Adventures in Sitting: The One Who Got Away

Occasionally- though lately it has been more often than not- I have had to sit. That's what we call it when a patient comes in for "psychiatric illness", or "suicidal ideation", or "ingestion", or "homicidal intent", etc, and a technician leaves off normal duties to make sure s/he is watched while in our facility. Either the patient has proven to be a danger to him/herself or others or has said the magic words "I want to hurt myself." Then s/he is granted the privileges of having someone watching them one-on-one for all the uncomfortable hours spent in the ER, of having that same lucky companion to accompany any trips to the bathroom, and facilitate the removal of all plastic cutlery from meal trays before eating. Apparently plastic knives have been an issue with cutters.

I hate sitting. It is an unwanted break from the action of treating emergent medical issues; it also makes me really tired, even though I'm not doing anything. My heart rate drops, my adrenaline gets used up, it's all sorts of terrible and useless. At least, that's how I felt, until I didn't meet my Mr. Towga.

One ordinary day, upon seeing me arrive to my shift, the tech I relieved sprang up happily, gave me a hug, and ran off to live his life. I was not informed that I was supposed to be sitting for two patients: one who had ingested a bottle and a half of aspirin, the other, usually a regular drunk, who had jumped into the river in an attempt to harm himself. I went about my duties, stocking and checking up on my new patients, when I heard "He went that way!"

"Were you sitting with that patient??" A nurse rushed up to accuse me. I looked at the rumpled empty stretcher.

"No, I was definitely not," I replied.

"Then who was? He jumped in the river yesterday. If he jumps in again, someone's head is going to roll. Are you sure you were not sitting with him?"

"I was never told I was."

"Then what are these?" She discovers sitter forms on the counter; it was a scary moment when I realized I was supposed to be sitting for both my ingestion lady and Mr. Towga.

"I was never informed I was sitting. I've never seen the man in my life."

"Well, we'll see about this," she huffed.

Mr. Towga took off in several wrong directions in his clumsy escape and was not wearing a hospital gown, only street clothes. Several seasoned nurses pointed him in the right direction of our exit. The last people to wave him goodbye were the security officers out front. It was only when he took off running that people got suspicious and realized he was a psychiatric patient.

The police were informed and a search was performed, but Mr. Towga was long gone. I didn't get in trouble because I was given improper (nonexistent) report, or so they say. I have a feeling it was more that some of our oldest and crankiest nurses were the gracious souls who showed him the way to the exit.

I take sitting duty very seriously now. Woe be to the uncooperative patient under my watchful eye! Mr. Towga came in again a few weeks later, thank goodness, and only as a drunk this time. I made sure to get a good look at him. Nice to finally meet you.

S

Panda-monium

My predictions were unfortunately accurate; the day after the 4th of July holiday weekend was unadulterated chaos. The waiting room had over twenty patients at any given time, the rooms and hallways were full, the center hallway was falling over itself with drunks. Great.

I was extra (unassigned), so I floated around to the critical care section, which was jam-packed with the most seriously ill patients. A new critical care patient was coming in, so I pulled Mr. Blegh, a quiet little-ol'-man (LOM) into the hallway in front of the secretary to free up his room. He was almost ready to be transported to his new room upstairs. The secretary was already besides herself with trying to move admitted patients upstairs into the wards to aid decongestion of the wing. She soon pulled strings to expedite his paperwork so I could take Mr. Blegh up myself. Mr. Blegh was polite, very diminutive, very quiet. I brought him into his room and raised the stretcher so he could climb into the hospital bed. I made sure his urinary drainage bag and IV bags were placed so he wouldn't pull on them when he moved. I began to wonder if I should have asked the nurses to come in and help move their new patient. Without warning, he said, I don't feel well, BLEGHHHHHHH. Mr. Blegh threw up copiously. Four times. Onto my pants. All over the floor. All over himself. During which, he also lost bowel control. After cleaning up, I came back downstairs to the ER and told the secretary about Mr. Blegh. "Oh, I just knew he was going to throw up. He had that look; I didn't want him to go up with just a transporter." ...... Oh well- that actually did make me feel better, since it meant that she trusted me to help Mr. Blegh if he got sick en route.

Charge nurse soon found me and put me to work in our ridiculously crowded and bs/drunk-filled triage bay. Among my favorites:

Mr. Smith:
Charge to me: "We need urine on Smith."

"Will patient Smith please report to the triage desk, Smith."

A boy walks up. I'm Smith.

"Hi Mr. Smith, what's going on?"

"My stomach hurts."

"In that case, we need a urine sample."

(looks shifty and uncomfortable) "Why do you need one?"

"We want to make sure that's not what's bothering you and making you sick."

"Umm, ok, I guess I'll try, but my stomach won't let me pee."

"Oh, ok, well here's the cup in case you can." My spidey senses tingled.

Charge to me: "Actually, we need bloodwork on Smith."

"Will patient Smith report to the triage desk again, Smith."

*no answer*

I walked out to find him. His family says, he's not here. Where is he? The bathroom.

I sprinted into the men's room. Someone was in the stall zipping up his pants.

"Mr. Smith?"

"Yeah, yeah, I'm here."

"We need a sample from you."

"Umm.... I was trying, see, and um.... I still can't"

He then flushes the toilet and comes out. What a sketcharoo. Then again, so am I, for following him into the men's room.
"Well, we need to draw blood from you too."

"What's the rush, man??"

"Excuse me?"

"Why you so in a hurry?"

"We've got a lot of sick patients here, Mr. Smith. We work fast."

I noticed he wasn't holding his stomach or groaning, that is, until we got back to the triage desk and he startled me with a sudden gasp of agony in front of the nurse.

Ah ha. A faker. Soon after, he left without being seen.

Ms. Lame

I called her up a few times to draw labs and for a urine sample. She suddenly decided she didn't want to walk anymore and plopped down in a wheelchair, refusing to get up again. I wheeled her to her bed, at which point she got up, rubbed her behind, walked to the bed as normally as anybody and said, "dang that doggone wheelchair gave me a pain in the a** cheek!"

Mr. Plug:

Stuck a q-tip too far into his ear. His was the first ear I've ever irrigated. I dislodged a large green, waxy plug occluding his eardrum. It took two rounds of blasting warm water in his ear to flush out what must have taken several years' worth of work to compact. He winked at me and said, I am ready for round 3 if you're the one doing it. Aww.

Mr. Sleepy:

He was just sleepy. He wasn't sure why the EMT's brought him in. He felt fine, really. Alert and Oriented x4, just really groggy. We were also wondering why he came in until the EMT's mentioned alcohol. He breathalyzed .443. Holy moly! He wins for the day.

All in all, a good day. See y'all tomorrow.

S

Land of Opportunity

Happy 4th of July to everyone! For all of its bad reputation abroad, America is wonderful. Americans are wonderful. They live by a few fundamental truths and a relatively simplified way of thinking, having been brought up on a steady lack of need. But of course, there is no lack of desire in this covetous, materialistic society, but that is beyond the point. It is a country where the rich are thin and the poor are fat. It is a country where soup kitchens are in almost every city feeding the homeless, and where Emergency Departments everywhere must accept anyone, by law, and provide medical care.

But why do I choose today to spew mushy speeches about why America is great? I love its holidays. What's more, I love working on its holidays. People with mild/bs complaints also want to spend the beautiful day outside with their families. Any other day, they would roll into the emergency room, crumpled in fetal position looking miserable, but no, it's a holiday today. They will enjoy the day (and let me enjoy my mandatory holiday shift) by staying out, eating, drinking, laughing, like anybody else.

My holiday in the ER was filled with real emergencies- things that couldn't wait, things that threatened lives- things that we as the staff actually expect to do there. What's more, as an extra bonus, gone is the clutter of drug-seeking hopefuls, even our regulars decided, perhaps, to drink more responsibly with family or other homeless folk in the streets, celebrating the birth of this great nation. I'm glad they didn't show up on their normal visiting schedule.

My patients on that beautiful day were grateful, polite, even absurdly apologetic for being sick. No, that's what we're here for- you are what we are here for. Isn't it funny how the sickest patients are also the quietest and least assuming? They did not complain about wait times, they did not complain about the temperature, or the quality of the food, or the wait they had to endure before they could eat. They smiled at me and appreciated the little gestures I made to increase their comfort. I was taken aback by the thanks- I had grown too used to doing these things, then slinking away to avoid being verbally assaulted about pain medication or the location of their doctor. Two of my patients even asked me to visit them on my next day at work, if they were still there. By HIPAA, I can't look them up once they've left my department, but I was touched that they'd want to see me again. These are the patients I say good-bye to at the end of my shift- to wish them the best of luck from the bottom of my heart. They are not only good patients, but good people that should really stick around to keep this world a decent place.

So Americans have enjoyed their long weekend, but the peace will not last. The weekday after any holiday is usually horrendous. As I put on my emotional armor in preparation for work, I can only hope that luck will smile upon me and save me from drunk tank duty tonight!

S

The Midnight Munchies

This is me after work:

I can't help it! As soon as I step foot in the door, I feel immediately ravenous. During work, I might be so busy that I don't feel hungry for hours at a time. Other days, I might stash candy in my bag and sneak them out one by one. I might go and buy yogurts and eat oranges from dissembled patient lunch boxes. Occasionally, I might snag a juice box for sudden dizzy spells or dips in blood sugar.

One thing that has really changed significantly since I started this job is my eating. Visually, it's resulted in a net gain of about 20lb. I don't really mind, but it's really interesting how it happened.

At work, we get a 30 minute lunch break, so I have gotten used to scarfing things down. At home, in a more relaxed atmosphere (and with more food available), I still scarf things down at a rapid rate, but at an increased time interval and increased amount. Also, in the middle of the night, it's hard to gauge hunger. I've eaten half a rotisserie chicken once without realizing it (and two bowls of rice, a bowl of soup, everything doused in copious amounts of sriracha, and some cookies). Whoops.

Also, I've started eating junk that I never ate before. Since I've noticed it, I suppose it's time to change my cookie-monster ways. Alas!

It was a great night in critical care; update in the morning! Meanwhile, it's time to get another snack.

S

Too Sweet

"Hey, can you go to pedi side and find me numbing cream so I can start an IV?" A nurse asked me.

Uh, sure... it was an odd request, but interesting. I came back to see the child it was for.

Just kidding, it was for room 9, a man in his 60's. The nurse and I walked in to see his glaring face.

"Now I'm gunna tell yous right now, I ain't gonna be nobody's pincushion. There won't be no stick stick stickin', you got that? I won't do it without numbing cream, so yous better go and get it now. And after this, tell the doc I'm ready to go home."

"Well, sir, I just brought the numbing cream. Please be patient with us because we're trying to help you." I said in my most calming voice. He glared.

Oh boy.

The patient has a baseline blood sugar of 400mg/dl every day. For normal people, the range is 70-100mg/dl. He came in today because his sugar hit over 500. Having such a high baseline is extremely dangerous and can cause raging infections and organ failure. His limbs were swollen to at least twice their size, scaly like old tree trunks, and darkened, like he had stuck them in molasses, then Oreo cookie crumbs. There were numerous open sores, like ulcers, pink and unlikely to heal. He didn't seem to care, though, and thoroughly resented being in a hospital. "I'm fine," he snarled, "can't wait to sign myself out of this ****hole."

It was already late in the evening, almost 2100, but in trudged some family members and a young toddler as we were going to begin the process. He ignored us now (thankfully) and started cooing to his grandson.

Grandpa: "Come 'ere. You's a bad boy, y'know that? A bad boy. But it's ok, if anybody messes with you, you say **** 'em."

"**** em," the boy repeats

Grandpa: "Ahaha, that's right, **** them"

Boy:"**** them" (stop saying that! says the mother)

Grandpa:"Pay 'em no mind. you can say **** them too"

Boy:"**** them."

Grandpa: "**** 'em."

Boy: "**** 'em."

The nurse I was with was losing his cool. He had young children at home. I watched the red slowly creep up his face at the exchange. "**** 'em!" "**** 'em!" "**** them all!" "**** them all!"He was still searching for a good vein, finally finding one on the wrist. He cleaned the site, but couldn't take it anymore.

"Excuse me sir, there are some very sick patients next door, please stop yelling- they don't need to hear that."

Our patient jerked his hand away, and shoved his blanket aside, pulling out his penis. "I'm gonna pee. now"

I ran for a urinal, and he peed, nonchalantly, in front of everybody. Finished, he handed it to me with a huff, as if it disgusted him, then went back to cooing at his grandson. The urine dipped positive for lots of proteins (bad sign for kidney filtering), ketones , lots of glucose, and blood.

I handed my 'numbing cream' to the nurse. It is actually quite cool- a refrigerant, if you will;

It temporarily freezes the area of contact, turning the skin white, distracting children from the pain of an IV insertion.

"**** that's cold!"

He barely felt the IV, which is good, but unfortunately it was only good enough to draw some labs, not good enough to use for fluids.

The nurse went out to the hall and recruited another nurse. We returned for round 2.

The patient rolled his eyes, yelled loudly about how terrible this place was, flailed, but to no avail. The doctor came in once more to cajole him and his family did too.

"I'm a let you know- this is the LAST time I'm gonna get stuck, you hear that?"

The nurse looked for a site, cleaning the skin with an alcohol wipe. Filthy! He showed it to me. Sixteen alcohol pads later with furious scrubbing, the alcohol wipes were still coming back black and dirt-like.

"What are you doing? Scrubbin my skin off?"

"Sir, it needs to be sterile."

"You don't need to scrub so hard."

"Well, sir, it's dirty." Oh boy, this nurse had a snarky sense of humor.

He jerked his hand back again and screamed some profanities. "Sir," I ventured, "we are really doing this for you- you really don't want to develop an infection, ok? We're trying to help you. It'll be over really quick, and look, we'll use the numbing stuff again."

He pulled the blanket down again. "I'm gonna doo doo."

"Come on, sir, are you really gonna whip that out in front of everybody?" The exasperated nurse asked. The family took this as a cue to say good night to grandpa.

I rushed out to look for a scat pan.

Coming back, we were to try again.

"So, where are you from?" I tried to distract him.

Grandpa: "Down South."

"Oh, I love it down there, people are so nice."

"You got that right," he smiled, "where you from?"

"well, I grew up right around here."

Grandpa: "really??"

"yeah, hard to tell, right?"

Grandpa: "I grew up here. I got the **** outta here when I could, boyyyy, ain't never comin' back. I'm here to see the family, then gettin the **** outta here."

"I see."

By now, the nurse successfully inserted an IV in the finger and drew the rest of the labs. Unfortunately, he was going to need another IV site- perhaps by ultrasound. Speak of the devil- the transporter was there to take him to x-ray and ultrasound. He left the room and we all looked forward to trying again when he got back.

I sprayed the numbing canister at the back of a co-worker's scrub pants and heard a yelp as the cold seeped through. I think I found a new toy. :-)

S

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

Rapid Triage and Friday Night Dance Party

A giant walked up the ambulance bay, flanked by 4 nervous-looking officers whose heads only reached the man's shoulders. He was smoking something, but thank goodness he was clinically sober. He didn't need to hop onto the stretcher at its full height, just bent his legs and sat down. The thing was higher than my natural waist. He also had to duck his head to come into our ambulance bay. Later, someone asked- he was 7'2"-7'4" plus 8" of fro. That was a lot of basketball potential, once upon a time.

Then we had 5 drunks in a row. One of them breathalyzed .413. My personal record breathalyzing a patient was .530. Keep going, sir, but you win for this evening.

People just kept pouring in. At one point, we had 6 people lined up on EMT stretchers with no space to go between them to take vital signs. The waiting room was filling up, and nurses from other sections kept trying to commandeer me to do things for them.

Someone changed my name on the assignment sheet again; I clearly saw someone else wrote my name in the drunk tank. I told charge, but she couldn't do anything about it- so ironically, without a dinner break of my own, I was feeding drunks who snapped their fingers at me and demanded food, then sneered at what I gave them. What entitled homeless bastards.

The mad urinator from last night was back. He pee'd himself again and stripped naked as the day he was born. We gave him paper scrubs so he could be on his way. I stopped him at the door, though, because he was carrying a restraint bag like a purse; he sighed, emptied it into his plastic patient belongings bag and walked out. Yup, nice try, but I caught you.

Everyone else back there was pretty much good-natured, except for the pretender. He came in, eyed me up and down, then suddenly yelled,

"Owwwwwwwwwwww! Owwwwww!! My appendix! My lung! My esophagus! Owwwwwww!"

He looked at me hopefully, then sighed, plopped on his side, and went to sleep. Apparently he faked a few seizures earlier.

Makes me wonder what happened to the singer... he was on visit 400something, but has since stopped coming in. Maybe for the best.

S