Thursday, July 3, 2014

Final Transfer

My best guesstimate is that I've directly cared for 50,000 patients. Probably more if we count the ones I've triaged - seeing 70-80 a night instead of 20-30. Nothing special there, my co-worker for a good chunk of the last 10 years had been a nurse literally since Eisenhower was president (for you youngsters for whom that rings a bell, look it up.) so she probably saw a number much closer to half a million.

And I certainly haven't kept a tally on this, but I'd say I've personally zipped about 100 people into their last sleeping bag for transfer to the Eternal Care Unit.

I bring it up because I was reading a completely separate story, regarding the grisly task of recovering the victims of an airplane explosion, and unbidden I was simply overwhelmed with the thought of the ones I've dealt with.

I don't care where you are, as much as we try to not let it happen, people die in the E.D. (Dammit. It still generally pisses me off.) For some it was a welcome friend, for many a blessing, and far too many a rude surprise courtesy of physics, ballistics, and man's inhumanity to man. I thank a merciful deity that none of them have been children. As a student I watched a futile but understandably prolonged full code on an 8 or 9 year old girl found at the bottom of a pool, long after there was any hope but the outcome expected, but thankfully, I didn't have to deal with that aftermath. Small mercies are always welcome.

Amidst a full code, there's things to be done, orders to chart, algorithms to run through, so you're busy, and amongst friends. The subject of the exercise isn't in any condition to respond, so you tend ( or at least I do) not to focus on them as much as on the rhythm on the monitor, the presence or absence of a pulse, and doing your part in the multi-person ballet at the bedside.

But one way or another, I seem to end up being the one doing aftercare, obviously on my own patients, but a lot of times on others' as well. Sometimes with the other nurse(s), or a tech, and even a couple of students from time to time. But a lot of the time, just getting it done by myself. Part of it is the amount of time on the job, and wanting to share a colleague's load, and to a certain extent, I'm pretty sure it creeps the youngsters out more than they want to admit, particularly when they're still kind of new to the job.

Of course we aren't perfect, and some nights, it's just that person's time. A number had their time come and go at some abysmally-run convalescent home, warehoused by distant family, or an uncaring system, and we just get to deal with the end result of low wages and minimal/minimally functional staff, taking care of way too many chronically sick patients. Other times it's someone set free from the ravages of metastasized cancer. And on more occasions than I'd like to recall, it's a traumatically rude unhinging of the mechanism of life.

It still doesn't happen a lot, maybe once a month on average. Then there was the night we had six in a shift. As Edmund Blackadder once said, "I'm thinking of a phrase that rhymes with 'clucking bell'..."
But any way I look at it, even as rare as it is, the mileage and the years on the night shift adds up; I just didn't expect to be one of the go-to people for "final prep".

I've just been thinking about it, because it's there now, and it's probably going to rattle around in my head awhile until I get it out, so I'd rather write about it than just mull it over. And it's not like there are a lot of people you can talk this over with one-on-one, at least not if you ever want to hear from them again.

I don't know why it matters to me, but the best way I've found to deal with it at the time is to talk to them as I clean them up, especially if there are family members a few doors down just getting the news. I do it some for them, and the patient, and some for me. It seems like it's the least I can do to acknowledge and maintain a little human dignity for somebody who's getting tags tied to a toe, some of the tubes out, some of them left in, and getting stripped just as naked as the day they were born, before zipping them in for their last ride down the hall to the morgue freezer.

Later on, there'll be time to talk with family members, when they have any. And definitely time to talk to the coroner, the organ donation line, perhaps the local PD, and to try to find a personal physician. I'm not a big fan of waking doctors up, especially for this kind of call, but it always seems to happen between midnight and 4 AM. And no transfer, not even to ECU, is going to happen until all the paperwork is finished, all the boxes checked, and the charting done. At least I don't have to call a floor report first.

But before that, and after the drama ends, I figure the least I can do is think, or say out loud, "Sorry you're here tonight. Hope it doesn't hurt any more, or where you are.", as opposed to thinking of them as so much inanimate hamburger. When you're dealing with what's left behind after their personal train has left the station, it's hard not to wonder about that, right? It's not like I'm doing comedy routines, or expecting any answer. But we take care of people, and when you do that, you talk to them, because it helps them to cope with what's just happened. Or, in this case, it helps me.

Monday, June 30, 2014

The Red Cross

In response to a notation over at Whitecoat's weekly update, where he noted "no more donations to the Red Cross".

For context you can read the whole thing, but the gist is that the Red Cross are being sneaky about where the money goes.

For context about my response, I was (note the past tense there) a volunteer with the organization for over a decade, including running multiple first aid stations within shelters immediately after the Northridge Earthquake, as well as working gratis on everything from rodeos to the Rose Parade, and was one of several monthly coordinators of event coverage for a group of nearly a hundred active medical providers. In addition, I was a certified instructor in Basic and Advanced First Aid and CPR, and took the gamut of courses for Disaster Operations, all before, during, and after attending nursing school and getting my RN license. So I have a wee bit of experience with the organization.

So, in the context of "Red Cross doesn't want to tell how they spent money collected from Big Disaster XX", allow me to furnish some insight.

When there's a metric crapload of human misery, and it makes national news, the pitch machine and collection apparatus at ARC goes into overdrive. This is because they are a completely NON-governmental organization, entirely funded through charitable donations. (Biomedical Services, AKA blood donation, is a separate financial entity, for good and for ill, going back to the early 1990s. It brings in a good chunk of change, and also a ginormous financial liability, both from fines, and from lawsuits, and the intent was to keep them in the Red Cross tent while splitting off the liability, to prevent the entire organization going under from lawsuits, esp. those from before the blood supply was tested for a host of previously unimagined nastiness.)

So far, so good.

People, most particularly Americans, really are human about seeing others getting raked over the coals of life. Even if people decided to build their houses in flood plains, tidal estuaries, or tinder-dry forests, they don't like to see anyone's whole life go up in a moment, and then watch them suffer and shiver. So they give.

Like numerous other organizations, the Red Cross funnels those contributions to help where it's needed. And now for the "But...".

BUT...sometimes certain disasters are more...photogenic, and TV-friendly, than others. Little kids with their toys strewn around the uprooted trees, along with their parents and siblings, and sitting on the curb crying, after some devastating tornado, tugs at heartstrings.

Kids sitting on the curb because the next door neighbors were meth-heads whose illegal lab burned down their ghetto tenement and made 40 people of limited means homeless, not so much.

But both need a helping hand just as much as the other.

So, in their wisdom, the Red Cross looks things over, and decides how much a given disaster will be funded. If donations are wildly higher than this, well and good. The extra money goes to pay for the little disasters that don't get donations rolling. And to funding the Red Cross itself, from staff members, to buildings, to materials for training, and hopefully, to keeping some stock of supplies prepositioned in places in every chapter in case something really earth-shattering, like a 8.0 earthquake, Cat V tornado or hurricane, or the Mississippi flooding to 500-year flood levels happens.

Anybody with a lick of common sense knows why this is both prudent, and necessary.

Now for the back of the coin.

The Red Cross is a charity. It's driven by volunteerism, of which there is no shortage, and a certain amount of organizational altruism, which documentedly exists.
But it is, let's face it, a business that has to pay rents and meet payroll, and exist next year, thankyouverymuch.

And some number of the sort of folks who go to work for well-below-market salaries at a charity, rather than take any number of much better and better-paying jobs, are not your Bill Gates', Donald Trumps, or Jack Welches. Or even anything remotely like it, by and large, even allowing an occasional exception to the rule of gravity.

So even though the people who make the organization work are the sort of people who can do high finance in their day job at a Fortune 500 company, and still find time to show up to teach a Saturday class, or roll out at 3AM when a twister levels a neighborhood two zip codes away, the people who run things day to day, decide what gets done, plan, and administer all the functions of the organization are far too frequently people who'd be woefully under qualified to be even assistant night managers at Party World or McDonald's.

And yet, they see that they have The Clipboard, and are In Charge, and so they foolishly assume that makes them smarter and more talented than the volunteers who make their responses and programs possible, both personally and financially.

And I'm here to tell you, it just ain't so.

Organizationally, the Red Cross has been living vicariously off of goodwill engendered by the organization since Clara Barton's day, and the fumes in that gas tank are getting pretty thin.

So it's certainly well within the realm of possibility that senior management (which generally comes from local management, which as Will Rogers noted are simply the town bandits send to raid HQ) may have decided that the peons out from somewhere beyond their offices don't need to know how and where the organization spends their money. IMHO, that's a jackassical choice, and without tying personal salary to names, everybody and every expenditures from the top down should be publicly available on their website 24/7. That it isn't is very likely either a sign that they think themselves beyond such an open accounting, or the truth would embarrass the organization. Or both. I don't know which, but I have my suspicions based on past experiences.

But it's their ball, and their rules.

I'm not saying don't donate to them. They do a tremendous amount of good work, and generally in a way far superior than government minions do so. They do decent training, the costs are a bargain, and hordes of pool lifeguards and medics got their start there. Hell, I worked for them for years learning the healthcare business long before I got to where I could get paid for it, and I'll always hold a warm spot in my heart for an organization whose emblem I wore.

But you should know what you're dealing with, and what you're getting for your money.
And eventually, if they don't knock off the silly stuff, they're going to wake up one day and find out that somebody else, say, the Salvation Army, has started doing first aid and lifeguard training, and that the S.A. already does feeding and sheltering better, and has done so 24/7/365 around the world for 100 years, and Red Cross will be out on the curb with the other unfortunates in a New York minute, wondering what happened to them.

Jerry Pournelle's Iron Law of Bureaucracy - In every organization there are two kinds of people: those committed to the mission of the organization, and those committed to the organization itself. While the mission-committed people pursue the mission, the organization-committed people take over the organization. Then the mission-committed people tend to become discouraged and leave.

Tuesday, June 24, 2014

Getting Cold Feet

On just another summer night at Callous Bastard Hospital, long after the fast track section is closed, Young Dude (with gf) come in with chief complaint of "foot pain".

So, hey, at least it's not a train wreck full-code from the local Con(next of kin out of their money while providing no actual care)valescent Hospital. Triage basically just did vitals and dropped him off, which is cool since they're busier and I only have two other patients, so I mosey in to get the details on why he's here at 3AM.

"Can't sleep, my feet are killing me."

So, after getting him to doff everything below the waist except underpants, and put on the stylish gown, I pop back in and have a quick look at the troublesome appendages before the doc gets in.

And the guy has ten toes that are cold, stiff as a board, waxy, and with large white tips on all ten toes and larger sections on the two smallest toes on each foot, in the most textbook-perfect visual appearance of frostbite it's ever been my displeasure to see live and in person.

Digging deeper, it transpires that he's an employee at one of the local food distribution warehouses, having just finished his second shift job there at midnight. Where he was ordered to clean out the frozen food freezer (the size of most suburban house lots). Despite protests that he hadn't been trained, and sans any sort of appropriate protective gear which OSHA, CalOSHA, Union rules, company policies, and mothereffing common sense dictate, his Idiot Boss, Mr. Sumdood, sent 20-something to shovel ankle deep frozen slush in 0-degree temps for 8 hours in his Van's tennis shoes, cotton socks, jeans, a t-shirt, and a windbreaker. And being a good (though perhaps not very clever nor worldly-wise) employee, Young Dude went and did his job.

Whereupon I send my truly fantastic tech to go fill a couple of splinting and casting chicken buckets (exactly what it sounds like) and fill them nearly full of water that's comfortable but well north of body temp warm. All the sinks in the department helpfully being temperature-safetied for morons to past the point of common sense, the only actual warm water in the entire department is down the hall in our break room. He returns, and we begin rewarming our patient's frostbitten feet - generally a rare find in SoCal in the summer - and I go to let the doc know what the "foot pain" is in relation to.

He avoided surgery last I heard, but only just.
Working in an E.D., I generally don't have much use for lawyers, but for the second time in my nursing career, I advised patient and gf to start with his union shop steward, save copies of all his paperwork, and to assume that from this point out Great Big Grocery Chain, courtesy of Idiot Boss' tenuous grasp of common sense, had just bought the bill for this and all subsequent care, and that any further intransigence on the subject ought to be referred to legal counsel, as part of his have-a-nice-day departure lecture.

And told him he's off freezer duty for the foreseeable future.

Clearly the biggest morons aren't always the ones who actually come in to the department for care.

Monday, June 16, 2014

Better Than I Could Put It

I've told people that folks don't kill themselves because they want to die, they kill themselves mostly because they can't take the pain of living any more, and they (mistakenly) think it's their only way out.

Go here and read this.

H/T to
Not Nurse Ratched.

Some people do really need tough love. (I know, because I keep getting them in my life and on my gurneys.)
But a lot of people just need love when that's tough.
And no offense to the docs out there, because I didn't make the rules, but that's a lot more our turf as nurses than it is or ever will be yours. (My drill instructor's eyeballs would bleed to read that, but deep down amidst the middle of his cold green amphibious heart, and after pushing a few thousand knuckleheads through boot camp 18 hours a day, I think he'd give a "Hell yeah!)

So for them, remember the words of Ian Maclaren:

"Be kind, for everyone you meet is fighting a hard battle."

Kind not only in how you deal with people, but how you think about them here, and hereafter. If for no more reason than the thought that you never know when what you say to them may be the last time you speak, when there's no more chance for apologies or reconciliation, but only the entire rest of your life to regret an otherwise mere moment in time.

Sunday, May 11, 2014

Waiting For The Other Shoe To Drop

Sadly for the drama quotient, life is just chugging along, and things at work have mellowed out considerably. Sunshine does a lot to end flu epidemics when people here decide to go outside and play, instead of all sit inside and share cooties.

I'm a little worried, because usually the one constant at work is suckiness in equal measure with sickness, but no complaints on that score. I just keep waiting for some enormous disaster to hit.

While we now have far less staff people to see far more patients (Hey, thanks, HopeyDopeyCare!) the numbers are still cruising in the happy days of spring trying to become summer. Next fall/winter will be another story.

And confounding all expectations, someone has evidently threatened biblical levels of wrath on the local university, famous for providing the staff at Callous Bastard Hospital with a weekly chance to play "Guess The Coed's BAC" in years past. I was almost at the point of offering to make their institution the subject of a weekly sojourn to the city council just to provide them with bad press, but it appears the local paramedics, FD, and PD were tres pissed off about things as well, and suggested to the dean of student affairs, and more importantly to their CFO, that they would start billing the university for every ambulance call after the first one for victims of ETOH, at a round cost of $2K/trip. That took all the fun out of things, and apparently The Word was passed to every frat, sorority, and dorm:
"Knock that shit off, knuckleheads, or daddy's getting your ass back after we expel you."

And people say today's kids can't learn!

Sunday, March 30, 2014

PSA: Trolling

Astute observers, or now anyone, will note the appearance of a new box to the right., entitled "Comments"-->

It will intimidate something less than 1% of anyone who reads this or any other blog, or comments thereon, based solely on my own research.
The terminally stupid less than 1% who most need it will completely ignore it.

I blog for my entertainment, and a sanity release valve. That it elicits anything from a laugh to an "amen" from others is icing on the cupcake. That it may occasionally cause someone to disagree surprises me not a whit.

But if you haven't got the balls to identify yourself, even with an Internet alias (seriously, did you really think my parents named me "Aesop"??), and a trackback to yourself, but still think you can run in here, crap the floor, scoop it up, and fling it on the walls or at me with all the glee of a spider monkey on crack, think again.

If something I write twists your tail, have at it. I rarely lose a debate on the merits, but feel free to have a go, if you can stay on topic, rather than go all ad hominem. I recognize on most of what I write here, I'm handicapped by only having nearly twenty years' experience doing what I do and seeing about a paltry million patients, out of eight billion people on the planet, so it's inevitable that somewhere someone may have learned something beyond my ken. I'm not omniscient.

But when someone chooses to start with rudeness and insulting comments, any possible intellectual validity has just been sacrificed. So has my toleration or patience. Any screed that follows will thus be shipped out with all the warm and tender feeling of Ripley sending the titular foe out the airlock of the Nostromo's lifeboat in Alien, and with all possible dispatch. Take bets on this.

When you start out by being rude and/or insulting, and as a bonus are demonstrably retarded and ignorant, you may possibly hear the word "Fore!" just before the #3 iron arcingly descends into your ass and sends it straight down the fairway of Life.

In all the known universe, this is the one corner of it where I am entitled to wave my magic wand and send refugee flunkouts from Etiquette School where they belong, with a pull of the handle of the Internet's flush tank.

Happily, in a year, I doubt I've had to do that even five times. I'd be even happier not to improve those stats, but not to the point of foregoing the pleasure when the need arises.

I fire abusive patients and eject jackassed visitors all the time in the real world; if you came here from under a bridge, I will return you there faster than you got here, and you won't even elicit a tiny internet virtual tear. It may come as some shock to learn I, like 500,000 of my ER colleagues, tolerate none of anyone's bullshit whatsoever.

If five minutes reading what I write here hasn't made my glee at using the "delete" option apparent, "Go ahead, make my day." 

And of course, if I'm bored, I reserve the right to make you an example, because even steak knives need sharpening from time to time, and sometimes I appreciate you volunteering to be the cadaver for today's anatomy lesson.

The 99+% of you to whom this note doesn't apply, go back to having a pleasant day.

Saturday, March 29, 2014

PSA: Preparedness

Last night I was typing away, and felt a sharp jolt for about a second around 8 PM. Went to the USGS "Did You Feel It?" website, self-reported my experience, noted it was a small earthquake a couple of miles from where I was sitting, and went back to web surfing.
A little more than an hour later, I spent the better part of 30 seconds under the same desk while the place got its ass kicked by the 5.1 that followed, again just a bare few miles away from where I'm sitting when I'm home. And I wondered if I had a handy set of clean undershorts.

Today it's mainly been just a drill, and the results were, thank a merciful God, extremely minor in the grand scheme.

The upsides are that the roof and walls are fine, the stuff I keep on hand was sufficient, and even a far worse shake would have likely been something I could've handled. (Still need more clean undershorts though.)

The downsides are that I really, really hate this stuff, because you never know a moderate small quake is either of those things until it finally stops (and thirty seconds of rocking and rumbling under furniture is a long time to wonder about that, believe me), because the little ones and the big ones start out exactly the same. The big ones just keep building and going on until you're pretty certain you're in deep doodoo. Ask me how I know.

So for last night, my issue was unfortunate proximity to ground zero.
That, and dozens of random noticeable aftershocks, including the 9:02 AM one that provided today's wake up alarm. That's all normal, and they'll continue with diminishing frequency into the next week. (And having gone through 2 bigger ones, which IMHO gives one a mild but permanent case of TSD, not PTSD, because it's never "Post-" until you die, in this case.)

The cat isn't liking things any better, having tried to climb into me during last night's festivities, adopting the spot beneath the chair I'm in now as her default Safety Zone with each follow-up shake, and generally regarding the entire world with suspicion with each additional aftershock.

So wherever you are, and whatever the regional problem is likely to be when the word "disaster" is mentioned - tornado, hurricane, earthquake, floods, severe winter storms, or what have you - do please take the time to do some proper prior planning, set back food, water, car supplies, and so on, and generally make all the preparations you reasonably can so that when things get suddenly crappy, you're part of the solution, and not part of the problem.

Added: And BTW, that happygas they've been propagating about "72 hours" on your own is utter rose fertilizer. 72 hours isn't a disaster, it's a minor inconvenience, like Woodstock. Make your plans for successfully navigating a period of 30 days without outside resupply of the major necessities of life, and then beef it upwards over time until you're ready for a problem of multiple months. All 72 hours buys you is the certainty of living in a FEMA shelter on Day Four, which is an abysmally poor prospect. 

And don't forget a change of shorts.

Song Of The Day: AC/DC You Shook Me All Night Long

Saturday, March 22, 2014

An Embarassment Of Riches

It's television pilot season in Califrutopia.
Which means that several networks and studios will spend millions of dollars and tens of thousands of man hours to create a host of programs which, thank a merciful deity, you'll never ever see, in order to cull the stack down to a manageable number, of which all but one or two, based on historical precedent, will suck, and probably hugely.

This matters to me about as much as the weather on Jupiter, because in the meantime, I get a lot of days as a decently-remunerated and medically licensed babysitter, and the checks all clear. How many in a lot? This week has been 14 days long, so far. And just about the time I could get used to it, it will be gone, and I'll be back in the salt mines. But until then, I just got to give my bank account a transfusion that should cure the recent anemia, but a side effect of multiple 12 hour days separated by 3-5 hour nights off is that I'm sleepy, cranky, and several of the other dwarfs, none of whose names I can recall at the moment. (Bitchy? Meany? Clumsy? Stupey?...whatever)

(Bonus Game for those in school, or back there again: psychoanalyze the Seven Dwarfs based on direct clinical observation of the DVD/BD, turn it into a paper, ace your psych presentation.)

That's not a whine (It's not! It's not! It's not!); I knew the gig was tough when I signed up.
But it means my usual fund of bile has been eating craft service, is a little gassy, and putting on a couple of pounds, and would really rather face-test the thread count in my pillowcase than saddle up for any rhetorical jihads or jousting the slumbering herds of pigs in our profession. At least for now.

My profound apologies, but that means anybody stopping by will have to entertain themselves for a bit longer while I nap. True to form, there are some very old obscure magazines laying about for you to read. This will probably cease all too soon in a week or three, then I can recert about half a dozen cards and classes to prove that I'm still nursey enough to market myself to greener pastures, as if they actually exist.

After a few weeks of Hollywood's amateur drama queens, I'm not looking forward to returning to the professional circuit. The catering there sucks, everybody is Scarlett O'Hara, and I can't fire them.

Submitted for your approval: What say we all pass the word, and on April 1st, apropos of the day, we all submit reviews on our most horrible patients, direct to hospital management and the Press-Ganey knuckleheads, and roundly bitch them out for the worst offenders?
In a perfect world, this catches on like Talk Like A Pirate Day, and the patient ratings for the entire country, complete with the best individual write-ups, get posted online. Anonymously, of course.

See you when I've thoroughly inspected the inside of my eyelids, and can open them spontaneously without using my hands. And hey, look, I just wrote an entire post about not being able to write an entire post. Sleepy, soooo sleepy... 

Monday, March 10, 2014

Rite Of Passage

For those of you with self- or preferred scheduling, those of us with more time on the job judge the rest of you worthy of basic respect when you exhibit the common sense sufficient to schedule yourself for the switch to DST in the spring, resulting in an 11-hour shift, but somehow seem to miss the 13-hour Bataan Death March shift in the fall.

Unless you share that you're a masochist, and other TMI gems about your personal predilections.

Saturday, March 1, 2014

Prehospital Pop Quiz

Q.: When is the 60 y.o. male with sudden onset 9/10 acute crushing epigastric pain and nausea, with a Hx of HTN and high cholesterol not having a classic M.I.?

A.: I don't give a damn, he's still getting the paramedic taxi to the ER stat, and a full cardiac workup until a board-certified ER doc in consultation with another board-certified cardiologist gives him the all-clear. Neither of which would be me and my Portable Ultra-Mini Field Hospital of Wonder.

Which they did, grudgingly, but only some dozens of hours later, after a highly suspicious day of full cardiac evals, and only after admission for acute pancreatitis secondary to a stone-blocked pancreatic duct.

Ain't nobody dying in my lap; your patient, guys. And thanks for the speedy response and great care.

For the record, I much prefer working surrounded by a full ER, rather than merely curious bystanders. But it's nice to know I can still take the act on the road. Especially when the patient relays personal "thanks" several days later, because he still can.