A Budding Emergencist
Sunday, December 17, 2006
  Nurse, May I Have A Word?

Hulk is getting ANGRY!


In response to Doctor, May I Have A Word?:

First off, good post by Emergiblog's Kim McAllister.

Second off, much respect.

Third--sharps. I agree wholeheartedly. I absolutely endeavor to police my sharps myself every time. I even get a little miffed if somebody wants to "help" by picking up my sharps. This messes up my count. I don't want to be stripping the bed only to find out my sharps were picked up without telling me. Anyway, go ahead and remind me. I do not mind. I will thank you for reminding me. Safety first. Go ahead and remind me to wash my hands, put in orders, finish the paperwork, too. I don't mind.

"Please let me push the drugs, doctor." I had a learning experience emphasizing this when I first pushed 5 of morphine. Silly me, I simply unplugged the I.V., fitted the syringe into the clave, and pushed 1 ml of morphine directly into the patient's hand I.V. I watched, fascinated, as the patient's arm turned bright red, creeping up from the hand. My previously AAOx3 patient said, "ooooh, I'm itchy," and again I watched in amazement my patient's rapidly deteriorating mental status. I stood there like a statue, transfixed by this metamorphosis, until a small, still voice echoed in my head--"Histamine release!". I snapped back to reality, and calmly asked the same nurse who had given me the morphine, "25 of benadryl I.V., please. Stat." The entire episode lasted about a minute, and the patient just as dramatically recovered after Benadryl was given. Lesson learned. No blood, no foul. Omerta!

So yeah, you should give the meds, nurse. Not only to avoid above rookie-type mistakes, but also for the sake of documentation.

However, don't look at me crosseyed when I want 4mg of Versed "to go," (accompanying delirious patient to MRI) or "5/2/1" mg of Haldol/Ativan/Cogentin "just in case," (okay, I'll evaluate the 250 pound gorilla in florid psychosis. No problem!) or the 20 mg of labetalol "for the road," that I want to be armed with as I escort my 92 year old pretzel with Afib/RVR to telemetry.

Sorry if I bogart the chart at times. I always try to ask. Doesn't really apply in my ER cuz we got a pretty good EHR, with patient tracking and results reporting in-line with nurse's and doctor's notes, in real time. Slam!

Respect for the triage and intake ritual. This usually isn't a problem for me--we are usually so swamped, I am 8 patients behind all the time--no chance to be chomping at the bit for more work. Almost a non sequitur where I work.

You get first crack at the new patients coming in. Believe me, I am grateful you do this--forewarned is forearmed. Vital signs are vital, as they say. In fact, unless the patient is crashing right there, I want you to spend MORE time doing this. More than once I've been blindsided by "historicus alternans," or inappropriate triage acuity.

On my last shift in the ER as an intern this year, I picked up a 65 year old with a chief complaint of "don't feel well", triaged to low acuity. The patient had been waiting 4 hours or so. The history was almost impossible to obtain--the patient was verbal and calm, but confused. Relatives were in other states, and no primary care doctor could be elicited. No significant medical history or medication list could be elicited. The only corroborating story coming from the helpful but clueless neighbor who found the patient.

The patient's answers to all my questions were noncommittal, vague, or just plain "I don't know". Unsure of what I was looking for, I proceeded with my exam, which revealed an obvious global cognitive deficit, and mild motor weaknesses in the right upper and lower extremities. Patient in no acute distress. Vital signs rock solid.

Puzzled, I presented the patient to my attending, lamely attempting a synopsis of the patient's present illness, with a working diagnosis of dementia, geared towards my plan of "social" admission until home care or nursing home placement could be arranged. As my attending stared at me in disbelief, I became painfully aware of how pathetic my assesment really was.

"Confused with unilateral weakness, huh? What's her baseline?" my attending snapped.

"Uh, she lives at home by herself."

"Do you think that lady," nodding towards the patient, "could shop? Clean? Cook for herself?"

"Uh, no."

"So it's fair to say that this is an acute change in functioning."

"Yes." I surrender!

"Did it occur to you that this patient had a stroke?"

I look at him in horror as my stomach churns.

"There was no history!" I blurt. "It took me 45 minutes to get a chief complaint!" My final defense--blame the nurse: "She was triaged to the lowest acuity! The chief complaint was 'don't feel well'!"

We upgraded the patient to the resuscitation area and activated the stroke team. I was struck by the ridiculous absurdity of this sudden rush to action, given that this patient had been docilely parked in a far corner for 4 hours. Coupled with an indefinite time period, anywhere from 3-4 hours prehospital, put her well out of range of any thrombolytic or interventional therapy.

The head CT showed a large fronto-parietal infarct. The temporal sparing, ironically, is probably what prevented her being promptly diagnosed--no aphasia, and the other clue of acute onset of weakness was clouded by the confused and noncommital history.

The attending saved most of his anger for the nurse for missing the (now) obvious signs of stroke during triage. The fact that I missed it too did nothing to assuage his righteous indignation, since the nurse in question had 20+ years experience.

I am reminded of four rules I learned in surgery (okay it wasn't all bad);

1. Don't trust anybody.
2. Do it yourself.
3. Do it now.
4. Write it down.

As far as waiting to take report from EMS until the nurse is present, I'm right there with you.

Thanks for the tips!

LOL - I love it!!! Thanks for responding!! I never look twice at any doc or nurse who wants meds on standby, or "to-go" just in case!

Fore-medicated is forearmed!!!! : D
Greta post about the sometimes difficult but always amusing interactions between nurses and docs
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Emergency medicine, from the beginning of a new doctor's career.

Location: Big City, Metropolis, United States

Walk softly and carry a big vocabulary. Don't be inhuman. Find and greet God in every person you meet. The patient is the one with the disease. Do not get distracted. Charity begins at home. Do good and be happy. Don't just do something, stand still. Wear sunscreen. Don't get anyone pregnant, and don't go to jail, young man. Budget your luxuries first. You don't know what you don't know. People like learning, they just don't like being taught. When in doubt, go out. When life gives you lemons, make lemonade. Honey attracts more flies than vinegar.

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