Sunday, March 30, 2014

PSA: Trolling

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

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.

Wednesday, February 26, 2014

Dear Miss Management

Once again, it's time for your semi-annual review. We continue in our hopes that you may someday achieve a grade of barely adequate, but we won't hold our breath or get our hopes up. Based solely on your documented performance to date, flying pigs and a winning powerball ticket are more likely to be in the near future for me.

First, we need to correct a mis-impression on your part: when it was suggested to you (and if we find out by whom, the phrase "heads will roll" won't be melodramatic hyperbole as much as an anatomical description of fact) that Nietzsche had suggested God has died, and left you in charge, it was a metaphysical jest. Yes, we do note that you are possessed of a shiny clipboard, and a disposition that would pucker a sour apple tree, thus perhaps leading you or any number of guidance counselors to think they had directed a round peg into a round hole, but we note with some firmness that as observed by John Cleese, the first prerequisite for a lion tamer isn't "Has he got a hat?" Thus mayhap you could rethink your career choices, or at least notch down your delusions of personal competency at this one.

For your rather bankrupt fund of personal information, all those rather curious-looking and odd-speaking folks down on the lower floors moving to and fro rather rapidly are what we in the trade refer to as "medical professionals". They all have advanced training and degrees which, unlike yours, required actual passing grades in actual scientific fields of study, in things like physiology, chemistry, and such. They have all sorts of rather specific functions, none of them interchangeable to any great degree, arrived at by literally thousands of years of trial and error in the medical arts. (Stop me if I'm going too fast at any point. I realize that when I'm talking to you about science, history, and medicine, I'm speaking ancient Greek to you; in no small part because the ancient Greeks had a lot to do with, well, science, history, and medicine, thus this is the first time you've heard any of it.)

Consequently, we tend to look at what we do with a certain bit of prejudicial pride, because we have this quaint notion that the measure of our success is two-fold:
how many of our patients we don't kill; and
how many of our patients actually improve when we do what we're supposed to do.

Shocking as it may seem to you and your colleagues, neither of these things (I believe you refer to them as "metrics", yes?) has any remote relation to how long they waited outside, how distressed they are at having to wait, their personal emotions about anything, nor their feelings about how well we do our jobs (which, once again, are not to kill them, and to make them physically better to the limits of our powers. Perhaps you're noting a trend here?)

Hereabouts, there's an additional complication, because in its wisdom (owing to no small number of 2x4s applied to the back of the state legislators' heads, both serially and liberally), one small subset of medical professionals known as "nurses" (perhaps you've heard of them) are limited by the state's nursing practice act (we call that "the law"; by a strange coincidence, so does the state's Attorney General, and every court from Oregon to Mexico in between. Perhaps someone in Risk Management could catch you up on this concept another time?) regarding how many, and of what severity, patients we are allowed to assume responsibility for at the same time. Just as a refresher, here in the ED, that would be 4 regular patients, or 2 serious ones, or 1 critical patient. (Funny, huh? It seems that both legislators and people with medical degrees and nursing Ph.D.s came to the incredible conclusion that someone who's a 1:1 patient when they go to ICU isn't somehow less serious before they get there. Close your mouth, dear, flies will get in.)

Consequently, in a colorful turn of phrase, we really don't give a damn about how that makes people outside with hangnails and kids with runny noses feel when they have to wait longer while we foolishly chose to save the lives of the acutely critically ill or injured. (That was acutely, not cutely. Don't worry, it happens all the time in your department.)

We also don't tend to give a damn about meeting farcical illusions about how long a visit here takes, or how long the wait is to be seen. We observe daily the overwhelming number of persons who elect to leave before being seen should have made that decision before coming in the first place, borne out by years of not finding their decomposing corpses littering the freeways they drive to get home, ever, at any time in history. (Curiously both the police and fire departments have told us the same thing about a lack of cat skeletons in trees. Crazy, huh?) We further note that most of their histrionics occur once placed in a room, mainly to fulfill their inner child's need for attention before they huffily depart in their bid for the award for Best Actor Or Actress In A Dramatic Departure.

Personal anecdote here: among a baker's dozen (sorry, that would be thirteen for you. Public school grad too, huh?) of eclectic hobbies, I enjoy competitive shooting sports. Coincidentally, one of my best friends is a world-class shooter. And he's even younger than you are. The way he got good, was to get fast, then work on accuracy. It worked, to the point that he's faster than everybody, and he doesn't miss much now. Hardly ever, even on multi-day competitions. It's rather scary to behold. Thing is, that's a fine way to learn shooting, when you're talking about wasting a few rounds outside the target's bullseye. They hit the dirt with a thud, rather than the target with a clang, so nobody minds all his previous misses in practice.

But (pay attention, this is where that literary meander hits the target, so to speak!) that method of improvement doesn't work nearly as well with actual lives, unless you apprenticed under Dr. Mengele. (M-E-N-G-E-L-E. You should look it up on Wikipedia, 'kay?) Because the optics of those metrics - a little management lingo I've picked up - are a truckload of corpses, and a courtload of lawsuits. Good for Risk Management's job security, but conversely, less money for management bonuses. (Got your attention there, did I?)

So it's far better that we focus on getting everything as near to flawless, and then slowly increase speed, to just short of the point where we start making any mistakes, rather than listen to you and your clipboard, and try it the other way around.

So let's talk turkey: You have the exact same staffing matrix in place in terms of nurses and doctors now as you had here ten years ago. Conversely, we see every 24 hours some 300% of the number of patients as we did ten years ago. (And by the way, they're one helluva lot sicker, person for person.) I've been watching my paychecks, and yet strangely, I don't seem to be making 300% of the money you paid me when you hired me a decade back. In fact, you can't even be bothered to fully staff the nursing positions such that there is a nurse everywhere we're supposed to have one any night in living memory, and the lowest paid workers in the department, the techs, without whom patients don't get to such petty things as X-ray, CT scan, ultrasound, or admitted to surgery or the wards, are so short-staffed we could count them on our thumbs most nights.

So here's another historical anecdote, and a wee suggestion:
In 1864, General Ulysses Simpson Grant, Commander of all Union Army forces, and future president of the United States, noted that cavalry saddles chapped his ass. Which occasioned him to do nothing but tolerate the distress. I bring this up because if a great man such as that could bear up under adversity, perhaps the folks crybabying to you on the surveys could sack up and learn to tolerate their petty inconveniences like something other than offended oil sheiks at a strip club. (Who, unlike a respectably large number of our patients, actually pay for the services in question, and reportedly tip better. Just saying.)
And instead of feeding those pigeons by polling about how they feel when their whiny little complaint (that should have seen them in an Urgent Care or their doctor's office during business hours, rather than the ED when we have enough patients for 10 hours out of every 12 to fill 320% of the available beds) isn't seen as fast as they order fries at the Burger King drive-thru, how's about you stop responding to your Press-Ganey happy gas imperative, reach down between your knees, and pull really hard until your head pops out?

Think of trying it as leaving your personal comfort zone.

When the oxygen rushes to your head, and the light breaks because your eyes are outside for the first time in several years, maybe you could toddle over to Human Resources, and ask them why, with EMTs by the score within the range of me swinging a dead cat are looking for better jobs, you can't find us an on-call pool of 40-80 folks with excellent work ethics and a functioning brain who'd like a 50% pay raise over what they get paid to ride on an ambulance, a shot at benefits and normal hours, and an employee assistance program that would help them transition to becoming nurses, physician assistants, and doctors. You know, the one you pimp on the company website, that I have to listen to for hours on end while I'm on phone hold as my ear goes numb, trying to get one of the over-worked floor nurses to take report on my sick-as-hell ED patient, so I can help keep the meat moving down here in the hell you never visit until the JCAHO clipboard commandos dither by every few years with more stories about the Tooth Fairy and the Easter Bunny, and demands so ridiculously irrelevant to actual patient care as to be unthought of nor unseen by Florence Nightingale amidst a war in the Crimea when nurses still had to boil the patients' linens themselves.

Failing that, you'll perhaps understand why getting your head out is going to get a bit harder if you're still talking to me five seconds from now, after I shove that clipboard so far up your ass it impinges on your cardiac preload. I'm sorry if that negatively impacts on your workplace karmic harmony, but perhaps you would be better served by a transfer to either the retail sales or fast food service industries, where things like how long it took to get your Whopper, whether you liked the toy in your Happy Meal, or what color things come in, are all far more germane to what's important than they are anywhere within shouting distance of the Emergency Department.

Are we clear?
M'kay, B'bye until next time!

{Also, my apologies if I used too many "S"es in your title, to the same degree that the hospital's board of directors seems to put too many "asses" in your department. My mistake is because I was raised by people who were both courteous and wise, whereas the board manifestly was not.}

Friday, February 7, 2014

Mini Mental Status Exam: The Bathtub Test

During a visit to the psych unit, a visitor asked the director how they determine whether or not a patient should be institutionalized.

"Well," said the director, "we fill up a bathtub, then we offer a teaspoon, a teacup, and a bucket to the patient and ask him or her to empty the bathtub.

"Oh, I understand!" said the visitor. "A normal person would use the bucket because it's bigger than the spoon or the teacup!"

"No," said the director. "A normal person would pull the plug. So, would you like a bed near the window?"

Courtesy of Sean Linnane at Stormbringer


Wednesday, January 29, 2014


Has it only been a year? Really?

Seems like three.

And looking over to the right, as noted earlier, four more blogs have pretty much died (I removed GuitarGirl RN, the link is dead and it's gone).

Swear to Buddha, blogging the Emergency Department is like crossing the plains and following the bones of the unsuccessful pioneers.

Ever a glutton for punishment, after doing ass-kicking Level I Trauma to start my career, I may be returning to it again soon. It should at least give me even more to write about, as the second time around I'll take better notes. And no discernible uptick in human intelligence nor behavior has been noted, whether one refers to patients, family members, staff, or management.

See you in the trenches.

Monday, January 20, 2014

Permanent Solutions To Temporary Problems

That's what suicides are, in case nobody told you.
It's the most brilliant summation I've ever read, and it stabs my soul every time I see another try.

Some people I work with get annoyed at suicide attempts.
I can understand that, and share the sentiment sometimes.
Like when you've attempted to slit your wrists with a dull plastic picnic knife, just to get 3 hots and a cot.
Like when you find out your crippling chronic inability to get gainful employment or panhandle enough change for another bottle of vintage Boone's Farm or Everclear doesn't equal a pressing need for admission to the Callous Bastard Hospital Hotel Bed and Breakfast Inn.
Like when you pull the "I'm suicidal" card out to keep from being bounced out of the gurney by Security at 3 A.M. on a cold, rainy night.

Those times, I pretty much wish they'd let me close the door and kick your ass for a few minutes, and see just how badly you really want to die. Because no one, the doctors, nurses, nor anybody else, has time for your pathetic histrionic shit, and the best prescription for you is about 5 minutes of crotch-kicking and a gratuitous measure of bitch-slaps.

All too sadly, both mostly unethical, and generally against hospital policy.

Then there are the other kind.
The people who really mean it. (Which, if you're keeping score at home, is probably less than 10%. Probably even low single-digits.)

But I get them.
Life will really try to grind you down. Some of us, more than others.  A philosopher once said "Be kind, because everyone you meet is fighting a hard battle." He knew what he was talking about. Whether it's physical or emotional pain, one of the things about it is that after a couple of minutes, you can't remember life without it, and you don't know when it's going to end. You just want to make it stop hurting. And in the absence of therapeutic alternatives, when that pain becomes too much to bear, people will do anything to make it stop.

Including kill themselves.

Part of the hidden fail in my job, is that the people I see (mostly) are the ones who aren't serious. The folks who eat a shotgun, jump off the 7th level of the parking structure - helpfully head first - or step in front of a freight train going 60MPH are deadly serious, and 100% successful. So I see the people making either a desperate cry for attention, or the incompetent. By definition, because they make it to the ER.

But the worst are the ones who are serious, and are only semi-competent.
Like the 15 year old girl, who was living in shiny SoCal splendor with a family that loved her, in a house near the beach, with no physical wants on earth, and stunningly model-gorgeous beautiful, who got dumped for someone else by her douchebag boyfriend the week of the prom. So, in a permanent solution to a temporary problem, she decided the remedy to make everyone pay, was to eat an entire 150-pill bottle of Extra Strength Tylenol. On Friday.

And then not tell anyone, like her mom, until Monday.

Seventy two hours later, there's nothing on the planet that will fix the ingestion of 75 grams of acetaminophen by a 45kg teenager three days after the train left the station.

But unfortunately, it isn't a right away solution. She came to us normal, scared, sorry, and a thousand other things. She left the same way, admitted for observation, and then discharged home. Over some months' time, her liver failed, and she got to die a long, slow, agonizing death, with her family at her bedside every step of the way, until long, long after she'd forgotten the pain of being snubbed by another 15 year-old juvenile jackass at school, she died, wasting the promise of her entire life, and emotionally wiping out a loving mother, father, brother and younger sister, and countless friends, with one agonized moment's thoughtlessness that will bear a lifetime of pain long after her passing.

Some things in life you don't get to do over.
So if you're hurting that much, long before you decide on that permanent solution, talk to somebody about other choices.
For the love of God.

Thursday, January 16, 2014

Pest Control

Sign TPTB made us (me) take down from the Triage window:

The common cold likely won't kill you.
We cannot make the same promises about the triage nurses if you keep coming back to the window to ask them about the wait to be seen for it.

I'm betting if I put it up by the TV set outside, it'll last a lot longer.