a day in the life of an Emergency Department Technician

Dude, Lets go get some free candy!

2009-02-03T14:36:00.002-05:00

So I am sitting out at triage talking to my supervisor about the impending JCO bogeymen lurking just around the corner for our annual surprise accreditation visit. We both glance up and see two young women in their 20's and what appears to be their father walking into the waiting room.

They all sit down in a triage booth...........

22 yo female disheveled, pin point pupils, lots of old bruises on her face neck and arms. Her CC: H/A s/p fall on ice. "I am allergic to anything without opiates in it." Are you with these other two people that you walked in with? No

21 yo female disheveled, pin point pupils, Swollen right mandible, lots of fresh cuts and bruises and a nice menage of old bruises all over. Her CC: s/p Assault. "I really need something for the pain." No other info given! Do you know the girl in both next to you? No

56 yo male disheveled, smells incontinent with a touch of GPC menthol smoke. His CC: I want a body scan for cancer! O.k. Sir, Do you know the two girls you walked in here with? Hah hah I wish! Seriously docta I needa body scan!

As the Nurse finishes registering the last of the trio they wander off to different parts of the waiting room. Gradually over the next three hours they slowly move back together until they are all sitting together assuming that we have forgotten the shitty cover stories and why they are here.

In the end Pop and s/p assault get copious amounts of percs and codeine. Fall on ice loses her cool and AMA's before she gets her share of the narcotic plunder. Later she reappears to demand a doctors note stating that she was in our ED all day. I decide to inform her just for shits and giggles that had she waited five minutes she was about to be d/c 'ed with a script for 20 percs. Oops now she wants to check back in!

Triage; means to sort

Still fighting Darwinism

2008-10-03T08:27:00.002-04:00

I know it's been way too long since I last posted. I don;t really have to worry about a fan base to piss off. Anyway I am still here living the dream in big city emergency department.

I will now continue along with my theme of the completely unbelievable moments of terror and comedy that are part of life in the Emergency Department.

9 shifts out of 10 I am usually working triage.

Working in a teaching hospital when your not a student

2008-05-05T11:56:00.002-04:00

.......sucks at times but is good at other times. July 01 is soon upon us where the Department will be flooded with new interns, med students and, PGY01's

I'll never forget the first year I was working in the department I noticed some of the senior nurses in the break room wisely planning vacations and switches for the first two weeks of July. It was like watching a high stakes poker game.

I found out soon enough what the nervous excitement was all about. I came into work one hot and humid early summer evening and was inundated with desperate pleas from young faces in scrubs bristling in arsenals of shiny new must haves for emergency medicine like trauma shears, pen lights and drug calculation cheat books.

We all need to start somewhere!

You can't make this shit up............

2008-04-28T06:29:00.002-04:00

It's just after midnight on a weekday and I am sitting at the triage desk staring out into the empty waiting room. I look out into the parking lot and see some one stumbling out of a cab. A 19 YO male stumble into the WR with lips and face severely swollen holding a can of planters party mix.

"Dude, We got a problem!" he blurts out.

"Right this way buddy." I reply

"I got wicked baked and thought I was eating cashews." he continues on.

We get him inside HR in the 170's. IV started, meds pushed, PT stabilized and held for OBS until the AM.

Two hours later I am again staring off into the void of our dirty WR. A delivery driver pulls up and comes inside.

"I have delivery for Mr. Jeffery" he states in broken English.

"Where you from?" I ask

"Thai Dragon" he replies

"We don't have a Jeffery that works in this department right now.' Are you sure they are in the emergency room?" I ask

The driver turns away from me and pulls out his cell phone. He makes a quick call speaking very softly and quickly into his phone.

He hangs up and turns back to me.

"I have delivery for Room 3"

Are you fucking kidding me!!!!

"Lets Go!" I motion for the guy to follow me.

I stampede into the PTs room where the resident is checking his VS after the med intervention.

"Did you order food????" I ask dumbfounded

"Yeah dude, chicken wings I am starvin!" Eyes lighting up

"Do you realize that everything is cooked with peanuts in a Thai kitchen you dip shit?"

"Do you have change for a twenty Doc?" he mumbles...................

Welcome to The Workplace Part 2

2008-03-29T23:29:00.002-04:00

I had heard the rumours.......

I had seen from a distance Nurse GiGi in action......

And Today, I finally had to work a painful 12 hour shift with her train wreck of an ass.

I walked into the breakroom for huddle and saw i was in the psych zone.

Fuck Me! Must have been for banging out a few Sundays before. I strolled into the zone and ran right into the tornado of Nurse GiGi. She looked up from the pile of notes, charts, seculusion forms and, section paper work-

"Oh thank god! Are you the tech over here??"

"Yup, Do you need something right away?" I asked.

"Oh yeah can you get an ECG in room 3 and labs while your in there, I am drowning here. I can't get ahead of all this work."

Fair enough I thought. After all there were 29 in the WR. I logged into the computer to dig up an old ECG for Daisheiki in room 3. Thats when I noticed there were only two beds occupied in our 7 bed psych zone.

WTF over!

Even worse only one of them was a psych peep. The other in room 3 was an overweight alcoholic with pancreatitis who couldn't lay still for a ECG for her 15 out of 10 chest pain. The labs were their own nightmare. I ended up chasing a small vein all over her left hand until I anchored it strecthing it like a rubber band.

I spent about 45 minutes in the room total. I walked out feeling like I was in there for hours. I walked over to the tube station passing GiGi on the way.

"Where were you???" she implied.

" In 3 drawing blood. Good luck with that IV." I snapped back.

"Oh the resident just ordered some zofran for her. Do you mind starting an IV for me? Oh an after that 2 needs vitals and something to eat."

Your kidding me right. We have two patients, one has already been here for six hours.

"Ok GiGi, I'll start the IV and you can take care the other guy." I reply

"I can't right now I need to catch up on his chart. The triage nurse won't leave me alone, i told her no more until I catch up." She blurts out.

I am used to seeing up to 11 PTs in Psych zone. Usually they are mostly ETOH and a few true psych players (see my pink zone post). There are 3 sitters, 1 nurse, 1 tech and, 1 security guard.

So I'm busting my ass, Nurse trainwreck is trying to print everything in the same color ink and, everyone else is sitting by the nurse station speaking loudly in jamican and playing dominos. Execept for Security, he is watching march madness on the internet eyes glazed over having already been on duty for 16 hours with another 4 to go.

As I walk towards the room with my IV set up in a kidney basin I see the resource nurse pushing a stretcher with PT, monitor, lifepack, nitro drip and 2 cards residents moving fast towards me.

"Brown, Get this guy up to the cath lab! He is a code STEMI Don't stop for shit! I gotta go help out on the code that just came in. Thanks Love ya!"

She hands off the pathway paper work and the stretcher to me in about three seconds in passing.

I come screaming around the corner in psych zone on our way to the elavator. I aim for the domino game and clear it out fast!

" Hey Watch werr ya goin Mon!"

Nurse GiGi looks up from her chart. " Brown your supposed to be putting that IV in for me. Where do you think your going??"

I laugh out loud and reply as I fly by "Just out for a cigarette, they are joining me from the cath lab."

We rush upstairs and I help slide the PT onto the table and make my departure back to the ED. When I get back downstairs I notice there is a different nurse in the psych zone. I ask where Nurse Trainwreck went off to. I am told she had to leave for a personal emergency.

More Truama For Your Mamma

2008-03-12T05:18:00.002-04:00

Another Monday Night from hell.

The triage clinic was open for business. Our 7 bed trauma zone was chock full of ICH, Code Strokes, MVA, more code strokes and, the usual gaggle of negelected ST and cough/ general bullshit hallway players hangin out for the show.

The theme of the evening was head bleed. Everyone got to hone their skills. The residents with there ryobi drills to relieve the pressure, the nurses navigating mountains of documentation and meds, me trying to figure out CVA leads and confusing lab specimen paperwork.

PT #1

BIBEMS sudden onset of acute HA and N/V still mumbling on arrival wearing a coat of regurgated chinease food. Dutiful EMT's bagging her anyway. Tubed, foley, central line, ekg, labs and fluff and buff done in less than 10 minutes or your money back. Oh yeah and she weighs about 320 lbs. Four of us go down to CT to help slide her onto the table.

Family= piss poor historians "She ain't never done this before! Momma never had no medical problems."

MR= Positive history of ICH, diabiates, AAA

CT says= Large global infarction 1% chance of cheating a body bag.

Next Victim-

PT 2- 19 YO male s/p assault BIBEMS ETOH on board. T00 bad he wasn't on a board. LOC for 5 min, kicked in the head. the word LUGZ clearly imprinted across his cheek. Throwing up blood and teeth.

EMS: Useless "He got the Shit kicked out of him! Oh yeah he is from quebec or something. Hah hah have a good night."

PT: "I only speak french. However I know plenty of dirty words in english."

CT says= early stages of pneumothorax.

Sometime around 0300 the onslaught stops.

Beds mysteriously appear throughout the hospital. We are down to 6 stoic peeps left in the WR. The call in fax machine spits out a travel agency ad for tickets to the bahamas $449 round trip. Someone overheads "Dunkin rounds at the board."

I smoke a cigarette outside in the Ambulance bay with one of the janitors. He tells me a story about being a waiter in lisbon in the 70's. Then we head inside I give him a hand cleaning the medical waste strewn trauma zone, preparing it for the next show.

Inza Inza Influenza

2008-03-01T06:38:00.004-05:00

It feels like an epidemic. We are getting hit hard in the Northeast. Acuity is up, Bed availibilty is down. For about a month now the department has seen an increase in ES 1-2's. Mostly respitory distress and failure hidden amongst a sea of "Flu-Like Symptons" in the WR.

Of course the emails and memos don't stop coming about Norwall virus pathways and documentation. One by one staff started dropping like flys out for days from this killer strain. I got nailed by it about two weeks ago and was in bed for four days. When I returned to work the next week about ten pounds lighter there was a CF of float nurses and travelers running amuck. The Nurse manager even made a point to have a meeting to verbally harass all those who had banged out sick over the past month.

si/hi etoh come one come all, we will make sure you leave medicated and a little crazier

2008-01-29T10:35:00.001-05:00

I suppose we are lucky that we are one of the few EDs with a separate psychiatric unit. The unlucky being the employees who work there. Management is pretty good about rotating nurses and techs through the pink zone. Those in the dog house sometimes find themselves marooned there for multiple shifts.

On any given night you can find the clinically insane, suicidal, homicidal, pyros, fakers, addicts, cutters, slashers, mumbling nanas, TBIs, ODs, glue sniffers, panty sniffers, homeless etoh, college aged etoh, yuppie etoh and last but not least combative, can't protect my airway and, I'm the best man in my brothers wedding in four hours etoh.

I think the most unfortunate are those who lack good insurance. All is well with the BEST team but don't let them find out your crazy bipolar ass is self-pay cuz then it's all over. These are the forgotten souls of society. These poor mental train wrecks end up boarding in the ED for a few days until they are quitely shuffled out the door. I have seen section 35 quacks get released back into the streets because the SW dug up some 3 week old papers saying that PT is clinically sane and able to operate heavy machinery and large caliber weapons.

Hey if you have some nice Blue Cross Cadillac insurance feel free to jerk the fuck out! Go out and pee on someone, Beat up a police cruiser, Get really drunk and pass out on the steps of the State House, Eat bottles and bottles of Tylnol PM and call 911 for fun. Whatever you do just remember to glue that shiny insurance card to your forehead.

Don't get me wrong, the ED staff will stabilize you regardless of you economic stature.

The card is what buys you the luxury of a top notch private institution. A month off from the fast pace of reality to think about what you did wrong. Who knows maybe you will master leather work or pottery glazing during your 30 day evaluation.

And when your all done and have recieved your endless prescriptions...................Feel free to do it all over again!!

The ED will still be here for your next episode and, after you gain frequent flyer status we will even let you hang in triage and entertain EMT crews and horrified PTs for hours and hours.

As the great Apu would say- Thank you! Pleaseeee come again.

Welcome To The Workplace Part 1

2008-01-17T22:05:00.000-05:00

The Tech- Mostly misunderstood, the tech dwells at the near bottom of the ED food chain hanging by a rung over patient observers and support services. We answer to the new travelers nervous overhead pages, we are beckoned by grim faced residents wearing precaution masks peeking from behind closed curtains. We are usually the only person left in the department to answer trigger finger call bell PTs twentieth ring. We share sweat with cardiac arrest PTs as we pound away on their chests like machines waiting for the stop compressions call from the attending.

We share the gallows humor with the veteran nurses and attendings as another rotation of fresh residents gap in horror at our running commentary. Not all of us in the ranks are the same though. Many different ages and personalities fill the dichotomy of the Department.

Although I can't classify everyone I can put most of us into these categories-

1.) The Lifer Tech- This breed is far and few between. These die hard techs are here to stay and when I say lifer I mean 5+ years. They mostly come from other hospital departments or like one of ours an orderly from a lock down unit for juvenile violent offenders. The pros of Lifer tech is that they can tell you were to find anything under the sun that has the hospitals serial numbers on it. They can also find veins on the difficult sticks everyone has given up on. Lifer tech is often accused of being lazy. Although Lifer tech will seldom do tasks outside of their scope of responsibility, their experience makes up for it when you need them in a pinch. Or as one of our gayer than Christmas SWs likes to say "a sticky situation"

2.) The Aspiring Doctor Tech (ADT)- This type of tech is painful for all involved. ADT can be found at shift change with docs on rounds, sometimes even volunteering their diagnosis and input. ADT loves to research med schools online while ignoring nurses requests and fellow techs calls for help. ADT has even been spotted checking tube placement with a mini stethoscope. Whenever ADT needs shift coverage for a med school interview they make sure the department wide email includes the name of whatever prestigious school they are interviewing with. But ADTs worst trait is telling PTs their diagnosis. This usually sends at least one shocked PT into a frenzy now needing a real MD to calm them down and explain in even longer words what the issue really is. There are no redeeming qualities abut ADT tech.

3.) The Workhorse Tech- Every nurses best friend. This Tech is usually one of two demographics- The first being the PA/Nursing student tech. This tech keeps their head down and gets the job done grateful for the minimal impact clinical skills. They're also always looking for something to do when docs need assistance in not so sterile procedure. The other type of Workhorse tech is the transient tech. This tech is usually an EMT sick of riding, veteran, college dropout, some guy that used to work in a pizza shop, etc that is looking for the next adventure. Some stay on becoming Lifer tech. The downside of this second type of tech is that they have a tendency to up and disappear.

A good department will have a nice mix of 1 and 3. All EDs will always suffer at least one ADT. The good thing is that they usually don't survive that long once they cross paths with the wrong senior nurse.

Stay tuned next time for Welcome To The Workplace Part 2: The Seven Nurses

Friday Night Fights

2008-01-14T23:52:00.000-05:00

Another Friday down the tubes. It wasn't that bad, we didn't get our first trauma basic until 0130. 20 something male with a nice deep stab wound to the chest. He was brought via EMS by some kick ass veteran basics who couldn't have done a better job packaging this ETOH induced ass clown for his arrival to the land of chest tubes and copious amounts of blood transfusions. They had successfully stopped the bleeding and applied a text book sucking chest wound dressing. From what the cops were saying it was a pretty hectic crime scene with party goers hurling bottles at the ambulance before the police finally showed up on scene. They rolled him into the trauma bay gave report and left. Thank you please come again. He was very combative at first yelling at us thrashing around refusing medical attention. It is amazing how cooperative a pt can be once they become hypovolemic. The attending cracked me up a little. First she told the trauma/surg team to get their shit together and pick up there sharps from the discarded chest tube kits on the floor then she turned to myself and the recording nurse and stated "I've never met a stab vic that i liked."

Of course in the middle of this trauma in came our second call, a drunken 19 y.o. female college student who was grazed by a cab. "OMG am i gonna die?!?!" No princess you got lucky. of course she refused to allow us to cut her favorite jeans off despite clear evidence of multiple right sided trauma. Whatever! She was gonna walk away from the ED in the morning with probably some minor injuries.

I walked out to the waiting room to find stab vics family after he was rushed up to the OR. There was his Mom and sister sitting there waiting looking pretty stoic. Standing next to them was college girls 3 friends all freaking out on cell phones about Princess. One of them saw me walking towards them. "OMG is Princess gonna die?!?!?"

Yup another Friday, another fight, another night.

You thought your Mondays SUCK!

2007-12-09T17:27:00.003-05:00

This past week was on of those ones that I hope I don't get to experience any time soon. It all started around 1900 Monday.

Another night on diversion!

One of our many senior nurse managers followed by the very angry chief attending called the resource nurse less than 30 seconds after our request went to CMED. They wanted to know why he was requesting diversion if we still had beds available in the hospital.

I was in the 7 bed trauma section where the two hardcore rock star nurses I was working with were pretty much one to one with two very sick PTs while their other PTs harassed me with every request from doctors and doses of pain meds to the Russian looking for her seafood salad sandwich.

The department as a whole was drowning in a sea of level 1-2s. ICH, Stemi, Acute GI bleed, three tubed ICU players, Sepsis, yup we had em all. It was an acuity party and the ED was the only department invited. Consult teams and floor nurses were avoiding our calls and pages like a resident avoids a call bell. A particularly ugly Monday meltdown.

And then the dreaded radio call arrival alarm went off. Several nurses and doctors cursed aloud.

Medical Student (b) speculates " I thought we were on diversion"

The double doors from triage opened and in rolled two cops and two paramedics with a stretcher.

Pedestrian struck around the corner from the hospital on a busy four lane parkway. This guy is in rough shape delta O2 and BP. The recording nurse makes a second overhead call for nurses to the trauma bay, The PT goes into cardiac arrest, intubation turns into a 5 minute ordeal for the senior resident. Despite everything the PT is revived and stabilized enough to be rushed to CT. The Trauma team wants the PT to go directly to SICU to be prepped and further stabilized for the OR. As they leave with the PT in a giant gaggle of equipment, RT and, trauma team the nurse shouts to me to call the SICU and inform them of whats going on and to have them call her in the CT control room for report.

I pick up the phone and dial the SICU and explain to the nurse on the other end what is going on. She bitches to me that we should have given the SICU a little more notice than this. The PT has now been on the property for just over 15 minutes.

Rock star nurse calls from CT she needs two bags of blood and more sedation meds "Please hurry!" she pleads. I tell her I am all over it like white on rice. as I move down the hallway I poke my head in her other PTs room to see why the alarms are chiming the monitor reads 68/- and HR hovering around 30. I overhead the attending to the room.

It is true Mondays really do suck!

The following week the resource nurse who was on duty that night is sat down for a formal Inquisition by a panel of senior management to explain why diversion was requested.

The Art of ED techery

2007-12-07T03:00:00.000-05:00

I think most people out there would agree that the emergency department (ED) is the official gateway to the hospital for all people whether they are there for something minor or, beginning the confusing time consuming transition to becoming an inpatient. Some patients will even find themselves spending days in the ED on a gurney before they see the inside of a hospital room due to no available beds or shitty insurance issues.

Your friendly ED tech is the first face and usually the last one that most patients see during their emergent visit. We take their vitals and chief complaint at triage. Once in the department we draw blood, start IVs, perform ECGs, flush wounds, splint, dispense crutches and turkey sandwiches. All this and the usual gofor duties. Plus how could I not include all things R. Kelly i.e. foley caths, UhCGs, U/As, Utoxs, and the good old code brown in all its glory and different forms.

We are the trench dwellers. The human insulation between nervous internal medicine residents and their unsuspecting victims. I listen to patients introduce themselves to me "You ain't the Docta!". After three or four hours waiting for the "Docta" I am now their only answer to the call bell.

"Whats takin so long?" call bell happy PT
"well two things, You need to pee in that cup for me and...."
PT cutting me off "Whatcha mean right here?!?!"
"No we have a bathroom down the hall for that" I reply
"You also got to finish that PO contrast so we can get you to CT." I continue
"It taste like shit. Gimme sumthin to eat!" PT exclaims hitting the call bell again. I reset it again.
"Miss, you can't eat anything just yet your here for severe abdominal pain and you said you haven't had a bowel movement in eight days........"

call bell going off again I reset it in seconds.
PT again cutting me off "Its startin to hurt more cuz I ain't got nothing in it."

Even though I get more of this shit than I do quiet and obedient grateful PTs I'll still advocate for them. One night recently I was going to the mother room to restock and a hallway player grabbed my arm and complained about nobody talking to him in hours and all he wanted was a glass of water and some pain meds. Of course I was automatically judgemental as we all know which stereotype is usually uttering this request. The patient wasn't in my section but I went to find his nurse to see what his NPO status was. It must have been someones lucky day because as it turned out the triage tech had fucked up royally and hadn't placed the PT's chart in the to be seen rack when they brought him back. What was initially triaged as a level 5 chief complaint ended up being two fractured ribs and a ruptured spleen requiring surgical intervention. Incidents like that always put the job back into perspective for me. Because at the end of the day if you forget that it really is all about the patient than you might as well go dwell in a cubical somewhere instead of potentially contributing to a PT fatality!