Wednesday, August 31, 2011

Hey where is the ambulance!

I am At the nurse’s station just finishing up on some paperwork on a patient that had been discharged, when I look up to see a police officer and what I would assume to be a prisoner. I am taking it for granted that he needs either a medical clearance for jail or some sort of psych consult. Already interrupted and paperwork is not my favorite thing to do anyway, I pipe up with a “how can I help you?” The police officer who could match me on size and stature states, “I don’t know I am just transportation.” Well this certainly is not helpful and I do not think that he cared about being helpful. I asked if the patient was under custody and he said no. He just needs to be seen. Ok I get that but seen for what and what is going on that led you to bring him into the hospital. Now this is when it all comes out. He has been doing meth. and he has been gambling for three days straight. Now mind you as the police officer and I are having this short conversation the patient in cuffs is pacing back and forth. I am getting a big sense of agitation and I invite him to sit down in our holding room down the hall. He obliges for now. As he enters the room the police officer says can I go now. Puzzled I look at him for a second before I answer the question. Is he in custody? No, he states. Well then I don’t think I can make you stay, however if he gets out of hand I will be calling back very soon. At this small hospital that I work they do not have fulltime security. Security has to be called in. Now in this ER there is one doctor and two nurses and one unit clerk. It can get busy fast and scary fast, but for the most part it is a critical access hospital and remains pretty slow. Of course I have an uneasy feeling over the police officer leaving and I have a sense of impending doom. The police officer was very adamant about his request and asked the same question. Can I go now? Well I started getting irritated with him and stated, “Go” I can’t hold you here. It was like I was at the gym or out on the ball field as this officer is sizing me up and down. I thought oh well I will just deal with what comes and I can handle it and if I can’t I just call the police and they will come back. Now the patient is calm at this time and obeying commands, however he has crazy eyes and I can tell this will not last long. The police officer uncuffs him and he leaves out the ambulance doors which have a sensor and open automatically. The patient remains in the holding room and I get some vital signs on him and limited questions are asked because I can tell that with every question he is getting heightened and I need to limit questions to what is important and forget the rest for now. This is when it starts to crumble. The doctor, not being busy pokes his head in because we only have one other patient in the er. That on patient is going to be transferred soon. So soon in fact that the ambulance crew is in the er and packaging the patient and getting ready to leave.  What’s up Rod? , he says and I give him the story that I got. He stays in the room with the patient and starts his assessment. I use this opportunity to go across the hall to get my equipment for drawing blood and collecting urine from this guy. By the time I get the equipment and come back to the room, the doctor is already done and is stepping out of the room and out into the hall and as he passes me he says. Holy crap that guy is crazy. I just simply state in a sarcastic manner back “you think”. I step into the room and he is standing up. I say where you going? “I got to go” No you sit back down and we are going to get you calmed down. No I am leaving. Well you can leave, but I am just going to call the cops back and they will bring you right back here. “I got to go”, he says again. He is fidgety and wide eyed with sporadic movements. Now I am no slouch when it comes to confrontation or scuffles however you choose your battles and I really have no right at this time to restrain him. Even if I did have the right to restrain him I would not do this safely by myself. I can see that he is determined to leave and each second with me gets him more aggravated. He leaves out of the room and down the hall to the ambulance doors. Remember these doors open automatically which is convenient however not safe. I get that and I also get that I am a pawn in the whole hierarchy of list of things to fix or change in the ER. I follow and am stating as I am following him that I am calling the police. I turn and yell down the hall at my wide eyed unit clerk at the nurse’s station, call the police and get them down here. This act slows me down and I am not directly behind the patient now and he has already out the double doors. I quickly pick up the pace however cautiously not to get struck from a blind side or if he is possuming me and waiting outside. As I step outside I am surprised to see that he is out of view already. Now mind you that some of ambulance bay is taken up by an ambulance that is parked and waiting to get loaded with a patient that is about to be transferred. I look to the right and glance by the small storage shed that is located in that direction. Nothing, he is not there. I look to the left of the ambulance and nothing also. I am forced to look in the front of the ambulance. I am just interested in telling the police the direction that they can go to track down this guy. As I am being cautious and step to the right of the ambulance and slightly in the front of it I am interrupted in my heightened thoughts by the sound of a door closing. Looking toward the noise I see the patient now in the cab of the ambulance. Now I am pissed and it is all over in my mind. I rush to the passenger side and have the door open quickly. This is when things start moving in slow motion. Now I know the medics are not so stupid as to leave the keys in this thing. Wrong, they are that stupid. I yell at him and not holding anything back. I think I yelled get the f$%^ out of this ambulance. I reach for the keys with my left hand and that’s when he grabs my left arm. I give him three shots to the face with my right hand and as he is screaming and wrestling with me. I jump over the center console and position myself behind him and start to choke him out with a rear naked choke. Now I am five foot nothing and weigh a good amount and I have this guy way quicker than he thought would happen. I am alarmed at the strength of him and also alarmed that I don’t think I will have him choked out before he starts this ambulance. In my rush to get into the ambulance my door has been left open and I am interrupted in my struggle with someone yelling my name. Rod, get the hell out of there. The ambulance has been started and is lunging forward by this time. It is now time to abort and my senses come back to me. The person yelling at me was the doctor outside of the passenger door and I jumped from the moving ambulance and escaped. The passenger door shut and the ambulance lurched forward. It barely missed my commuter car parked in the back and rounded the corner down the road. I stood there with the doctor and he and I just had a puzzled look on our face, like what the hell just happened. About that time the ambulance crew showed up with the patient to be transferred and just looked at us as we were standing in the spot where the ambulance had been parked. The patient on the stretcher said, “Hey where is the ambulance”?

Tuesday, August 30, 2011

Useful tools for the ER

Very important tools that I work with:

1.      Tarascon Adult Emergency Pocketbook

2.      Rapitube Adult and Pediatric RSI dosing guide

3.      Dose Right Adult Vasopressors/Inotropes dosing guide

4.      Of course my IPhone with downloaded app. Rapitube

Tarascon is the quick guide for treatment of most disease or disease process in the emergency room. It will quickly guide you through without any candy coated bullcrap.

Rapitube: this is for RSI Rapid sequence intubation and this is pre-calculated

Dose Right: this is for the vasopressors/inotropes that you would use in shock, ACLS, etc. It is also pre-calculated and if you can do these in your head or even quickly without this tool wow to you.

Here are some quick links:

Search for tarascon emergency department quick reference guide

The emergency room Dr. is not your personal physician


noun /iˈmərjənsē/ 
emergencies, plural
1.     A serious, unexpected, and often dangerous situation requiring immediate action
§  - your quick response in an emergency could be a lifesaver
§  - times of emergency

2.     Arising from or needed or used in an emergency
§  - an emergency exit

3.     A person with a medical condition requiring immediate treatment

This is the definition of emergency. I understand living in the United States where the culture is I get it my way and I get that now. At no time is it an emergency because of your lack of planning or not being a prudent person. Geography is also not an emergency. I began in the days way before EMTALA and I realize the abuse that was done by some. I believe that if someone takes the ambulance into the emergency room for a non-emergent problem then they should get a ticket. Oh no…. we would make someone unhappy and they would make a complaint when the hospital does a call back. Maybe you should not be in an ER if you say this upon arrival:

1.      How long is this going to take, I want to go the movies after this.

2.      I just need a pregnancy test.

3.      Can you give me a prescription for Tylenol? I don’t want to pay for it.

4.      No I can’t pay my six dollar co-pay, I don’t have any money. (this is stated as she proceeds to play a game on her iPhone)

5.      Can I get a sandwich? (within seconds of arrival)

6.      I need to get my ears cleaned; I have a lot of wax.

7.      Is this a pimple? (yes….yes it is)

Am I bitter? Hell no, I am thankful for what I have and will have. People are people and their small interaction with me will never change their lifetime of how they cope. It will also not change their thought process or what they perceive as an emergency, so I laugh and shake my head. I used to fight it and educate, argue, bitch and that elicited complaint after complaint. I sift through the non-emergent patients for the hidden legitimate sick one. Oh and they are always there lurking and testing you. I never let my judgment inflict bad decisions on medical care. I have had several grazes and brushes where I could have been burned. This would have ended up being a detriment to the patient and all  my fault for missing it due to disregarding the patient.

Now that is only a very small example, however you get the just. Hang on and buckle up people because I have got 23 years of shit in my head and it all needs to come out. I will be posting rants, stories, complaints, views, philosophies, and my general beliefs that are related to the Emergency Room. It will be wonderful so hang on. If not then it will be therapeutic to my mind.