A Cranky Tour of the ER

Mr. Crank was in a minor motor vehicle accident with his grandson in the car. Both were our patients in urgent care.  "I'll do it myself," he snapped when the PA tried to help him into a gown, "but I need to go to the bathroom right now." His expression and tone of voice was pure insistence. He was the kind of person that wanted things done in his way, his time.

I wheeled him to the bathroom and helped him out of the wheelchair. He grumbled, and complained, but I soothed him by asking him about his family.

Mr. Crank's urine dipped positive for blood and he also had had several spinal fusions and felt pain in his lumbar back.  Due to all these criteria, we sent him back to the regular section of the Emergency Room.  "Throw him on a stretcher in the hallway. We can't deal with him now," said Triage Nurse Cranky right in front of Mr. Crank.  "Throw me in the hallway, eh?" he grumbled. "Well now, Mr. Crank," I appeased, "since you are going to have an x-ray anyway, let's go see if they're ready for you now so you don't have to wait."

I wheeled him to x-ray where x-ray tech Crankier with whom I have a friendship accepted Mr. Crank even though the orders weren't complete.  "Now you gotta get in a gown, Mr. Cranky. We don't got all day." He mumbled and began undressing. "Now what are you gonna do with all that stuff?" I volunteered to get a bag. When I came back, she was positioning him on a table. "Don't you roll back this way, stay still or we'll never be done. Hold it! Hold your breath!" I helped position him and distract him from his pain.  Yelled at and out-cranked by x-ray tech Crankier, Mr. Crank stayed quiet and followed instructions very nicely after that.

When I left him in the other section to return to urgent care, Mr. Crank thanked me for being his advocate in the face of nurse and x-ray crankiness.  He probably knew that he would have been neglected had he been "thrown in the hallway."

Later, I checked on the computer and Mr. Crank was transferred to critical care.  An hour later, I checked again and he was now a full-trauma.  Mistriaged, misdirected, and out-cranked.  What an ordeal for Mr. Crank!

When I left urgent care after closing down the section, I returned paperwork back to the main ER to see Mr. Crank sitting, discharged, outside valet parking in his wheelchair wearing a neck brace.  He called me by name and I sat with him until his son came by to pick him up.  He had received an unprecedented tour of our ER that day, but he turned out to be pretty mellow by the end. Mr. Crank proved to be only cranky as a stranger, but a gentleman with acquaintance.

S

Kitchen Nightmare Recipe

Triage note states: Left finger laceration from cutting an onion (personal notes in parentheses)

Materials:
1- (very pleasant young lady) patient with cut on (dominant hand) finger
2- visitors, a friend and a 2 month-old newborn in a cradle (optional, but helpful)
1- box of pizza (adds to atmosphere)
1- technician (yours truly)
1- (busy) physician's assistant
1- suture removal kit, soaking solution
bandages
length of time: 2 hours

First assess patient (she is in no apparent distress).

Uncover the finger gently (patient winced and barely allowed me to gently lift gauze from finger)

Assess quality of cut. (the smell and appearance verified that:
1, The cut actually occurred 2 days ago.
2, Patient never sought care until today.
3, The fingertip is horrifyingly puffy, crusty, leaking fluids, and green.)


Staunch bleeding and flush debris from cut. Discourage patient from eating pizza with the same hand. (In this case, I had her soak her finger, to her relief in some sterile water/soap)

Inform PA of situation, help prepare bandages.

(Hold patient's hand as she flails and shrieks at the size of the needle as) PA administers tetanus shot.

Assess cut (and realize that part of soft tissue is necrotic to bone and may need debridement/surgery. Explain to patient that debridement means to scrape off necrotic tissue. Allow patient to squeeze my hand and screech in fright as friend laughs at her misery), cut away some dead tissue and skin flap

Call hand/plastics (who refuses to come see patient and refers her to a clinic for the next day)

Wrap finger in antibiotic cream and gauze bandages, send her away with antibiotic cream, follow-up information, (and misgivings).

(Wonder what is happening with her now.)

Enjoy newfound appreciation for having all my appendages intact.

S

Chapped Lip Service

"How can we help you today?"
"I got this sore and it hurts real bad."
"So where is the sore, Mr. Abuse-of-the-System?"
"Right here, can't you see it?"
"That cut on your lip... is that it?"
"Yeah, that's it."
"Well, don't keep touching it because it won't heal up. You can put some bacitracin on it so it doesn't get infected."
"Like this?"
"You don't have to glom it on... just a little will do."
"Thanks so much!"

-__- Really?? You came to the ER for a chapped lips??

Nurse Crotchetty: Did you really come on the ambulance for a sore tonsil? Is that really necessary?
Mr. Tonsil: (nonchalant grin)
Nurse Crotchetty stared him down... : Put him in the waiting room.
Mr. Tonsil: Aw man...

Another day in the life...

S

Of Chance and Drugs

This is my 100th post! And I worked a double shift- out of the last 32 hours, I worked 24 of them...  It doesn't feel so bad, but looking at it that way makes it look that much worse! Luckily, most of these past 16 hours in a row were  not on my feet, as I was in Urgent Care and had a lot of paperwork to do.

And little did I know, I missed the memo that declared today the unofficial Drug-Seeker Day!
It's the holiday where opiate addicts of all ages, shapes, sizes, and intelligence levels come to the ER to feed their gambling vice.  Will they score? Will they score big? And on our tab? (That would be the jackpot) Or will they get escorted out by security and blacklisted? Take a roll of the dice- somewhere along the way, many have apparently found reward in this terrible game.

Naturally, this game of opiate-collecting is equally one of chance and skill.  As far as chance goes, they might meet one of our new providers that doesn't know them by name/face/habit.  Perhaps they might come when we are tired/distracted/discontented and hope we might not notice how regularly they visit every 30 days to get that magical prescription. Maybe they might have a legitimate (self-inflicted) injury.  Or perhaps they might be skilled players and alternate between different pharmacies and providers every few days. Maybe they developed incredible powers to break down the will of providers or just the gift of gab and persuasive power.

In any event, I was working with a well-seasoned veteran APRN who knows the numbers to local pharmacies, certain pharmacies outside state borders, the websites to trace narcotic prescriptions for certain individuals, and  has an exceptional sensitivity for people.  His sarcastic pen broke many dreams and wrote many prescriptions for motrin and tylenol today. Becoming rather seasoned myself, I made sure security was already awaiting our problem clients on their escorted walk back outside.

There were quite a few seekers from out of state that were found on our databases to have been flagged in multiple states. They were very surprised to be found out so quickly, but I am sure they will find other places and other ways to gain these prescriptions lawfully.  Or they will come back tomorrow for another roll at the dice in urgent care.

S

Adventures in Sitting: The Strength of the Strongest Bond

"S, we need you pull you out of your current assignment to sit in urgent care." I gave the nurse a strange look. People that require sitting- alcohol abuse/substance abuse/psychiatric problems- aren't supposed to go there.  "I know," she said, "it's a special situation. They'll explain when you get there."

It was a beautiful late summer day and the afternoon sun was still dappling through the trees that were rustling gently in the sweet breeze.  I reluctantly entered the glass doors of the clinic to see that in room one was a woman, feeding a baby, speaking tensely with our manager.  The manager pulled me aside and explained: Mr. and Mrs. Feckless came today because he needed stitches removed from his hand.  They came to urgent care but it became glaringly obvious that both of them had had alcohol, both breathalyzing above .300.  DCF was called and we are waiting for them to arrive- Mrs. Feckless knows this.  "Where is Mr. Feckless?" I asked. "In the drunk tank," the manager said, "just stay in the room with her to watch her with the baby."

I entered the room and introduced myself.  Mrs. Feckless saw me and said, "I don't need to be babysat with. This is my baby, I would never hurt her." I diverted the conversational path by simply asking, "so how old is she?" She scanned my face and decided there was no intention of harm. With the indulgence of a proud mother, she smiled and said "7 weeks tomorrow." I admired the little one, who could not? The minute fingers, perfectly arranged little eyebrow hairs and eyelashes, a bow around her head, little stubby legs, the fresh smell of new life.  She is going to be such an exotic beauty, with olive skin and dark blue eyes.  This skein of conversation let Mama Bear put her guard down, and she told me about caring for Baby Feckless, bathing her, feeding her, rocking her to sleep.  Meanwhile, the baby was cradled in her arms and didn't make a peep, her gentle eyes at peace with her surroundings.

She was so gentle with the baby, knowing exactly what to do with every hiccup, burp, squeak, or kick of a little leg.  They knew each other better than anyone else.  The baby rested comfortably in complete trust, nestled on the mother's chest; it was the epitome of Madonna and Child, transcending time, space, culture and it was beautiful to see.  They gazed at each other with an unspeakable bond that was almost visible, shimmering in the air.

Mrs. Feckless looked younger than she was, but the lines on her face told me she didn't have the easiest life.
"She is the best thing I have. The only thing I have," Mrs. Feckless sighed, "I used to live in a half-way house. Then I met my husband. Everything changed. Everything bad that happens to me happens because of him!"
I paused, "... is he good to you?"
"Oh, he's the best. He's my best friend and we understand each other. We love each other so much.  It's just that he can be so stupid sometimes. Never shuts his mouth and now look, DCF is coming again."
"Again? You mean this isn't the first time?" I was incredulous.
"No, hah, it's ridiculous. The day she was born, I was alone. He was drinking and being an ******* on the streets. Then he realized he was gonna be a father and started calling my cellphone nonstop, screaming at me and the nurse telling me to hold it while he comes in the room. I mean how can you hold it? I was having a baby! The nurse told him never to call again and not to come in, but he burst in and caused a scene cause he was drunk, you know.  They called DCF that day.  But he's good to me, he really is."
On the day the baby was born. Unbelievable.

She was comfortable with me and made easy conversation, cradling the baby close.  The baby had dozed off and slept comfortably, positioned next to her mother's neck.  Maybe she never had anyone to talk about this with or maybe I was just a receptive listener, but she relished in the details of describing exactly how the baby would smile only at her, and how to decipher the squeaks that the baby used to communicate with her, and how gentle, quiet, perfect this baby was compared to her now teenage son, who was a nightmare baby.

"You don't have any children, do you?"
"Oh, no," I laughed, "that's... far in the future."
"It's a good thing. I was your age when I had my first. I was barely a baby myself and I had to grow up real fast.  If I had any advice for you, since you're nice and sweet, it would be this: travel, go to school, have fun, and never settle."
"Oh, I'll never settle, don't worry about that one."
She smiled at me and DCF walked in.

"Can you step out?" asked the severe woman wearing severe high heels.
"Of course," I said, feeling a chill and they shut the door behind me.
The tech that brought DCF over pulled me aside. "When those drunk fools came stumbling in, you know what he said to me? He looked me in the eye and said *****, get these ******* sutures out of my hand now. And I was like uh, hold on, sir. I told them he was drunk and was like you need to call DCF. You know what, they deserve this for being idiots. That baby is not safe with them."
I listened in silence. Maybe... but could anyone else take better care of someone else' baby when the mother is already attentive? Mrs. Reckless didn't seem very drunk at all- in fact, I would consider her to be more competent than many mothers with very young children I've seen in the ER so far.

The door cracked open and I heard, "I need to call my supervisor, so just hold on."
"Please don't take my baby from me, please, I'd die without her, please."
"I said I would call my supervisor. Please wait a minute."  The she-wolf in heels nodded at me and I went inside.

"I told him not to drink, but then he got ME drunk, and I never drink. You can ask any of them and now look!" Mrs. Feckless started crying and I got her a box of tissues, "He ***** up so many times. I do it once and now I'm being punished for it. It's not fair! I've done everything I was supposed to do- I sat here quietly, I waited, I didn't make a scene... but I'm still being punished."
She cradled the sleeping baby in her arms and kissed her several times. "Never, never... They're all liars. I don't believe a word they say.  She wants to put my baby with a foster family and says I'll get her back, but I don't trust her. I don't trust none of them. I just want to go home with my baby!"

I heard the clinic door open and watched 3 county officers walk in.  DCF came back in and I exited the room and grilled the officers.  Mr. Feckless had been arrested and Mrs. Feckless was papered. She may well be arrested as well. That would get her fired from her hard-won job at a supply depot.  I couldn't help but feel a cold horror, like I was taking part in something terrible and wrong, like a hapless grad student working in the monkey room under Harry Harlow.  http://en.wikipedia.org/wiki/Harry_Harlow

DCF came out once more and asked another tech to go inside and "distract her" with the paperwork. Mrs. Feckless was helpless and laughed bitterly, "I know what you're doing. You're taking my baby away."
"No, we're just making sure she's healthy," DCF said as she slowly wheeled the stroller out of the room.
"But what about all her clothes and things?"
"Well, do you have a bassinet at home? If you give us your keys, we'll take what she needs for her stay."
"But how am I going to get in and out of my house?" Mrs. Feckless looked so worn.
"We'll figure that out."
"Where is my husband? Did he get arrested? I'm have to leave him... this is too much, I can't take this. I'm losing my baby..."
"You won't lose her forever if you go to the session tomorrow as it says on this paper, since it is your first offense. If you do everything like we say, you'll get her back soon." The DCF woman said.
"How soon? Tomorrow after the class?"
"It depends."
It was too cruel.

Quickly, matter-of-factly, efficiently, it was all done and she was asked to leave.  I gave her a hug and told her to take care as she was escorted out, silent and broken, by the officers into the gorgeous afternoon. I watched her look longingly as they walked right past the van where DCF was tying in the still-sleeping baby.

S

Weak Acid, Strong Consequences

In Urgent Care, we are supposed to receive patients that triage nurses deem to have minor problems. Because triage nurses are not omniscient, however, occasionally we get something that is very serious. For example, we had a "minor motor vehicle accident" victim arrive, whose symptoms started and worsened while she was being treated, eventually leading to one-sided numbness and tingling. I transferred her to the trauma room soon after as a full-trauma so they could do a full work-up for spinal cord/nerve damage.

The other day, I saw that we had a "chemical burn" coming. The man and his relative were non-English speaking, but handed me a materials safety sheet that listed concentrated "Hydrogen Fluoride". He had accidentally submerged an index finger at work while cleaning masonry. I saw that the finger was inflamed with small, dark, funnel-like holes. HF, as I learned in high school and college chemistry, is a relatively weaker inorganic acid. Neither the PA nor I knew much more before we looked it up online.

Apparently, HF burns of less than 3% of a person's body can cause systemic failure and kill a person.

According to medscape, these are mechanisms behind how that can happen:

"The 2 mechanisms that cause tissue damage are corrosive burn from the free hydrogen ions and chemical burn from tissue penetration of the fluoride ions.

Fluoride ions penetrate and form insoluble salts with calcium and magnesium. Soluble salts also are formed with other cations but dissociate rapidly. Consequently, fluoride ions release, and further tissue destruction occurs.

Systemic toxicity occurs secondary to depletion of total body stores of calcium and magnesium, resulting in enzymatic and cellular dysfunction, and ultimately in cell death. Majority of deaths are resulting from cardiac arrhythmias that were precipitated by hypocalcaemia and consequent hyperkalemia."

http://emedicine.medscape.com/article/773304-overview

Yikes!! How long had it been since he was exposed? A day and a half ago! The inflammation might have been from the acid already etching away at the bones in his hand. That's much too long to not have been treated, so we sent him immediately to critical care. Our critical care physician deemed it serious enough to be immediately sent to the burn unit at a nearby hospital and the man was sent there by ambulance.

However, we found that the other hospital, through a serious oversight, did not look up how to treat HF burns and ignored the suggestions by our own physician to treat him immediately with intravenous calcium gluconate... and discharged him with bacitracin ointment and a few band-aids.

I've been thinking of him for the past few days, hoping that the polite young man will be able to keep his finger/life. It's a dangerous world we live in....

S

I'm Tellin' duh Troof

Mr. First-timer:

S: So it says on your triage note that you came in for back pain that you've been having for a month. Did you fall or lift heavy objects? How did your pain start?

Mr. First-timer: Well, when I was a kid, a car hit me.

S: That's when it started??

Mr. First-timer: Then, last year, I slipped and fell on some ice, y'know. Like, it was slippery.

S: Ok... anything happen recently? What made you come in today?

Mr. First-timer: Well, I went to the dentist last week, to get a toof pulled (points), and I got some percocets. And when I took them, I noticed, my back pain went away too... (expectant eyes)

S: ... I think I see. I'll let the doctor know.

This rookie obviously has not trolled for pain-killers before- that or he's just really honest.

S

Urgent Nonsense

Patient 1 had her toe stepped on 3 weeks ago. The pain was suddenly unbearable, so she came in today, wearing really cute sandals, baring all her toes. I can see how they got stepped on...

X-rays showed nothing, so she went home with a post-op shoe. Very cute, but a bit clunky for my taste.

Patient 2 had an abscess on her buttock. She hyperventilated to freak herself out, then screamed before the lidocaine (numbing agent) even went in. She didn't want to admit she didn't feel the pain anymore, so she screamed at times she thought were reasonable for pain production. If she is like this for popping a pimple in her (well-padded) butt-cheek, I really feel bad for the nurse on duty the day she has a baby.

Patient 3, Ms. Excuses, wasn't really our patient, but she said she was here last week. She needed a work note to replace the note she had "lost."

Me: Hmm, Ms. Excuses, let me check for you... How do you spell your last name?

IE: E-x-c-u-s-e-s.

Me: Ok, that's what I thought. What date were you here?

IE: July 6, and the doctor gave me the whole week off.

Me: Hmm, Ms. Excuses, I don't see you in our database.

IE: (Wide-eyed) Oh! But I was really here. I was here twice for the same thing... The first time was in April, where they gave me prescription xyz, and I came back last week to get another one.

Me: Ok, Ms. Excuses, I'm looking at all records with your last name through April. Is your first name "Illegitimate"?

IE: Yes, that's me!

Me: Ok, you're right. You were here two times. The first time was May 3, where it says you eloped. You left without being seen.
IE: Oh yeah, that's because it just took so long and I was feeling better... (trails off)

Me: (continuing) You were also here on June 1, and the x-ray did show you had a small amount of fluid around your knee.

IE: Yeah, so I was wondering if I could get a work note for when I was here last week. I can't believe I'm not in the system! Computers these days! (increasing nervous pitch) But yes, I had a note for the whole week.

Doctor: Well, we can write you one for when you were actually here. (writes note for June 1, able to return to work on June 2, gives to Ms Excuses)

IE: Ok, thanks Doc!

(returns 5 min later)

IE: I just wanted to make sure- is this a 6 or 7? I see you wrote over the 6, and I just wanted my employer to know for sure that it's the right date.

(Doctor writes new note with "JUNE" and hands to her.)

IE: Thanks Doc! Have a great night.

You, too.

S

(Thanks Dave H. for image sources)

A Good Day in Urgent Care

Yesterday evening was the perfect follow-up shift to a few days in the drunk tank. I was stationed in a separate little urgent care clinic where people come in for less medically serious reasons- small lacerations, broken fingers, muscle strain injuries, small abscesses, rabies shots, prescription refills, etc. The technician can help clean wounds, dress wounds, splint injuries, apply ace-wraps, knee immobilizers, sling and swaths, ice bags etc to an orthopedic injury, as well as a lot of the computer work.

Besides one aberration patient, the day flowed very smoothly and I got to hang out with some of my favorite nurse practitioners ever.

The drama-king came in screaming, my wrist, my wrist! he had it bent backwards with an ice-bag filled with hot water. For some reason, he was in a wheelchair. APRN took one look at him and said, take him to x-ray (and don't bring him back). "I need meds!," he yelled, "I'm in so much pain. Get the doctor here right now, I can't go without pain meds!" There was alcohol and who knows what else on his breath. I got him an ice pack, and he went off without meds to x-ray. He had 2 visitors come in soon after, a disheveled girl and a man with a gold grill in his teeth. I have never seen anything like it... it's like

But with this:

Why in the world would anybody do that? But anyway- there was something strange about this situation. When they heard he might be coming back to this clinic, the girl angrily said "I'm not playin' these games. He better get the meds over there. Let's go."

They're obviously still young and green in the drug-seeking game. Better luck next time...

Urgent care can be really hard to work in when there are a lot of patients sent to us, all of whom need x-rays or stitches, or abscesses lanced or a consult from orthopedics/podiatry/plastics/etc. There are just so many procedures and tasks to do for each patient.

It's hard on the physicians assistants/APRN's for different reasons; they were talking about the ones who couldn't take it anymore- the ones who had quit. A woman came in for thoracic back pain and was sent home with a followup appointment and pain meds; the next time she came in was for a massive pulmonary embolism, dead. The PA who treated her quit soon after.

You also get really weird/funny/stupid cases, like the cop who came in for a human bite.

Where did you get bitten, sir?

Here on my arm. Is it gonna get infected?

It looks like it didn't break skin. That means you're ok.

But there was saliva!

It didn't break skin, sir. It's ok.

Even with saliva?

Yup.

Or the guy who came in for "genitourinary problems" who ended up with just a blackhead/ingrown hair on his pubis. It wasn't even remotely red or swollen. He made sure to call his wife a few times and leave messages to assure her he was ok, but that he was in the emergency room, not telling her what it was for and scaring her half to death.

Or the kid who had a giant abscess on his butt cheek who grunted the whole time we were lancing it. Just grunted- no yells of pain, per se.

I walked by the drunk tank to take a look; it was even worse than the night before. THANK GOODNESS I wasn't in there last night. If anything, being there every day is what is going to make me burn out.

S