Medical News

Assembly Line Medicine

Or alternatively titled: Why I Don’t Watch TV.

Nearly every medical show irritates the piss out of me. That’s why I can’t watch those shows.

Chicago Med doesn’t appear to have any nurses- the doctors do everything.
I saw one show where there was a car accident near the hospital and the doctors ran down the street to the scene, snatched the extrication tools from the firefighters’ hands, and extricated the patient from the car.

This is how it works-

  • the patient comes in and is triaged by the nursing triage team.
  • The patient is taken to an ED bed. The nurse assigned to that bed conducts the initial assessment and orders some basic tests, and maybe even a few medications.
  • The doctor reviews the patient’s chart and orders some additional tests and more medicine.
  • Then we wait for the results if testing and imaging
  • More medications are ordered and the patient is either admitted or discharged

The doctor may appear to see the patient at any point in this process, or may not. There are times when the patient may not even see the doctor until hours after they arrived. It doesn’t mean that the provider isn’t evaluating you- it means that some maladies don’t require him to physically be in the room for most of it.

Not so on TV. On television, the doctors are waiting outside for the ambulance, then they run into the ED with the patient, frantically shouting orders. People see this, and when they come into the hospital are shocked and angered that it doesn’t work like that.

I get at least one patient each day who asks: “So when is the doctor going to come see me? I’ve been waiting for an hour.” In reality, the doctor and I have been in constant contact, you have an IV, blood has been drawn, a CT scan was ordered and done, you have received three or four medications, and we are awaiting the results of all of that testing. It’s remarkably efficient, fast, and maximizes the wise use of everyone’s time.

Even shows about EMS and firefighters is nothing close to reality. I once watched a show where a paramedic needed to deliver a shock to a patient in cardiac arrest, but the patient was lying in a puddle of water. He then placed the paddles on the patient’s chest (paddles are largely a relic of the past) did a handstand on those paddles to get out of the water, and shocked the patient.

I can’t tell you how many times someone has said to me: “Why aren’t you doing X? It always works on Greys Anatomy/Chicago Fire/Rescue 911.” People watch this stuff and think that it’s a documentary.

The few times that my wife tried to get me to watch shows that cover topics in which I have some knowledge, I spent the entire time rolling my eyes and making comments. She doesn’t watch them while I am around any more.

The only thing that all of those shows get right is that there are tons of people who work together that are having romantic affairs. Every hospital seems to have a doctor or two who enjoys diddling the nursing staff, and there are plenty of young nurses fresh out of school who think that they are going to bag themselves a doctor husband, not realizing that they are the fourth or fifth nurse he has bedded this year.

At this point, I just assume that every show on TV is BS. Then there are the people who Google their symptoms or malady and want to know why we aren’t doing what Google recommends, but that is another topic entirely.

By Divemedic, ago

Permissive Hypertension

I am going to take this time to explain how strokes are treated in the hospital. I am going to make this understandable to the layman, so there will be some things that get simplified, or even omitted to make this easier to understand.

Strokes are the fifth leading cause of death in the US, so treating them is an absolute must. When people have signs of a stroke in the Emergency Department, the rules say that we have to get them a head CT within 10 minutes. The CT is looking for bleeding in the brain, which is called a hemorrhagic stroke. About one in eight strokes is caused by bleeding in the brain. The other seven are called ischemic strokes and are caused by blood clots.

Immediately after the CT scan is done (the patient is still in the CT imaging room), they are interviewed by a neurologist to see if they are showing signs of an ischemic stroke, meaning one caused by a blood clot cutting off oxygen to the brain. The nurse does the evaluation at the same time, and each of them come up with what is called an NIH score. They then compare scores and, if different, they discuss why. The idea is to give the score that is most advantageous to the patient. An NIH score measures the likelihood and severity of a stroke through a score that ranges from 0 to 42. The higher the score, the more severe is the stroke. A score of eight or higher means that the patient gets screened to see if they are a candidate for TPA administration.

TPA is a miracle drug. It breaks up blood clots, and allows blood to again flow, saving brain tissue from death. If administered within the first 4.5 hours of a stroke first beginning, the patient frequently leaves the hospital with no permanent disability. Sadly, many people with stroke symptoms wait too long to come in and are not candidates for this therapy.

If they are having a stroke, but are outside of that 4.5 hour window, they are admitted and we see just how much brain function they have lost. Then they are discharged to be rehabilitated and taught to live with their new disability.

In 84% of cases, patients who have just had a stroke will see their blood pressures greatly increase as the body tries to use this pressure to force blood past the clot that is cutting off blood to the brain. This process actually reduces the amount of damaged brain tissue in an ischemic stroke, reduces the amount of permanent disability, and decreases patient mortality due to ischemic brain tissue.

The risk of this is that the large increase in blood pressure greatly increases the chances that a blood vessel will rupture, causing a second, hemorrhagic stroke, and that second one is often fatal. I believe that a hemorrhagic stroke is what killed my mother last year.

Since 2019, the American Stroke Association and the American Heart Association both recommend that a patient with an ischemic stroke that isn’t a candidate for TPA administration be permitted to have high blood pressure for the first 24-72 hours after the stroke while being closely monitored. The only high blood pressure to be treated in these cases is a blood pressure higher than 220/120. In those cases, the patient should be medicated to reduce blood pressure by 15%. This is called permissive hypertension and is the current way that hypertension in stroke patients is being treated.

The problem is that this is not received well by older medical professionals, who have spent their lives thinking that “high blood pressure is bad” and want to reduce blood pressure no matter what. They just haven’t remained current in their clinical knowledge, and secure in their ignorance, will violently defend what they have always done, even when that has been shown to be the wrong thing to do.

I recently had a stroke patient with a BP of 263/152 and had formed a plan in conjunction with the doctor to lower her BP slightly to 220/110 using medication. Another nurse (who used to be a charge nurse) came over and started a loud shouting match, telling me that I was being dangerously lazy in not controlling the patient’s blood pressure. She accused me of being a shitty nurse and reported me for poor patient care.

I produced all sorts of studies showing that I was right, so I won’t be getting in trouble, even though the QA department agreed with her, trying to tell me that blood pressures of over 200 are too dangerous. They pointed out that the units on the floor have a policy of not accepting patients with a blood pressure that high. I told them that maybe the policy should be revisited in light of current literature.

Why? Because medicine is evidence based, and the evidence and current literature is on my side. I presented my nursing plan and the current literature to my department head, and she agreed that my treatment was in keeping with current AHA and ASA guidelines.

That required me writing a long dissertation to support my position. It wound up being a 460 word essay, complete with references to the AHA and ASA guidelines, as well as referencing multiple studies carried out since 2020, showing that patient outcomes are better under these guidelines.

It’s cases like this that show why good nurses make a lot of money for the level of education that they have. I’m probably going to present my case to the hospital’s clinical standards council (one of whom already spoke with me and thinks its a great idea) and try to get the policy changed. It’s a stupid policy that is likely killing people. The bonus is that, if I am successful in forcing the change, I get a raise and I also get published.

By Divemedic, ago

ED in the Aftermath

Hospitals have a hurricane plan in Florida. The employees of the hospital are split into two teams: Team A, and Team B. Team A reports to work about six hours before the storm begins and remains at work until the storm has passed. Team A is divided into a day and a night shift, and they sleep in unused rooms of the hospital for the duration. Team B reports to work once the storm has passed, and works shift work until the hospital returns to normal operation. Team B gets to go home when they are not actually working.

There are benefits to both teams. Team A gets paid for the entire time they are there, and even though the rate of pay is lower while you are sleeping, you ARE still getting paid to sleep. Even when Team A is actually working, there isn’t really much work to do, as no one comes into the emergency department during the storm. During Hurricane Milton, there were 98 nurses on Team A, and they had a total of 12 patients.

Team B gets to go home when their shift is over, but your home may not have power, and the hospital is usually really busy. You definitely earn your money. There are no mid shifts on the hurricane teams- there is only Day shift (7 am to 7 pm) and Night shift (7 pm to 7 am).

The team you are on is up to you. In March of each year, they ask everyone what team they would like to be on for that hurricane season. I would rather be home caring for my wife during the storm, so I always select team B.

Team A reported to work at 7 am on Wednesday. They stayed at work until Friday morning at 7 am. That’s when Team B came in. I was on Team B days for Hurricane Milton. I was assigned to the Red zone, and I got the three lowest numbered rooms: room 4, 5, and 6. Since they are the lowest numbered rooms, you have two jobs- you support the nurse assigned to the three trauma rooms and take care of the sickest patients.

Let me tell you, there was a lot of sick people in the aftermath of Milton. On day one, every sedentary 50-something year old man who was trying to clear storm debris found out whether or not his heart was healthy. I had a parade of middle aged men who reported the same complaints- “I was working outside, cleaning up, when all of a sudden, I got dizzy, cold, and broke out in a sweat, then my chest and left arm started hurting.”

I sent half a dozen patients to the PCU on day one. I was slammed with unstable cardiac patients with high troponin levels who had to be Heparinized. The very first patient of the day had been clearing storm debris and felt tired, so went inside the house to lie down. There was a generator running in the garage. When the wife went inside, she found him lying on the floor, gasping like a fish. He didn’t make it. His CO levels in his blood weren’t really elevated, so it looks like a heart attack from exertion. Hurricane related death.

I went home exhausted, got home at about 8 o’clock, and was in bed asleep by 8:45.

Then came day two. That day was stroke and sepsis day, on top of the heart attacks. Some of the high points:

  • I had one patient who was on four different drugs for the heart attack she was having, and I took her to the ICU with a central line, heparin, amiodarone, and pressors running. I was glad to get rid of her, she was taking a lot of effort to care for.
  • Then there was the nursing home patient who pulled out his G tube during the hurricane.
  • There was a woman who came in complaining of a headache, dizziness, and vomiting since Wednesday night. At first I wondered why triage sent her to my rooms, but they must have had a hunch. Her head CT showed a large area of infarct (dead brain) in the rear of her brain. She had a stroke during the hurricane, but didn’t come in until it was to late to give her TPA. The damage is permanent.
  • A guy who was working in his yard when his 4 pit bulls who were overstimulated from all of the activity decided to use him as a chew toy. He had over 40 puncture wounds, including his cheek being ripped open to the point where you could see his teeth while his mouth was closed. They also tore off his right ear, and tore a 3 inch gash in his right thigh. The man’s brother came in an hour later to tell my patient that he had shot all 4 dogs because he couldn’t get them under control.

Most of the day, our 100 room department had only 30 or 40 patients. So, at 3:30, admin decided to send a quarter of the nursing staff home to save money. I took over one of the trauma rooms, so that I had Trauma 3, 4, 5, and 6 as my rooms. At 4 o’clock, all hell broke loose. I went from having 2 patients to having 4 in less than 15 minutes- with one of them being my sickest of the day:

A woman who was in septic shock that came to me unresponsive with a Lactic acid level of 3.4 and a white blood count of 24. Her blood pressure kept dropping- at one point to as low as 72/50. Her rectal temperature was 96.4 degF. Cold sepsis as it is called, is a very ominous sign. Patients in cold sepsis are frequently on death’s door, especially when they have a low blood pressure. She got three IV lines, 3 liters of lactated ringers, as well as the antibiotics Vancomycin and Rocephin.

I got her stabilized, but then she started shitting watery diarrhea every 5 minutes. I had to stay late to help night shift clean her up. I also earned points with the night shift by inserting the Flexi Seal for them. If you don’t know what that is, it’s a plastic tube you stick up a person’s ass, and it directs fecal matter into a bag. Ah, the glamorous side of nursing that no one tells you about.

So I got home from day two at about 9 pm, and was in bed by 9:30. I slept in on Sunday.

That’s it for my work journey from Hurricane Milton.

By Divemedic, ago

Three days in the ED this week

Day One

I was working in the red zone when a patient came in and went into cardiac arrest in the lobby. I went to the trauma room, and was put in charge of the code cart. That means you draw up the medications, run the defibrillator, and deliver shocks as needed. You don’t usually look at the patient, as you are busy with other things. When I did look over, I realized that the patient was the 30-something year old son of an old friend. The last time I saw the kid, he was still in high school. The entire time we worked him, his wife was in the room. We had offered to take her to wait in the chapel, but she refused to leave the room. When the charting nurse said, “Time of death, 6:17” the wife let out the most anguished scream. It was something that you felt all the way to your soul. I spoke with his father, who told me that parents aren’t supposed to bury their kids, and asked me in anguish what he was supposed to do next. It’s much harder to stay detached when it is someone you have known since he was born. I had trouble sleeping that night because of it, and woke up at 3 am before staring at the clock for an hour and a half. I wound up only getting about four hours of sleep, not nearly enough after a day like that.

There was the man who lived in a group home because he was mentally retarded. He came in with stomach pains, but couldn’t tell us what was wrong because he is mostly non-verbal. It turns out that the group home served him refried beans the night before, and he needed to take a gassy deuce.

Day Two

Day two saw me assigned to the green zone because I think that they were feeling sorry for me from the previous day. That day was rough because I was sleep deprived. A woman was angry because her teenaged daughter was diagnosed with COVID, and we were sending her home with instructions to take Tylenol. The woman wanted us to write her a prescription for the Tylenol so Medicaid would pay for it, because she didn’t want to pay for it herself. So of course we did, gotta have those Press-Ganey scores to get paid under the Obamacare rules, you know. Your tax dollars at work.

Day Three

I was in triage for day three. A guy came in complaining of abdominal pain. Said he hadn’t seen a doctor about it. Then I pulled his chart, and an alert came up that he had just been seen at another hospital 30 minutes away. He was just discharged 35 minutes before for the same problem. He said in response, “Yeah, but they didn’t give me what I want.” He has been seen 14 times in one ED or another over the past three months. But we can’t say no, thanks to EMTALA. So again, your tax dollars at work.

I slept in this morning, then went to a local eatery for some chicken fried steak and eggs breakfast. I paid extra for onions in my hashbrowns. Now I have to get prepped for our next hurricane, set to arrive on Tuesday. So this is all of the posting you get today.

By Divemedic, ago

Lies

The left is claiming that a woman who died after she elected to get an abortion is the fault of Republicans. Amber Thurman died while she was getting an emergency D&C that was needed because she took an abortion pill and had a reaction that caused a large amount of hemorrhaging. The timeline is telling:

Thurman discovered she was pregnant with twins in the summer of 2022. She made the decision to kill her unborn child after she had moved out of her family’s home into a gated apartment complex and had plans to enroll in nursing school. A child would have spoiled those plans, so the most convenient thing that she could do was kill the inconvenience.

Thurman had wanted a surgical abortion in her home state, but at nine weeks she sought care at a clinic in North Carolina. The clinic gave her mifepristone and misoprostol, otherwise known as an “abortion pill.”

After taking the pills, Thurman experienced cramping, but her condition worsened over several days with vomiting and heavy bleeding. She was transported to Piedmont Henry Hospital in Stockbridge, Georgia, on the evening of August 18, where doctors discovered she had not expelled all the fetal tissue from her body.

She died during the surgery that followed. Georgia’s maternal mortality review committee, which includes 10 doctors, concluded that there was a “good chance” that Thurman’s death could likely have been prevented if the D&C had been provided earlier.

Maybe, but then again, maybe not. There is no way to be certain. What caused this woman’s death is not a delay in surgical intervention. What caused her death is that she took an abortion pill, but that doesn’t fit the narrative that the left wants to portray.

About a year ago, I had something similar happen when a woman who had taken an abortion pill came in complaining of vaginal bleeding at two in the morning. Over the next hour, I had to give her 2 liters of saline, a unit of fresh frozen plasma, four units of packed red blood cells, and a unit of platelets. All together, that adds up to about 4 liters of fluids- or roughly her entire blood volume. That’s when the on call surgical team came in and took her for her emergency D&C.

There is a price to pay for taking these drugs, and they are much higher risk than the left wants you to believe that they are.

By Divemedic, ago

So there I was…

I was working in Yellow the other day and triage sent me an 80 year old woman whose family brought her in because she had pressure sores on her bottom. She’s a paraplegic and had bleeding pressure sores on her hind end, because frankly, the family doesn’t turn her enough.

We get her into the bed, and the patient responds only to pain, her blood pressure is 86/42, her HR is 70 and V paced, her RR is 40. I called a medical alert. Less than a minute later, I had a doctor, two staff nurses, a charge nurse, a paramedic, and a technician. I asked the Dr for orders to give a liter of fluid, and it was granted. He told me to give a liter of saline, followed by a liter of ringer’s.

I started two IVs and drew blood cultures, a CBC, a CMP, a lactic acid, and a type and screen.

For my medical readers: Her labs came back with all sorts of critical results. Her hemoglobin was 4.3, lactic acid 3.8, troponin was 202.

By this time, she had almost liter onboard and her blood pressure was 76/48. I got the doctor to order 1 unit of emergent O+ blood, followed by two more units of type appropriate blood. The only problem was I had to discontinue the fluids because she was showing signs of fluid overload and congestive heart failure. Her SpO2 began dropping and I had to start oxygen.

It wasn’t long before she was on Levophed. I tried talking to the family about end of life and signing a DNR, but they insisted that she was “a fighter.” I spent the next 8 hours trying to keep her alive and stabilize her. I had two other patients who had to wait awhile because nearly all of my time was being taken by this patient. When she went to CT, I went with her, and the report came back showing all sorts of gas bubbles in her chest and abdomen from the large amount of sepsis. None of the surgeons would touch her because she was too sick. Simply put, she is dying. I was incredibly happy when the time came to transfer her up to the intensive care unit.

By Divemedic, ago

More Reports from the ED

This past week was a busy one in the ED. We are seeing a lot more cases of COVID as of late. I was working in “fast track” one day, which is where our minor illnesses go. I saw six different patients who were positive for COVID. None of them were serious enough to be admitted, and were sent home with instructions to get lots of fluids, rest, and take OTC medications to control symptoms. So we are seeing lots of COVID patients, but none of them are seriously ill.

If you want to know more about how emergency medicine is done, read on. If that doesn’t interest you, then there will be other posts.

The ED is organized chaos. There is a lot that goes into a large emergency room that is seeing hundreds of patients a day. How this is accomplished is that the ED is divided up into zones, each color coded to indicate the acuity of the patients within it.

Gray Zone

Gray is not really a treatment zone. This is where patients are checked in and triaged. The gray nurses decide which treatment zone a patient will be sent to. It’s staffed with two technicians, two nurses, and a registration clerk. Security is also here, because this is where people decide to be assholes. If the ED is really busy, a doctor and an additional nurse (called the pit nurse) get assigned here and began treating the easiest cases out of two exam rooms (called the pit) in gray. The idea of the pit is for people with simple requests like toothaches, wound rechecks, and medication refill requests be treated and discharged within 30 minutes of arriving.

Green Zone

The “Green” zone, also called Fast track, is a subunit of the ED and is entirely made up of patients who the triage unit believes can be treated and discharged in less than two hours. Fast track itself contains three sections:

  • Treatment. This area consists of 12 rooms staffed by two or three nurses. The nurses here are usually nurses who are still learning how the ED works. It’s a great area for nurses new to the ED to develop the skills and workflow that makes the ED more difficult and challenging than some other units. The idea of this area is to get the patient assessed, treated, and discharged in less than two hours. The team nursing concept is used in this section, so nurses see a lot of patients in a very fast paced environment. It isn’t unusual for a nurse to see 30 or 40 patients in a 12 hour shift.
  • If the patient is not really ill, but we are waiting for some test like the results of a CT scan or some lab work that will take a bit of time, they are moved to RPZ (Results Pending Zone) to await a further clinical decision. RPZ is like purgatory, where a patient waits for the results of those tests to see if they will be discharged or admitted. The patients here have received medication and have been assessed and found to be stable. RPZ is staffed by a single nurse and can contain as many as 12 patients awaiting results, who sit in reclining chairs and watch TV while they wait. There are two rooms here that are used so that the providers can talk privately to patients to discuss lab results.
  • Holding. This area is for those times when triage got it wrong, and the patient will be there for longer than two hours. Things like blood administration, medications than take awhile, or patients waiting for an inpatient room on one of the hospital floors. Holding is three rooms, staffed by a single nurse. When I am in fast track, I am usually (but not always) the holding nurse.

Fast track moves a lot of patients through it, over 150 patients a day. The cases are usually mild: toothaches, STI’s, lacerations requiring stitches, FLU like symptoms, and other mild illnesses go here. For that reason, this section sees more COVID cases than any other zone. If the pediatric patient load decreases to the point where they close pediatrics, the children go here for treatment. If patient load drops further, fast track gets closed at either 11pm or 1am. There is one charge nurse that is assigned to both green and purple together.

Purple Zone

Across the hall from green is the purple zone, or pediatrics. It is exactly what it sounds like. It consists of 8 rooms and a pediatric triage room. This zone is staffed by 3 nurses. This is a secure unit that is located behind locked doors. When the ED is especially busy with pediatrics, the gray nurses will send pediatric patients to a separate waiting room so they don’t have to be seated next to the druggies and other people in the gray zone waiting room.

If there aren’t enough pediatric patients, this zone gets closed at 9pm, and pediatric patients go either to the red, orange, or green zone. It’s rare for them to go anywhere other than green, as kids usually aren’t all that ill.

Yellow/Blue Zone

This zone is called “subacute” but it usually is anything but that. With a name like subacute, you would think that this area has patients with complaints that aren’t that serious, but you would be wrong. Some nasty stuff happens in here, and I swear that some of the rooms in this area are located on top of an Indian burial ground or something, because they seem to be cursed. If Red/Orange is full, then any other high acuity patients who come in wind up in Yellow or blue. This area contains 36 rooms that are staffed by 9 to 12 nurses, a charge nurse, and 1 or 2 technicians.

Red/Orange Zone

This zone is called acute care. The patients who are deemed to be the sickest come here. If EMS brings in a patient in cardiac arrest, they come here. Severe respiratory distress comes here. This unit contains 36 rooms that are staffed by 14 nurses, a charge nurse, 3 paramedics, a respiratory therapist, 3 patient care technicians, a clerk, and a lab technician. Three of the rooms are called trauma rooms and are kept empty as much as possible. The most unstable patients are initially put in them, stabilized, and then moved to other treatment rooms as soon as possible. Additionally, there is a room that can be accessed through a decon shower room, and a psychiatric room that is the classic “rubber room,” but thanks to a court case from another hospital deeming that to be inhumane, that room is no longer used for that purpose.

Other staff

Staffing for providers varies, but there can be as many as 6 doctors, a pharmacist, and 2 midlevel providers (Nurse Practitioner or Physician Assistant) in this ED. Also included here are 2 pharmacy technicians, some transporters to move patients around, and two janitors for cleaning rooms. There is also Xray and CT, which are staffed by another 6 technicians, and the lab which is staffed with 4 more technicians, as well as the radiologist who is offsite, but interprets all of the imaging that is done.

So there you have it- a 100 room Emergency Department that, when fully staffed, contains 10 providers, 40 nurses, 20 or so technicians, and 8 to 10 other personnel.

And yeah, this is a filler post, with most of the content written for the day when I needed a post but didn’t feel like writing that morning. (To be honest, it’s because I am out mowing the lawn and doing other honeydew chores this morning.)

By Divemedic, ago

This Week in the ED

I had a few notable events happen in the ED this week.

  • A man was brought in by EMS who was gorked out of his mind and was under arrest by the local gendarmes. He was tweaking hard. Unsurprising to anyone who saw him, his urine tested positive for amphetamines. It seems that he used some meth, beat up his elderly roommate, stole the roommate’s gun, and walked around the neighborhood firing off shots. I spoke with the first cop to arrive, and he told me that he ordered the man to drop the gun, and was only going to tell him once. To treat him, all I could do was give him 2mg of IV Ativan every hour to keep him calm. Two days later, he was still in the PCU and still feeling the effects of the meth.
  • A woman came in with abdominal pain and symptoms that made me think she might have COVID. I tested her for it, and she did in fact have COVID. When the results of her abdominal CT came back, she had a large mass in the head of her pancreas that was consistent with cancer. There were also masses in her liver and lungs. The Dr and I had to tell her and her husband that she likely won’t live to see Christmas.
  • A 95 year old woman came in after driving her car through the front of a store. She got the gas and brake pedals confused. In her defense, when she learned to drive, there was no brake pedal. All you did was say “Woah.”
  • Had a 16 year old with mono, and another one who had spinal meningitis.
  • A 30 year old jumped out of the car he was riding in and attacked a motorist in an apparent case of road rage. The target of his ire put the car in drive and ran over his ass. He became my patient, and it took up more than two hours of my time getting IVs, X-rays, giving pain meds, and all of the other things needed to treat an idiot with a blood alcohol of over 300 and a pair of broken legs. He is going to need surgery.
  • We got a new director for the ED last month, and she announced that nothing would change. This week, she laid off 25 nurses. The very next day was my day off, and they called me at home to ask me to come in and work a 12 hour shift for overtime.

Posting has been and will be thin. I have a major project coming up that I need to work on.

By Divemedic, ago

Stories From the ED

A young adult woman comes to the ED, having been brought there by her mother for having abnormal behavior. Displaying many of the classic signs of mental illness, she is obviously having a mental health crisis. The mother even said that she woke up in the middle of the night with her daughter standing over her with a large knife in her hand. The doctor considered her to be a threat to her own or someone else’s safety, and subsequently signed the Baker Act paperwork.

As I always do, I am explaining to the young lady that she is being held on an involuntary 72 hour psychiatric hold. I am trying to explain the rules to her- she can’t wear her own clothes, can’t have any of her possessions with her, she will be searched, and she can’t go home.

As I am doing that, the mother keeps hovering and trying to talk to her. The girl keeps trying to negotiate and delay: begging her mother to take her home, asking to go to the bathroom, and looking over my shoulder at the exit, obviously planning an escape. The mother keeps insisting that the girl can’t change clothes with me in the room, needs to be permitted to use the bathroom without a male present, kept blathering on about the woman’s rights, and said that she wanted to “take it all back” and sign her daughter out. I explained that it doesn’t work like that. Legally, once the doctor signs that order, the only person who can cancel it is a psychologist, and that is after the patient is examined by that psychologist. The doctor who signed the order can’t even rescind it.

After over an hour of trying to deal with this, I finally told the mother that she needed to be quiet for a minute so I could do my job. She replied with: “Wow! You’re rude.” I called security to come over so we would have someone that is wearing a body camera there for backup. Then I told the mother: “This is how it’s going to be: Your daughter, my patient, needs to be supervised and has to be within sight of a staff member at all times for her own safety. She doesn’t get to decide who or how that is going to happen, as that is all done according to state law and hospital policy. She is going to take her clothes off and put on these paper clothes voluntarily, or I am going to cut her clothes off and dress her by force. If she resists, I will sedate her. If you continue to impede my ability to provide patient care, I will have you removed. This isn’t a debate, it isn’t a negotiation, and this isn’t a courtroom. That’s how it’s going to be. You can either let me do my job in caring for your daughter and I will allow you to stay, or you can keep getting in the way and I will ask you to leave.”

The patient continued to argue and resist, so I gave her 10mg of Haldol after which we got her dressed in the paper gown, and put her down for her nappy nap. I put a hospital employee in her room as a safety sitter. Mom filed a complaint, and when the charge nurse came over to talk to me about it, she said, “I was waiting for you to have enough of that. You were more patient than I would have been.”

By Divemedic, ago