Posted on 03/12/2007 10:19:53 PM PDT by 60Gunner
They came out without warning. They seemed to have been dumped off by the busload (both short and long). They clogged our ER triage area all night long with non-acute complaints. They also filled the ER treatment areas with the high-acuity consequences of their stupidity. They caused highly-educated and battle-hardened ER doctors and nurses to bang their heads against the walls in frustration and dismay. They became fodder for endless hours of break room stories for months to come.
The ER was awash in knotheads.
On the night about which I write, it seemed like the Great Big Knothead Circus had come to town, and one of those little clown cars had pulled up to the ER door and the knothead clowns just kept on pouring out. All that was lacking was the calliope playing that silly circus song. (You know the music, don’t you?)
Dee-dee doodle-doodle dee-dee dee- dee, Dee-dee doodle-doodle dee-dee dee-dee…
I felt like if the ER became a haven for the knotheads, my assigned rooms were Knothead Central. It was just wrong. Everyone marveled at how many stupid people decided to hurt themselves at the same time. It's as if they were doing their things and the Great Cosmic Knothead spoke to them all at once, saying:
"Okay, everybody! One, two, Three...!"
I can’t remember the last time that happened on a non-holiday, moonless weekday between paydays. It wasn’t Friday, so the psych units weren’t dumping their patients. Tent City was in a different part of town this month. Mardi Gras was long gone, and there was no WTO convention or peace demonstration going on.
I strongly suspected that some ER staff member had incurred the wrath of the overly-sensitive Gods of Emergency Medicine by uttering the heretical words “Gee, it’s kinda quiet today.”
Behind Door Number One I had a teenage boy who decided to blow through a red light while flipping off a police officer who was at the same red light. He got so caught up in watching the police cruiser’s flashing lights in his rearview mirror that he forgot that it was rather important to watch where he was going. So he drifted off the road at around 50mph (in a residential area) and into a stand of new-growth alder trees.
This would not have been all that bad, had it not been for the fact that behind those spindly alders lurked a rather large old oak tree. We were going to be picking pieces of tempered glass out of his head for awhile, and he will henceforth have the smile of a hockey player.
Behind Door Number Two was the teenage girlfriend of the teenage boy behind Door Number One. Evidently, she dared her boyfriend to blow through the red light. So it is now proven that not all the stupid decisions of teenage boys are self-generated. It often happens that stupid teenage girls are behind them. She also had deep facial lacerations and a broken nose. I hope Mommy and Daddy can afford a plastic surgeon.
Oh, I almost forgot: both kids had alcohol on their breath and their parents in their rooms...
Behind Door Number Three was the Queen of All Knotheads: a morbidly obese woman who was well-known among all the ERs in the county to be a malingerer and drug-seeker. Her primary doctor was an excellent physician who had a reputation for being careful yet effective in dealing with patients who had chronic pain issues. But evidently, my patient had taken umbrage with her physician’s caution. So on this day, she arbitrarily decided that her doctor did not prescribe enough Methadone to cover her pain. One 10mg tablet of Methadone was not sufficient. (I’d have been intubated after taking that much.) So she took ten tablets. When her “friend” (a scruffy-looking cuss if ever there was one) found her, he called 911. The medics found her in complete vascular collapse and respiratory arrest. They could not find a vein. So they punched a 16-gage intra-osseous (IO) needle into her right tibia and pumped 2mg of Narcan into her while bagging her on 15 liters/minute of oxygen. As if on cue, she snapped back into our world in less than a minute.
When she arrived at my ER, she was agitated and begging for Ativan. “Pleeeeeeeeeze give me Ativan,” she whined. “You have to give me Ativan! I have a history of seizures!” She kept thrashing that leg with the IO needle in it. I got in her face and made her look at me.
“Take a look at your leg,” I said firmly, "Look at your leg right now." She looked at her leg. “Do you see that thing sticking out of it?”
“Yes,” she replied.
“That’s a great big honking needle that goes right into your bone. If you bonk that against something, it’s going to HURT. And if you knock it out of your leg, it will HURT and it will BLEED a lot. Savvy?”
She looked at me defiantly and declared, “I will calm down if you give me Ativan. I need it. I have a history of seizures!”
Oh, yeah, lady. Hurt yourself. That'll teach me, I thought.
I found it hard believe that she did not recognize me, because I had been her nurse on many of her previous visits to my ER. And she was alert and oriented to person, place, time and situation. She was pretending not to know me. But I sure recognized her. And I knew her long, long history of visits to the ER (more than twenty in the last 12 months, either for “pain,”,“anxiety,” or because she "just had a seizure"). She did not have a history of seizures. She had a history of benzodiazepine abuse. (Ativan is a benzodiazepine.)
She was squirming, whining and kicking, and that IO needle had to stay in her leg, so we put her in restraints per MD order. She of course did not like that, and asked us to please give her Ativan if we were going to do it. The MD told her that considering she had overdosed on narcotics, it was necessary to keep her conscious and alert. Therefore, Ativan was out of the question.
“But I have a history of seizures!” the woman whined.
The MD looked up from a sheaf of papers and replied, “No, you do not have a history of seizures. I looked at your history and nowhere in there is a single seizure documented.”
“Well, my boyfriend (the scruffy gent) saw me have one!” The MD and I looked at the boyfriend, who suddenly developed an acute interest in something on the floor.
“OK,” the MD said with a grin. "I see you go to Medical Associates.” The MD looked at his watch. “They’re still open. I’ll give your doctor a call and ask him about your history of seizures.”
“He won’t know!” the woman shot back. "He doesn't know what he's talking about!"
The MD flipped once more through the patient’s history that he had printed out before coming into the room. “You have been seeing Doctor So-and-So for more than three years, according to our last encounter less than a month ago. That's a long time to stick with a doctor who doesn't know what he's talking about.”
“Please.” The patient pleaded, evading the challenge. “I need Ativan to calm down. I promise I’ll be still if you give me some Ativan.”
“Nooooo, I don’t think so,” the MD said with a smile and in a wickedly smooth tone as he shook his head. “We’ll take the restraints off as soon as we can, but we have to make sure that you can stay calm first. But I am not going to give you any Ativan since you just nearly killed yourself by taking too many narcotics. We have to keep you awake and alert.”
The MD turned, signed off on the “restraint order for medical necessity” form, wrote for a bolus of one liter of warm normal saline through the IO access and for a new IV line to be started ASAP, to be followed by the removal of the intraosseous needle. Sure enough, the patient was able to stay calm in spite of the fact that we had not given her any Ativan. She never so much as gave a twitch. We were able to remove all the restraints within the hour. I started a peripheral IV and removed the IO needle without incident. I then called report to the Progressive Care Unit RN and get the patient ready for transport upstairs.
While at the nursing station, I sat next to the MD as he called the patient’s doctor and talked to him about our patient. I could clearly hear her physician shout “She did what?!” through the phone and our MD caught my upraised eyebrow. Our MD then asked about the patient’s statement regarding a history of seizures and apparently got an earful of spleen-venting from the poor guy. After saying, “Uh-huh,” “I see,” and “Well, that’s good to know” a few times, our MD thanked the patient’s doctor for his time and hung up. He then drew a deep sigh, rubbed his eyes, and then related to me how the patient’s doctor explained the whole “seizure” thing.
At some time in her past, when she had collapsed after an overdose of some unknown drug, her “friend” told the EMS responders that he saw her twitch a couple of times and that it must have ben a seizure. Subsequently, every neuro test in the book was done, and at no point was anything found to be indicative of seizures. Yet the patient had been claiming to have seizures ever since as a means to scare ER doctors into prescribing Ativan, which the patient’s physician refused to prescribe without objective data to support her claims- much to his credit. But since then, she has been hopping from ER to ER in search of a doctor- and a nurse- who hasn't met her yet. And even if she doesn't find one, she'll pretend they never met.
The patient never got her Ativan. She got sent upstairs, relapsed, the Methadone outlasted the Narcan, she got more Narcan, and when the Methadone finally wore off she ended up being discharged the next day. She’ll probably be shopping for a new primary physician after this.
The ER treatment room she vacated was filled with another knothead before I even got back from transferring her upstairs. The new patient, a leathery-faced 32-year-old woman who looked all used up, was a GDFD (Got Drunk, Fell Down) from one of the local taverns who did a faceplant against a barstool. She had a 7cm full-thickness laceration extending from above her right eyebrow well into her hairline. The slick, white connective tissue covering the skull was laid bare underneath. She was a bloody mess, and of course- lucky me- she was also belligerent.
Great fancy Moses, I thought. It's not even 10 PM yet! I sighed, picked up her chart, and walked in.
Dee-dee doodle-doodle dee-dee dee- dee, Dee-dee doodle-doodle dee-dee dee-dee…
ER Nursing Stories Ping!
So do all nurses hate their patients, or just ER nurses?
Burn out?
Another excellent installment in the "I should have gone to vet school chronicle s."
So they punched a 16-gage intra-osseous (IO) needle into her right tibia and pumped 2mg of Narcan into her while bagging her on 15 liters/minute of oxygen.
That's going to leave a mark.
...wrote for a bolus of one liter of warm normal saline through the IO access...
What was the significance of the saline solution being warm?
I used to be an ER nurse and I wasn't amused. When you get to this point you need a break.
Drunks and drug addicts. How *do* you maintain?
Thank you for the latest saga.
Look. This was an unusual night, that's all. I love what I do. I look forward to going to work. This was simply a night that had every single nurse on the shift shaking their heads.
I don't hate my patients. It bugs me when they do willfully stupid things. Our ER was full of people who did willfully-stupid things. Does relating the story make me hateful?
I wasn't trying to be unkind. I've been there.
Wow. Talk about irony... Thank you for your post. I never knew what that song was before!
Sometimes compassion is manifested through tough love.
Why didn't EMS use a Fast1? It's to my understanding that that route is faster than any other for IO administration of fluids.
Nice going, 60G. What you guys/gals do is important...keep telling yourself that on nights like this one. It always gets better, well, usually...
It sounds like you have transplanted most of the patients I see on a regular basis in the ER where I work. Calling their acts stupid is not IMHO,an indication of burn out. Stupid (running a light , gigging a police officer, hitting a tree) is STUPID AND BEING compassionate and warm and fuzzy all over does not make it NOT STUPID. HERE in my workplace this week We have been hit heavy with Psychiatric patients. One man cut his testicle off with a pocket knife AND while being brought into the Emergency Department by his family, gouged out his eye with his finger. Another came into the ER, went into the bathroom and hanged himself- and died. I am sure this is George Bushs' fault, or MAYBE JULIANIS'..
Whew! That's good then. It's just that too many good nurses are leaving nursing and I was thinking , great, here is another one that has had it. If I had read who wrote the article I would have just sent you an "are you ok?" private post, so I apologize for that. Peace, ok?
She had another male patient who had collapsed at a disco. She discovered that he was wrapped head to toe in saran wrap, and had a salami taped to one thigh.
Great stories, I hope we can all learn from these drunk/drugged knotheads' mistakes. You either have the best job in the world or the toughest, and maybe both! Thank you for your service in this vital capacity.
ACLS protocol calls for an IO route if two IV attempts in the field are unsuccessful.
Yeah, but the F.A.S.T. 1 is an IO route. I thought most EMS had them now. It goes into the sternum as opposed to the tibia
The fact that you were your standard professional self and giving her the best care possible while she tried to con you out of narcotics and especially that you refrained from "bumping" that 16 gage needle tells me that you do not hate your patients. Quite the opposite. Even dealing with decent people who are not at their best on a day to day basis has got to be tough. Add in the self destructive knotheads, and I truly don't know you do it, but I Thank God for those of you who do.
You need a lot of patience with these patients, that's all I can say.
I think that beats my RN wife's story of the fiesty
Scripps SD CA labor & delivery doc who would get the ready to deliver mother all ready up in the stirrups, stand between her legs, click his heels together, salute and say:
"DR KILTY AT YOUR CERVIX!"
I have a sister who used to be an ER nurse. She has plenty of stories about patients who drove the docs and nurses up the wall. I'm sure you've probably heard them all. Some are very amusing. Like the young couple who came in the ER with an electronic sexual aid uncomfortably lodged up the rear orifice of one of the pair...and still running when the couple arrived at the ER.
Please add me to your ping list. I don't want to miss a single episode!
Creighton is making a mint from his combination of medical exploits plus mystery...
..you should consider this...you really have a knack.
Years ago, I was all set to be the next Florence Nightingale or Clara Barton...(solely based on the fun time I had as a Candy Striper in our local hospital)
..imagine my horror when I realized nursing is more than cheery smiles & gifting the patients with candy, flowers and magazines!
What a rude awakening when I arrived at a large university teaching hospital!!
I cringed in 'shot class', balked at bedpans, and gagged at my first cadaver!
I, therefore, have the highest respect for those who are truly dedicated nurses.
..I believe they are born to this profession!....and we are blessed to have them!
Awesome story...keep 'em coming! I love reading about stupid people doing the stupid things that stupid people do - stupidly. LOL :)
Sometimes unwinding is obtained by writing about it.
I enjoy hearing from you, keep it up.
"So do all nurses hate their patients, or just ER nurses?"
That was EXACTLY my first thought.
Maybe you should go visit a ER sometime, particularly on a friday or saturday night. I worked as a security guard in a hospital for a year and a half (night shift) while going through school, and 60Gunners' stories are spot on, including his descriptions of some of the visitors your typical ER gets. You would be surprised by the number of visits that drug-seekers and habitial drunks make.
I've been bitten, slugged, spit on, barfed on, crapped on, bled on, etc...etc...Never once did I ever think..I hated them personally for doing it...as most were drugged/drunk out of their minds, or sicker than peach pit eatting dogs.
FWIW-
Whoa..!!
I will be re-certing ACLS here in a few weeks....I will ask about that.
Awesome writing style! Have you ever been published, or would this be considered some sort of heresy in a medical journal?
Blood regulates internal temperature. You want it to stay warm.
Thanks 60G, you made my morning.
FWC + Drugs = Shirley. We had several Shirleys we saw regularly - you know, the ones with the current medical folder 3 inches thick marked "Vol 4"? With the admit sheet showing nothing but narcotocs asdiction/problems/abuse. The reason NARCAN is now sold in 1 liter 'industrial strength' doses....and everyone still tried to help, refferals, etc.
I look forward to the next installment of "Tales of the ER" - and my offer to try and help you get published still stands.
Love your work. Will endeavor not be one of the knuckleheads.
But doesn't this violate HIPPA or something like that?
No names have been given, or any other personally identifiable details. "Teenage boy", "obese woman", things like that are so generic that unless you were there at the time it gives you no clues whatsoever to the actual identity of the person.
I'm inclined to say with that in mind, no HIPAA violation.
If there really is a "60Gunner nursing story ping list" please add me. :)
I love your posts! Sounds like a crazy night.
Thanks for taking the time to write and post them. :)
That's interesting! I watched that episode--love that show.
Now that you mention it, it is ridiculous that they did all the complicated, expensive tests before a pregnancy test. :)
Would they rule out pregnancy just as a matter of course, or because of her symptoms?
Was it a full moon that night? Might explain the influx of bozos.
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