Do not judge lest ye be judged.

What a busy night for ETOH. We had at least five, but I may have simply lost track. One of the guys apparently crashed his ORV and hit his head. After he was rushed to CT, and he was starting to wake up, he was mumbling things. He said, "I have to go pee."

One of the nurses decided she had to put a catheter in, and nothing was going to stop her. She ripped down his pants, at which time the patient said, "Where are my legs."

"You can't feel your legs." She started poking his legs.

"You took my stuff away," the guy said. Apparently he couldn't find the worked "pants" in his scrambled alcohol saturated brain.

"I'm putting a catheter in you," the nurse said, "You're going to feel something cold."

"You will NOT touch me! I don't want that!"

"If you don't cooperate we'll have to hold you down!"

Now, I understand it was a busy ER that night, and the adrenaline was flowing, but I am a firm believe if a patient is adamant you just leave him alone -- drunk or not.

If there is one thing I've learned working with people the last 12 years, it's that when confronted with an undesirable option, most normal people's initial response is defiance. Then, after given time to think, they reconsider.

I mentioned this to the nurse. She said, "He's drunk. He deserves a catheter."

I stepped back, and got ready to help hold down the patient. I knew I was not going to stop the RN I knew the RN was not going to be stopped, and she wasn't.

I'm not picking on this one nurse, because this seems to be the general philosophy of nurses and doctors & other medical staff with anyone who drinks. They say things like: "Since he's abused his body he needs an incentive not to do this again."

That's also the reason every other invasive procedure the doctor can think of is ordered on these patients -- including ABGs.

Fine. I understand this philosophy. But I also understand that not every person who drinks is a drunk. In fact, most are not. Yet in the ER, all of you who drink are drunks.

But my opinion on this philosophy is that it is a bad philosophy. While many people drink, few are drunks. Likewise, all people, no matter how good, are fully capable of making stupid decisions. And just because someone has one bad night, drinks too much, and ends up in the hospital, is no reason to treat that person like he's a loser.

In fact, the person I wrote about yesterday who came in with a 476 ethonol level was not a loser nor a drunk. In fact, he works in a hospital in another town. He's like you and me, only he made one dumb decision not to cut himself off.

I've seen people come into our ER after doing something stupid, and those people aren't treated like losers. So, just because you don't know someone is no reason to alter this special treatment.

I'm sure every person who is reading this has done something he later regretted, including those who work in the ER who are so perfect they use the power they have to treat those having a bad night like dirt.

Likewise, every time a person walks into the hospital reeking of alcohol that person is immediately deemed a loser by medical staff. The truth be as it is, there are many members of the community who drink responsibly, and for whatever reason sometimes one of these people finds his way to the ER, either as a patient, or as a concerned mom or dad or friend.

Yes, there are those who deserve to be treated as dirt, but not every person who drinks. In fact, I've seen just about every member of that same ER team at bars or partys, or heard stories about their attendance at such places.

So, lest ye be perfect, one should not be so quick to judge. Or, stated another way, do not judge lest ye be judged.

He almost drank himself to death

The page said the ambulance was 5 minutes out, but when I arrived 2 minutes later the patient was being wheeled in. He was a 20 YO non responsive. He reeked of alcohol. The family said he had between 20 and 40 beers at a family outing.

He did not respond to the testicular squeeze the doctor performed -- not good.

He did not respond to the chest rub, nor the foot rub -- not good.

I prepared the ETT and the doctor stuck the blade into his mouth, and the patient gagged. That was a good sign. In fact, the patient gagged enough that the good doc wisely deferred sticking the tube into the young man's airway.

As the blade was extracted from the patient's mouth, the patient started to spew lots of secretions, and for fear he might puke we were all ready to turn the board sideways. The worse news was the direction they were planning to tilt was in my direction.

"Let's get him some Zophran," I heard someone say. I prayed that stuff worked fast, because I hate puke. I especially hate puke when it's coming my way and there's nothing I can do to get out of the way.

The good news is he did not puke. The better news was he was still breathing. So, because he had fallen and hit his head, we rushed him to CT. The results showed no bleed and no spinal injury, which was also good.

The EKG I did upon his return showed ST elevation, though. That was not good. While he escaped head and neck trauma, he may have drank himself into an MI at 20 -- once again, not good.

But he was breathing on his own, that was good. And he was waking up. The first words were of the sorts that cannot be repeated. And his parents came in and said he was a 4.0 student who was just having a good time with his friends and family.

I imagine he won't be drinking for a while. Once I deemed my services would no longer be needed, I left the ER. In the hall I ran into the good doctor. He said, "A person is considered drunk when his ethanol level is 80. This young man's ethanol level was 476."

Hopefully the EKG was just a fluke thing, and all this man will suffer is a major 2-3 day hangover. I can't imagine it will last much less than that. I've been drunk a few times in my day, but there always comes a point when my body says enough is enough.

Social drinking is good to do if you can handle it, and you can do so with a degree of responsibility. Apparently this man couldn't handle it, nor the responsibility. There comes a point when common sense must prevail, 4.0 GPA or not.

It's best to smile and go on with your business

I was in the middle of a series of breathing treatments in the ER on one of our regular COPD patients when I over heard the following over the din of the ER rush:

"I suppose I better page Rick again," it was the unit secretary, "he's notorious for not getting his pages."

"Um, he's already doing the treatment," a nurse said in defense of me. "In fact, he happens to be standing right there."

I turned around, stared viciously at that cranky unit secretary and said, "You know what, I wouldn't take so much time getting down here if you guys didn't call me for so much crap. I'd say 80% of the stuff you call me for is B.S!"

Okay, so that's what I wanted to say. What I really did was go about my business, smile, and pretend I didn't hear that exchange. And the rest of the night I smiled, was my normal cordial, phlegmatic, equanimitous self, and went about my business.

I'm telling you guys, when you work in a busy hospital around an amalgamate of people with an amalgamate of personalities, you learn to take such things with a grain of salt -- especially when you work nights.

Good ridance to the NBC hit "ER"

I wonder how many of my fellow medical workers watched "ER". I watched it when it began because I thought it would give me a perspective of life inside a hospital. Yet after I started working as an RT I'd find myself watching it with a fine tooth comb.

My friends who'd watch it with me were continuously vexed by my effort to critique everything that wasn't realistic. I never did see a person talking with an ETT stuck down his throat like on the old Emergency show from the 1960s, but there were equal inaccuracies in this show.

The last episode was a perfect example of this. In one scene we see Dr. Carter sitting in a bar with his friends, and in the next scene he has just left the bar and is walking into the ER. His friend says, "Dr. Carter, what are you doing?" He said, "There is work to be done."

So he all of a sudden -- after drinking -- decides he should be working in a hospital he is no longer employed at. If this happened where I worked he'd be fired on the spot.

Oh yeah! He can't be fired because he didn't work there.

In another scene a lady just gave birth and she is bleeding out. As I watched I could see blood pooling onto the floor. The doctor said, "Where the hell is OB?"

Why is it on this show the only time you ever hear about RT or OB the words, "where the hell are," proceed them. In the real world, a lady who was about to give birth to twins would have been RUSHED up to OB, and the babies would have been born there.

Second of all, the doctor in the show kept saying, "Push! Push!" In the real world, if a mom who is at a place she shouldn't be delivering a baby were in labor, the last thing you'd want to to is rush it out. This wouldn't even happen in the OB.

So these are just a few of the inaccuracies I found in the last episode of ER. It amazes me how busy that place seems to appear all the time. Not even the busiest hospitals in the world are that busy.

Likewise, the doctors ran all those codes as though they do everything themselves. When in that show do you ever see a respiratory therapist assisting with an intubation, or intubating, or doing CPR, or doing ABGs, or advising the doctor. Not on this show.

In real life, the doctor gives the order, and the RNs and RTs perform them. Yet, the only time on "ER" the letters R-T is said is when it is yelled by a pissed off doctor after the RTs services are no longer even needed.

I do enjoy watching shows like CSI. As I do, I wonder how many things those forensic scientists
do on that show that they never would do in real life. I bet there is no forensic scientist who works out on the field AND in the lab.

Or how about all the lawyer shows? I bet those aren't very accurate either.

Yet, all the same, they make for good entertainment for the majority of watchers of those programs. But those of us who know better, or are all the wiser, are not fooled by this false entertainment.

ER is done. Good ridance.

The strangeness of hospital life

Only in an emergency room would they put salsa in an emesis basin sitting next to the chips on the counter. Yep, only in an ER near you.

Yep. Only in a hospital will you have people working around a lady who is puking, and moments later dip into that salsa.

Yep. Only in a hospital will you dip into that emesis basin with a crunchy chip with the sound of dry heaves in the background.

Yep. Only in a hospital will you suction gross, thick, green tinged secretions from a patient and moments later be eating dinner.

I suppose stranger things have happened in the long history of the planet.

NO duragesics in the mouth -- okay

I was called to ER because we had an OD patient being wheeled in. The EMT was bagging. I assisted with the scooch over from the EMT cart to the ER bed. Then I took over bagging.

"Oh, not again," I thought. "I'm so sick of being busy all night because some person tries to kill herself."

The patient was vomiting. Oh, if that's not the grossest part of this job I don't know what is.

She still wasn't breathing, so as soon as she was done I rolled her back to her back and started bagging again. But, as soon as that Narcan was given, the patient was breathing again.

Dr. Click ordered for an NG, but as it was being inserted the patient started vomiting again. She vomited and vomited and vomited until there was a humungous pile of puke sitting there on the bed, floor, patients hair and everywhere.

"Oh, I think I'm going to puke," Dr. Click said. She looked like she might puke too, except for her smile. She was a cutie doctor.

Anyway, by the time she was done puking that second I looked up at the doc and said, "So, I bet we don't need to tube her now."

"No," she said, "I think what we were trying to prevent already happened."

Later, when the patient was being wheeled up to the critical care, she said she was in so much pain she put the duragesic patch in her mouth. She passed out.

The EMT later told me when they arrived the patient was lying on the floor all cyanotic and all, and the family was on the couch watching her. One of them said, "Yeah, I think she OD'd again."

The patient later admitted, "I was just in a lot of pain. I wasn't trying to kill myself."

In the hospital you never see it all.

RTs demand TVs in the ER

If RTs ran the world, there would be a TV in every room where RTs had to give a breathing treatment.

It's nice that on the floors I can go room to room giving treatments, and if my patient is out to lunch I at least get to watch TV while I'm standing around waiting for the treatment to get done.

So why do we not get this same luxury at other RT stops during the shift. Back in the psyche unit they don't have TVs for a good reason, but what is the reason not to have them in ER?

If ER were used the way it were intended -- for emergencies -- TVs wouldn't be needed. But, since 80% of our patients are sitting around bored waiting for something to be done, a TV would come in handy.

And since 90% of the treatments we RTs do in ER are on that 80%, it would be ideal to go room to room doing treatments and watching different TV shows like we do on the floors.

Yet, since RNs were in the world prior to RTs, ERs do not have TVs. At least not where I work.

A Kodak moment in ER

I deserved a good night tonight, and I got one. In fact, about half way through the night I tired of blogging, so I decided to go for a walk.

As the double doors to ER swung open, I could hear a TV. Looking at all the patient rooms, I saw the lights were off. At the nurses station, there were no nurses.

But I could hear a TV.

I walked through the nurses station to the small doctor's room, and there was the doctor, all three nurses, the unit secretary and the nurses aide watching Sarah Palin's speech on the Internet.

They seemed to be enjoying it.

It was an amazing sight. Hardly ever do you see members of this particular department with the time to fool around in this way.

"What a sight for sore eyes," I said, "I should shut the door and lock you all in, so you don't bother your RT the rest of the night."

The charge nurse looked at me cockeyed, then she smiled. "What did you say."

"Nothing...nothing at all."

An RTs worst nightmare

I certainly picked a good night to come back to work -- a full moon. Hopefully a full eclipse of the moon brings me some good luck as opposed to the usual bad luck normally associated with full moons.

I'm sure I'm not alone in dreading the first day back after a long vacation. But was especially dreading coming to work tonight considering the last six days I worked were pure hell, and the last hour of the last day before my vacation were the worst ever.

When I say the worst ever, I mean it. Think about this a minute: As an RT, what is your worst nightmare?

Mine is that I'll stare at a piece of equipment when a critical patient is depending on me, as are the nurses and doctor, and not have a clue what to do.

The EMTs informed us enroute the patient would need to be intubated as soon as he arrived in the ER, so we had all our stuff ready. And when he arrived he was blue, moderately labored, but I had seen people in worse condition not be intubated.

Whether or not the patient would be intubated was completely dependent on the doctor on duty. In my opinion, probably 90% of doctors would have intubated this guy right away. But, we weren't dealing with any normal doctor this night, we had doctor Krane, one of the best doctor's in critical situations.

Instead of panicking and intubating, she ordered me to set up BiPap. Considering how the patient looked, I rushed upstairs to grab the infamous Vision BiPap system instead of using the LTV 1200 that was setting next to the bed for such circumstances.

To be honest, the only reason I didn't use the LTV was because I forgot it was there. Up to this date, I had never had a problem using it as a BiPap, although I had read about problems other RTs at other institutions had had with it.

Once the Vision was set up, the patient's SpO2 jumped from 40% on a NRB to 98% with only 60% FiO2 dialed in. And, within a half hour, the patient noted that he was breathing fine.

But, his X-Ray was whited out. According to Dr. Krane, the patient was in ARDS possibly secondary to bilateral pneumonia, but, she said, even that was difficult to diagnose at this juncture. And, secondary to being hypoxic so long, the patients cardiac enxymes were starting to rise, indicative to cardiac damage.

The patient needed to be shipped. No problem, right. As soon as the EMTs arrived the patient would be out of my hands, especially since the EMTs in our area now have their own ventilators.

When the EMT arrived pushing the LTV 1200, I felt completely confident this would be a quick and easy transfer, until Bill said, "Gosh, Rick, I've never set this up as a BiPap before."

"I have," I said confidently. "I'll set it up for you."

I pushed the button, and the damn thing would not go into BiPap. Bill and I felt equally stupid. Finally I gave in, and called my boss, hoping she would remember. What she told me was exactly what I had already been doing.

"Well, come down here anyway," I said to Boss, "We could use a fresh brain."

Bill and I laughed at that, considering he had been up for 24 hours at this point, and if it weren't for this transfer he'd probably be on his way home by now. And I was in the last half hour of my 12 hour shift. I was quite beat, as it was a swamped night. We were both burned out.

Just as Boss arrived in the ER I realized what hadn't before, and Bill and I removed the vision mask from the patient and set the LTV BiPap on the patient. According to the vent, everything was working fine. But the patient was panicking. "Take this off. This isn't working," he chimed.

The nurses were trying to fix the mask, but I knew the problem was with the machine, even though all indicators showed it was working. The patient was getting the dialed in VT, RR and pressure.

I felt especially stupid because I was the one who trained every one in my department and the EMTs how to use this vent as a BiPAP. I suppose my mistake is that I disregarded warnings that it didn't work well as a BiPAP more so because I had used it on other patients and it had worked just fine then.

I checked the internal settings. Everything was set appropriately. The machine was simply not working with this patient.

Then a lightbulb went on in my head:

Flow. It's not giving the patient enough flow. Isn't that the big complaint about using the LTV as BiPAP. This patient isn't getting enough flow

"It's not the mask, you guys," I said. "This isn't working. Take the mask off."

I set the Vision back up, and the patient was fine. "Ah, much better," he said.

It had occured to me then that we had never tranferred a patient before on BiPap. We had always just intubated patients. But, as Dr. Krane assured the RNs, "This patient is doing fine on BiPap, he doesn't need to be vented."

And she was right. He was awake, alert, orientated and breathing fine on the BiPap. So long as he didn't need to be suctioned, and so long as he wasn't a candidate to vomit, he would do just fine on the BiPap.

But, we needed to transfer him.

"Can we send him on the Vision?" Bill said. He lifted it right off the stand. "I think this will fit in the rig."

Sometimes in this job we have to jury rig.

Grrrrrr

Nothing like a little Calvin and Hobbes to sum it up for me.

But that headline there about sums up my weekend from hell. And I still have six hours left.

It's one thing to be busy just in ER. It's one thing to be busy just on the patient floors. It's one thing to be busy just in the critical care. But when they are all paging you one after the other all weekend long, it's.... Grrrrrr.

Every person who could posibly have gotten sick this weekend did. I've taken care of everything from sick kids (see my last 2 posts) to adult vents.

Actually, about the only thing I haven't had is a code, but I have had at least five occasions when a patient has come close. And even a code would be better than trudging from one room to the next, from floor to floor to...

Come to think of it. Is there a reason that emergency rooms and critical care units are so far apart in hospitals. That's how it's been at all the hospitals I've worked at.

I think they do it this way to wear out us RTs. I don't think hospital builders think of how far RTs have to walk. No wonder my feet are killing me. I read one place that an RT walks on average 20 miles a day. I bet there's some validity to that.

And, here's another observation, whenever I have a ventilator in the unit (not like they put them anywhere else, but you know what I mean), ER is almost always busy. It's like clockwork. Just as you start a treatment in the unit, ER calls. Then you get to ER, and CCU calls you back.

Then when you sit down to have something to eat, they both call you at the same time, and then you get a third page that a patient on the floor needs (wants) a treatment.

I suppose it wouldn't be so bad if there were two of us, but it's just me. And, for whatever reason, I never call in help. It's not so bad being swamped the first two nights, but by the third night, when things still haven't slowed down, you start to drag your feet.

I'm sure you guys know what I'm talking about.

Now, on the fourth night, I'm... Grrrrr. I'm a freight train coming through, get out of my way. If you order a stupid procedure, I might slip up and tell you what I think. I will try to hold back, but I don't know if I will be able to.

And, if those two RSV kids in ER right now end up getting admitted, I think I might break down and cry.

Okay, so I won't do that. But I could.

That pretty much sums up how I feel right now as the lone night shift RT.

Grrrrr...

Holter monitors not emergency room precedure

I was just sitting here when I was called STAT to ER to do a holter Monitor. Normally I wouldn't gripe about ER calling me no matter what the reason when I'm just sitting here, but it was a STAT holter Monitor, so it warranted a groan and a gripe.

I don't know if all RT departments do holter monitors, but I know that most of the ones in this area do. However, we have other staff do them during the day shift, and RT just has to do them at night.

Which, one would think, would cover all holter orders, considering holter monitors are an outpatient procedure. But, lo and behold I get called to do at least one STAT holter monitor a week.

And, usually, it's during a time when I'm really busy.

When you are the only RT working, you learn to prioritize your therapies, and I can find very few things, aside from a STAT IS, that a holter set-up should be ahead of. Occasionally, I've been known to take over an hour just getting to the holter.

"This is the ER," one doctor told me once, "nothing in ER deserves to be put off for over an hour."

My short-of-breath patients on the floor are more important than this holter, that I shouldn't have to be doing in the ER in the first place, I thought. Yet I smiled and said, "Sorry."

If there are any readers of this blog out there who can think of one reason why a holter needs to be ordered in ER, please let this RT know. I can think of none.

Because the patient has chest pain?

Hardly. If he has that symptom he should be admitted.

What about if the patient had a fast heartbeat, but when she got here we didn't pick up anything on the rhythm strip or EKG?

If that patient is symptomatic, admit them. Otherwise, schedule them for an outpatient holter.

Another goofy thing we do after giving a patient a holter is give them this little log book for the patient to record any symptoms they might have such as chest pain, palpitations, etc.

If the patient is having these symptoms, they shouldn't be recording it in a log book, they should get themselves back to the ER.

Does a holter need to be ordered stat? Absolutely not in my humble opinion.

On the other hand, if the ER doctor called me and said, "Hey, if you guys have the time, and a holter monitor available, we would love it for you to put one on a patient so she doesn't have to come back in two days to get one."

If that happened I'd be ecstatic about doing the holter. In fact, it might cause me to have chest pain, and then I'd need a holter set up on me.

I'm going to be written up -- I hope

I'm going to be written up, and I'm happy about it.

About seven hours into my shift I had a patient with a bad heart of whom the ER doc had already decided to ship. I had a bad feeling about this patient, so I decided to hang out in ER until the patient was secured into the ambulance, and the ambulance was gone.

Leaning against the wall, being cool, I casually looked down at the counter and saw that someone had written something on a note pad. This is what it said: "Respiratory did not respond to do an EKG after 2 pages."

I smiled, stood by coolly, and pretended I didn't see it. Most ER nurses understand that I am the only RT on duty, and that my other patients are just as important as ER patients, but this new nurse, her name is Mary, hasn't figured that out yet.

During my recent stay in the hospital, she was the only nurse who didn't treat me like royalty. In fact, when she was my ER nurse, that was the first time I had met her. Now I'm quite certain that not only is she a bitch from the patient POV, she is also a bitch from this side too. She is a rare and unfortunate scar on an otherwise awesome staff here at Shoreline.

Despite my opinion, which is subject to change once I get to know her, I continued to treat her with respect, and I continued to coolly smile at her each time I passed her. And, to my surprise, she was quite nice to me the rest of the night. She even smiled once.

As you guys know from a previous post, I have a proposal for ER EKGs that I have yet to take to the powers that be here at Shoreline. If I get written up here, I am going to use this as a prime opportunity to state my case for STAT reform.

Instead of paging me "EKG in ER" I think I should be paged "STAT EKG in ER" or "Just because EKG in ER" so that I can prioritize appropriately. However, I did tell this to a nurse once, and she paged me STAT for every EKG, because, as she said, "All ER EKGs are STAT."

"No they are not," I said.

"Everything ordered down here is STAT."

"That's not necessarily true." And I proceeded to give her many examples: Treatment for sputum induction, treatment on a not SOB patient, pre-op EKGs, etc.

I said, "If you start paging me STAT to all EKGs, then I'm going to get numb to the word STAT. It's not fair to my patients on the floor if I drop what I'm doing every time I get a STAT page, especially when the EKG in ER isn't needed."

When this nurse I do not like paged me the first time, and to my defense, I was with another patient. I did get the page. I was tied up in another room. And, since about 80% of ER EKGs are done just because, I figured I'd finish up what I was doing before going down to ER. And, lo and behold, I received a second page three minutes later, and still decided to finish up what I was doing.

I was swamped all night.

Okay, yes I could have called. I am at fault there. However, most of the time I call to say I'm going to be a while getting down there, I get down there 20 minutes later to find the EKG is still not done, so why bother calling.

Now, you might be thinking, "If they thought to page you a second time, didn't you think that perhaps they thought the EKG needed to be done urgent?"

No. The reason I didn't think that was because ER always pages me three minutes after the initial page, especially if I don't get down there right away. I get tired of it, especially when I drop what I'm doing and the patient has an EKG ordered for a hang nail or something stupid like that.

I'm the kind of RT who gets along with everybody for the most part. I never complain. In fact, just last night I walked into a room to do a STAT EKG on a patient who was being packed up to be shipped to the CCU, and I observed the patient's NC was hooked up to a tank.

"Is that tank even on," I said while hooking up my leads.

"Yeah, I'm sure of it," the young nurses aid reassured me.

I casually unplugged the tubing from the tank and hooked it to the flowmeter, and turned the flowmeter on. Then I checked the O2 tank. Yes, it was on to 2lpm, but there was something she didn't notice: the tank was empty.

Now, instead of jumping all over her and telling her she was a stupid ass like some people might do, I used this as a teaching opportunity. She probably thinks I'm going to write her up. I won't.

Why won't I write her up? Because I know that some day I'm going to do something stupid. We are a team. We need to stand up for one another.

This ER nurse however. I am very confident that once I get her trained I will get along with her just fine, so long as there is any humanity in her. In the meantime...

I hope she writes me up.