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

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

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

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!

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

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!