Wednesday, March 28, 2007

NurseWilliam Gets Thinking Blogger Award

I have been by tagged by The Angry Medic for the Thinking Blogger Award meme. This is a singular honor for me, particularly since it comes from among my peers in the medical profession.

Here is the lovely emblem:


The award originated with The Thinking Blog.

In turn, I would like to tag the five bloggers who have given me the most food for thought:

Jennifer Gallagher of Now For Something Completely Different;

Stefan Sharkansky of Sound Politics;

Ed Morrissey of Captain's Quarters (whom I credit for getting me interested in blogging in the first place);

Hypnokitten and PaedsRN at Mediblogopathy;

And last, but certainly not least: The Cassandra Page

Note that not all of these bloggers focus on nursing issues, but they all do one thing most admirably: they make me think. Thus they are most worthy of this award.

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Monday, March 12, 2007

Night of the Knotheads

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.

Behind Door Number Three was the Queen of the Knotheads: a woman who had a history of anxiety, panic attacks, and chronic pain. She was also 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. 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…