card and couldn't figure out what it said. First letter S... squash? spill? Or maybe that's just a squiggle and it starts with a J, or a G... hmm. No idea.

I called the patient into the triage bay, sat her in the chair, and asked what brought her to the ER today. She said, "I have a problem with my squirrel."

Oh, that's what the card says, I thought. But that didn't clarify much. "Excuse me? Did you get bitten by a squirrel?"

"No. I said have a problem with my squirrel."

"Um... what kind of problem?"

"A squirrel problem."

"Say that again?" She did. I still heard the same thing. "I'm sorry, You are saying 'squirrel,' right? The animal that lives in trees?"

She looked at me like I was stupid. "Yeah."

"So, what happened with the squirrel?

She actually rolled her eyes. "I'm telling you I have a problem with my squirrel." And she pointed down at her lap.

The penny dropped. "Ah! I see. What symptoms are you having?"

"I fucking told you five fucking times already! A squirrel problem! Fuck, didn't you go to school for this shit?"

I guess not.