Seventy three

It's October and I try to at least to make a post once a month. Last post was about folks getting shot in the genitals. Let's face it it's very cringe worthy esp if you're male. It's notable and dare I say educational.

Let's keep in mind that Crusty ER Tech ususally blogs once a month with a drink or two aboard.

Aside from a gory story or bitching about asinine nurses ( or docs, midlevels etc) much of what I say goes into the void. Being an ER tech is very much a transitional or dead end job.  So why stay why do the job still for piffile?

One reason is it's better than the ambu. seriously.

You're (that's right buzzed I still know the difference between your and you're) warm and dry in the winter and cool (and dry) in the summer.

I can only say I love the job. Sure I get the occasional horrific code brown and deal with ignorant medical or nursing staff. Often I get looked down upon and people are surprised by my knowledge and experience. Smart charge nurses let me do my thing and ask for specific tasks occasionally. I see and experience a lot more. More is better.

I don't work in your common ER I work in a a large urban area level 1 trauma center which affords me a great deal of latitude. Some days it can be maddening and others it can be uplifting. it's a tough job in a tough place and no I am not blowing smoke up your ass.

For those aspiring EMT types out there. There is more you just gotta push yourself but for those of us who cannot get past the math based courses in college there is no shame in the blue collar ethic of EMS or the ER tech. Keep training, keep pushing no matter what.

Seventy Two

It's becoming a "thing"

Crusty (that would be me) has noticed a trend in penetrating trauma as of late. Penetrating trauma in the sense of the GSW. This trend is far from empirical and purely anecdotal on my part. It comes from what I have been told about and seen over the last several weeks.

This new "thing" in GSW is male pts being shot in the genitals. I can think of 4 off the top of my head in the last several weeks. Now before you readers start saying "Well Crusty obviously a very angry female must have shot this guy in his cock and balls." I will tell you in these cases that you are very wrong. This particular subset of penetrating trauma is not because of some angry female but due to gang violence.

I have been told by people in the know that certain high ranking gang members are wearing Kevlar vests now, that people who want to be the high roller say they wear a vest even if they don't wear one. So because for whatever reason one gang member gets angry with another and they assume the other is wearing a kevlar vest they aim for the genitals.

Smart yet VERY mean spirited.

Yes I know getting shot is in itself mean spirited but jeez to get shot in the genitals intentionally is just harsh. These bullet wounds despite the caliber can be rather damaging because of the soft tissue involved. Also if you are male and see this injury it does as a part of male nature makes you cringe.

I was also told that this is a way to avoid a bigger charge if the shooter gets caught. Makes sense but really I'm no lawyer so I cannot speak to it directly. Seems to me if you point a weapon at a person and pull the trigger no matter where they get hit at that it's gonna be an attempt murder charge from the get go.

Also those of us who work in this business and have the most basic knowledge of A&P know that here are some real important vessels in that region that if they are damaged that the entire volume of blood in the body can be lost very quickly unless there is serious diesel bolus from EMS followed by bright lights and cold steel therapy by a trauma surgeon.

Just some thoughts on the GSWs I've seen or talked about as of late.

Seventy one

PT assault

Lets keep in mind Crusty ER Tech has now had several shots of liquor and decided to post. With that said ....


Recently again I have been attacked by a patient. this time they actually connected giving me a black eye among other scratches and bruises associated with fighting with a pt in a dynamic urban hospital environment.

I encourage you all to ALWAYS press charges against pts of people that attack you. The other is to get trained on how to defend yourself. Often you will get put in a position where you will be attacked, do all you can to defend yourself. Know your protocols, know which drugs work best for chemical restraints and above all know how to handle yourself if and when the system breaks down.  

Reassurance does nothing stay on your toes.

Seventy

The Willfully ignorant Nurse Bass

As promised this next entry is about for the 3rd or 4th time the willfully ignorant Nurse Bass and I have had a run in. In the recent past Crusty ER Tech had yet ANOTHER run in with her. Crusty has tired of this and decided once and for all to slap his cards onto the table and in the most figurative sense slap some sense into her.

Other techs have approached me about her she has said some real hum dingers one of which I will include here:

"Honey we want you here but we don't NEED you here."

this comes from an experienced charge nurse in a large urban ER. Nurse Bass is of the opinion that staff that is certified like EMT, Paramedics and others are not necessary to running an ER. That the nurses, docs and midlevels can do effective patient care with out us.

Let's put it straight the ER tech does a lot of the scut work that is needed to make the ER run effectively. I ain't talking about code browns either. ER techs stock the rooms run paients to the floor and to various places in the hospitals. Meet the ambulances in the ambulance bay. Dispatch ambulances, answer the EMS calls into the ER and direct them (at least in two of the ERs I have worked) Go get oxygen tanks, find anything you need in the ER. In many places the ER tech is taking over the ward clerk job because the paper push is no more. You just need a dedicated person to field and make phone calls and help direct patients ER techs can be cross trained to do that. Need a suture set up ER tech can run down everything the doc needs. Warmers and linens need to be stocked, ER tech has got you. Need scrubs because you are covered in some sort of human goo, ER tech can find you another set of clean scrubs. Need a pelvic set up ER tech has it all on hand. That way the nurses, docs and midlevels can do their jobs and frankly not sweat and worry over menial stuff. All of this is just stuff off the top of my head. So if the ER tech is needed to do the smaller things that help make the ER run smoother.

I think I have proven my point.

Nurse Bass decided to yell (yes yell) at me in front of patients in the waiting room when I was doing something that our bosses boss told me to do. The details are not important but needless to say her tone was condescending as usual and I was in a foul enough mood not to let it pass. Knowing that trying to reasonably resolve things with her proved futile in the past (Which included her calling me a liar and denying the incident took place) I had no other option except sit down and bring in manglement.

I don't really like bringing in manglement because it can turn into a mess and things get put on a back burner. Lately though I have done somethings for manglement that shows the true effectiveness of the ER tech and shows how we are valuable assets to the dept. Plus I have tried to back channel this problem to manglement and still this problem persists.

We got called into the office and there I took off the gloves and dismantled her verbally. At one point I called her an ignoramus. Now it helps that I've been working with manglement a bit more lately and it helps that this particular manager REALLY likes me and is keenly aware of how Nurse Bass is and has been privy to some of Bass's back stabbing attempts to me. As one unit clerk told me recently "Crusty ER Tech you're a sneaky fucker."

Indeed I am.

I won't go into the details of the entire nearly hour session but at one point Nurse Bass tells me:

No shit full stop. I laughed at this. At this point the manager face palmed and shook her head. This among other just as condescending things she laid out. I was not kind to Nurse Bass and my assessments of her interpersonal relations with staff. At the end of the session the manager asked me did I need to say anything else. To which I said "I do believe Nurse Bass has said enough for both of us" Nurse Bass chose to stay behind and talk to the manager for another 20 minutes after I left the office. Bass realized that she had royally inserted her foot into her own ass and mouth.

Since then I have worked with Nurse Bass once and she was rather pleasant. Will this hold? I have no clue I honestly don't know. For now it's good enough for me. I had to expend some political capital in the department which is fine if it makes my day to day in the ER more tolerable.

Lessons learned:

Over the years I have had numerous run ins with nurses of this ilk. Rarely has it turned out for the positive for me. In actuality in rare cases are ER Techs respected. There is a lot of ignorance surrounding what we do and what we are capable of.  Many nurses are really do not know and a few like Bass are willfully ignorant and only see us as gophers who need to shut up and do what we're told. With that said me spending now a few years in this urban ER and knowing manglement as well as I do got me a bit of favor with them. I am by no means an ass kisser but I have shown my worth to the department time and again. This got me a nod and because I followed guidelines, because Bass did not know when to shut up got me a favorable nod. Write shit down and if you're being treated like shit don't blow up esp after trying to calmly resolve an issue just keep plugging way eventually you'll be heard.

Now hopefully Bass will go work in some clinic in the suburbs some place.

Sixty Nine

I was going to sit down and write about how quite recently a nurse told me that it was not in my scope of practice to assess bleeding. Then I realized it was entry number sixty nine and well the number conjures up thoughts of genital injuries.

Genital injuries and the insertion of various objects into the rectum are great fodder for ER and EMS types. In fact the subject of objects inserted rectally has it's own book:

Never read the book, I'm sure you all get the point though. This entry will not be about this because frankly there are shit ton (pun intended) of these stories and when we all gather around the nurses station or after shift for drinks there is a tendency to one up each other concerning inserted objects.

This dear readers is about genital injuries. Now I won't talk about genital injuries sustained during a sexual assault. Those are a sensitive subject and Crusty takes those rather seriously. Male genital injuries are more common because hey let's face it our anatomy hangs out. Again, this is easy fodder for those of us in the business. Less common are the female genital injuries that are not related to sexual assault.

I was trying to remember a real rare genital injury and then I remembered the home bar stool accident.

Way back when I was a new ER Tech I assisted a doc with a woman with lacerations to her vaginal wall secondary to sitting on a home bar stool.

Pt was a mid-50's female. Nice woman. Her husband a few years prior made their basement a home bar with taps televisions pool table and such things that normal bars have including bar stools. The bars tools they had were of the four legged padded top types the ones that you can find in discount furniture stores all across our great nation. The stools got wobbly over the years and the husband said soon they would buy newer better ones. The wife being "thrifty"(cheap) decided to fix the stools herself when the husband was off at work, she got home early and wanted to surprise him with the repairs.

She grabs his portable drill and what screws she can find which if I remember right would have been 2 or 3  inch drywall screws. She screws the legs into the top of the seated portion of the stools which takes the wobble out. She's proud of herself pours up a beer turns on the TV behind the bar and sits onto one of the newly "repaired" stools and it collapses once she puts her full weight on it. She was not a hefty woman, she was weight to size appropriate.

Naturally this hurt then the woman discovered she was bleeding from what she thought was her behind. She thought the screws came up and poked her in the ass. Which honestly I would have thought the same thing. Problem is that she's bleeding a lot. She goes into the bathroom drops her pants and looks in the mirror no holes in her ass besides the ones she already had.

Then she notices that there is blood running down her leg from her vagina. No she was not preggers and lost the baby. She feels inside her vagina and feels the laceration in her vaginal wall. She runs out of the bathroom wraps a sheet around her waist and calls the ambulance. Which of course brings the police and fire too. What can I say it was a slow day in this particular suburb.

Husband pulls up as they are wheeling her out and asks what's going on all he hears is that his wife's genitals are injured and sees the police. The cops assure him that there was a strange accidnet and his wife will explain.  Which she does once they get to the hospital.

Ended up that she had a couple of decent lacs to her vaginal wall secondary to a lot of embarrassment. I had to assist the doc in the lac repair. The couple had some humor about it but the wife was clearly mortified.

The husband and wife decided that night to use the stools for fire wood and buy nice top of the line stools instead for future use. Thus endeth the story.

Next the willfully ignorant Nurse Bass.

Sixty eight

 Ol' crusty got a question here recently:

Crusty (ER TECH), any thoughts on combative patients and ER staff being hesitant to help out to restrain them?

I apologize for the late reply. Every situation is different. Sometimes with enough patience you can talk them down which if possible should be the first thing you do. I highly recommend "Verbal Judo" by George Thompson. Pick up the book and give it a good read and try to re-read it once a year. When I worked the ambu for a major west of the Mississippi river urban agency they sent us all through the training, it changed how I dealt with difficult and violent patients.

You can't always talk them down though and sometimes no matter what you say the pt is altered via a substance of their choice or mental illness (or both) and it'll be go time.

I gotta buddy who works in a left coast state who told me they have an overhead page for a violent page where all males in the area show up to help restrain the violent pt. and there is a standing order for chemical restraints in that situation.

 Where I work at we have a crack security staff who get in there and really do the job.

One really shitty I worked at we had terrible security that just patrolled the parking lots and if a pt really got out of hand the charge nurse would call the cops which may take forever.

Along the way I have learned a series of wrist locks and holds that help control a violent patient. If you wanna go that way I recommend getting trained. People are reluctant to get involved because let's face it's a hospital and we're there to heal not wrastle with pts. Besides that staff often is not trained on how to deal with this type of situation hence the hesitation.

If it is a huge concern organize some fellow staff members and propose a solution to manglement. Then once you propose something dig in and don't let up til they resolve the problem. Never tell someone about a problem unless there is a solution.

Bruh, if ya got more questions about this drop me an email and I'll give ya some more idears.

Above all dude stay safe. Never go in to restrain a pt with less than 5 people (one for each limb one for the head) We prefer 7 one for each limb one for the head one to apply restraints and one to supervise, talk to pt calmly and to medicate. remember I currently work in a very large urban hospital with a shit ton of resources. Other places are not so fortunate

I cannot stress that enough BE SAFE BE SAFE BE SAFE.

Ol' Crusty has got a shift today soas the kids say" I'm outtie". Take care out there.

hopefully that helped you out and some others

Sixty seven

Plumbers, HVAC and other home contractors love retired ambulances.

Ambulances that survive or don't have the box removed and put on another chassis get auctioned and are usually snapped up by these guys for a couple of reasons. The primary one being that the compartments are convenient for them to put tools, fittings and other bits of their trade into and sometimes the electrical systems hold out so that you still have electricity in the box.

One fine spring morning I am standing in the ambulance bay grabbing ass with an ambulance crew and out of nowhere we hear a siren and of course it gets closer and closer. I stay outside to help with whatever comes rolling up.

The ambulance comes screaming into the ambulance bay which in itself is highly unusual emergent ambulances unlike what you may see in the media are usually pretty careful when they pull in because there is usually an unrestrained medic in the back working a pt.

The ambulance looks familiar yet unfamiliar it's a dead ringer for one of the local fire depts but no markings. I'm intrigued and then stunned to see a guy in blue come stumbling out of the drivers side all bloody. He has his left hand elevated with blood pouring down his arm. For some reason my primal brain thought that this ambulance crew had been ambushed and they drove straight to the hospital.

This is not the case.

Turns out that this particular ambulance had been auctioned off a few months before by one of the local FD after having their markings removed. Home contractor snaps it up and uses it. Turns out he cut off some of his fingers in a saw. Instead of calling an ambulance to take him to the hospital he just figured that fuck it, I have a retired ambulance and the fire dept never disconnected the lights and sirens so I'll just drive emergent to the closest hospital and park in the ambulance bay.

I laughed at the reasoning and loved the clear mindedness of his thinking although did not appreciate him driving like a lunatic with one hand the few miles to the hospital. After we got the bleeding stopped and the pt calmed down I moved his vehicle (the retired ambulance) out of the ambulance bay and parked it in the ER managers spot. Security did not dare to tow it because they thought it was an in service ambulance and we all know certain types of clip board nurses don't show up on weekends.

Sixty Six

No. 66

A good ER tech is always watching and listening, that helps them anticipate the needs of patients and their coworkers. It also gives you a leg up on how your co-workers especially charge nurses will treat you. If they treat other people well then you have a good chance on getting treated fairly by that person. Same holds true of the opposite, if they treat their coworkers poorly you can bet your ass they'll treat you the same.

Nurse B-ass is a  prime example. She and I have a couple of run ins and after the first run in I started paying a bit more close attention to how she treats other folks. Yup, she treats others just as poorly over often trivial things including her nurse peers. It's one thing to shit on the ER tech at this point I kind of expect it but your peers...c'mon. She's jumped all over her peers from wanting a stapler to getting a patient she did not want.

When she walks up to me after the shift meeting and assignments and tells me that I'm going to be in "her" area for the day and she's going to see that I'm going to do my job and will be checking on me to insure it. I decide to make a stand. I tell her that I remember a couple of our run ins and that she is a bully and that frankly I'll do my job no worries there but I will not take her trying to intimidate and bully me. She asked for an example and I gave her this particular encounter.

At this point she tells me that "I've never done such a thing" and "I don't remember that." I tell her that I have no reason to lie that I'm not the one that came up to her trying to intimidate her she came up to me and "informed" me unsolicited. She walks off. A few minutes later I am informed by the charge nurse that my assignment has changed to another area. Hmmmm, no coincidences there.

The saga will continue with Nurse B-ass I'm afraid.

A couple of shifts later I had a chance to work a good trauma. Pt is flown in and due to an explosion he has had one of his appendages blown off completely and totally. The pt has no burns and the limb that was severed was not viable according to the flight nurse. Another words it was blown into tiny bits or not enough was found that was worth saving. The pt is brought into the trauma bay and the flight crew has some how gotten their lines all sorts of ways fucked up. Their IV lines are wrapped around everything, the respirator tube, the portable respirator their cords for their monitor in the pt clothes and of course the pt himself. It was one of the worst rats nests I had ever seen. It's my job to help get this mess untangled and help get the patient stripped and get additional IV lines if needed.

I'm untangling the mess and it just is not working we cannot even get him off the flight transport bed it's such a mess. If we snatch out comes the tube and lines a certain no go. the pt is transferred onto the trauma bed and I turn to work on this shit. We cannot move the flight stretcher too far because all the flight crew stuff is wrapped up in that stretcher as well. There is no real estate on that side of the patient which by happenstance is the same side the amputated limb is on.

Let me stress here that the patient despite this horrible injury is hemodynamically stable for the moment. The field applied tourniquet has stopped all bleeding his VS are 130's systolic and a little bit tachy at just over 100 with about 250 cc of NS in. We had a little bit of extra time still gotta get to the limb though. I'm exasperated with this mess and tell the flight medic if this shit does not get cleared up soon then I'm gonna cut his monitor cables. I'm not mad just like "Dude WTF?" we get their monitor clear and we get the pt on our vent the IV lines are all tangled but fuck it lets move on and see where we can put some uncrossed "O" blood in. The lines work until a surgical resident snatches something and pulls out the line we are using for blood. We had a second line fortunately.

These things happen.

I talk to the flight medic and apologize for getting terse with him and we're  all good. Never have seen a flight crew's monitor and lines SOOOO tangled.

Pt makes it to OR and goes under the bright lights of trauma surgery.

This trauma gave me a chance to work with Nurse Star. Nurse Star is fantastic! She is the type of nurse that anyone worth a shit should aspire to be like. Over the time I've been at BCH she's been promoted a couple of times because she's that good. But today she comes in to do something else like clip board nursing paperwork and pokes her head into the dept to see what's up. Naturally because we are short nurses she drops the paperwork and takes an assignment. This means she'll be here extraordinarily late because she has some sort of office thing due the next day.

 Most of the staff now only knows Nurse Star as a clipboard nurse and don't believe me when I tell them that she is more than capable at bedside. Watch and learn I tell them. She works this trauma then afterwards helps us straighten the room then helps the newish nurse finish up the chart. All while fielding calls related to her clipboard nurse job. Awesome! Crusty ER Tech misses working with Nurse Star and says so often.

So ends the shift and this post. I'll cover the rest of what I intended to write next post. The life of the Ol' Crusty ER Tech continues.

Sixty five

Preview for yous guys...

-Nurse Bass, bully extraordinaire.

-Massive hemorrhage and your fucking lines.

-Falling in love with the job again and the abusive co-dependent relationship I have with it.

-Training...always training.

-Nurse Star drops the clip board for a day, rolls up her sleeves and shows us why she is a true leader and no matter the day or hour, a superior nurse.

-Good techs are watching always watching and listening.

Sixty Four

Quote of the day overheard from a senior resident bragging to junior residents and medical students:

"I did my rotation in this ER for a month. Let me tell you THAT was traumatic!"

Just another day in BCH for the rest of us.

Sixty Three

The Cleaner

No matter where you work we all have one of these. One of the pinnacles of OCD behavior, cleaning. In our business it's not a bad thing in fact it's encouraged. There is no fault in it, washing hands is a good thing. Keeping sterile and clean fields uncontaminated is fantastic. The person or persons I am talking about is the cleaner who wipes down everything at the beginning of the shift.

Again not a bad thing. Its just in my dumbass ER tech perspective it's a waste of time to clean the computer, desk area and phones once. These things are just gonna get contaminated again and again so in reality you must clean them again and again. It's not like magic you clean something once in an ER and it stays clean. In the rush to take care of patients often folks clean these common office once and that's it. Just like the paper towel under the doughnut and covering your coffee lid with yet another paper towel is going to keep what ever wild funk from getting into your food and beverage much less keeping a hungry homeless guy from eating said doughnut or guzzling down your triple espresso iced mocha chai latte whatever coffee drink.

So I don't clean any computers, phones or desk tops unless they're visibly soiled. I can't tell you if this is from apathy or laziness. Probably a mixture of both. I wash my hands religiously and scrub equipment within an inch of it's life when necessary. Our decon room practically has a hot water fire hose in it. I've been accused of being nasty by a fellow ER tech but I take what he said with a grain of salt because well my nasty ass never got sick or infected from a patient (knocking wood here).

May I present to you "tech A" aka 'The Cleaner'

Tech A was a decent tech the did the job well or at least good enough his special talent though was keeping himself and anything within six feet of him clean on a level on par with the best of the OCD cleaner types. He was and still is a good guy even though he hated to be shushed, ya know "Shhh" like when you're trying to hear important info. He hated shushing and he would not get shushed if he kept his fucking mouth shut. That's besides the point.

Tech A would sit down to chart and his OCD cleaning would kick in. Mind you he is charting an IV which after logging in on this particular system takes like two maybe three clicks and you're done. A minute maybe two at the most. With Tech A it was a 10 minute ordeal of wiping down everything and charting wiping down everything again and then putting a sign on the computer saying that this was his computer for the shift and not to touch it.

We all have our quirks

Naturally he'd get miffed at someone (usually me) when they used "his" computer during the shift. He would get completely unhinged if a patient touched his computer during shift. Naturally being the jerk that I am known for being from time to time I would throw his sign away and have other people use his computer. I hand him a weighted empty canister of wipes if he felt the need to clean and pretend to lick the phone if he said he needed to use it. He told me I was nasty and I replied "Funny that's what your mom said."

He did not talk to me for a week after that one. Possibly because the truth hit too close to home.

He'd tell the other cleaners that they'd get sick because they were not cleaning good enough, he would tell me it was only a matter of time before I died of some horrific infection because I never cleaned our computers, phones or desk areas. I told him that since I did not clean as well as he did that my immune system was built up better than his and I could fight off infection better. He snorted at this and gave me a hard time, that is until he got C.Diff from a patient.

C.Diff is a real gut churning experience. Well at least from what Tech A said. He lost a considerable amount of weight and his cleaning habits doubled. I was willing to concede that any body can get c.diff all it takes is just some bad positioning and rotten luck and well...I'll spare you the rest. he came up to me and said that I was still wrong in his opinion. I told him fair enough and let it drop until he got pink eye/conjunctivitis.

He had to miss a bit more of work after that. When his infection cleaned up I again offered up my little lame opinion on the insane amount of cleaning he does. I told him that perhaps some of the industrial cleaning agents that we use maybe got into his eye and caused this recent infection. He was none too pleased with my thoughts.

I was pleased by his anal retentiveness. It was a near constant source of amusement for me.

In the end clean everything until it's damn near atomized if you like (or til the letters are worn off the keyboards) Me? I know how many times we use each others computers how the patients hack, cough and slobber all over the phones. So why bother? I wash my hands many many many times during the shift and always keep gloves in my pockets.

Me nasty?

Nah.

Sixty two

When ER patients stay WAY beyond their discharge.

I get a lot of guff from patients and co-workers about cutting off patient armbands after they have been discharged from the ER. Patients and their family members and I think the public in general sees the arm band as a sort of strange badge of honor. Ive had serious "discussions" with patients about the validity of an armband once it's cut off. "I have to show it to my boss" I always explain that well we also gave you a work excuse and your name is still on the arm band even after we cut it off.

I've been told by a lot of co-workers that it's trivial bullshit on my part to cut off armbands, naturally I scoff at that and then tell them this little story.

I was at my first ever ER tech job after getting off the ambulance and really dug the hospital I was working at. It was a moderate level one on a weekend night crew that was seemingly always understaffed so naturally all of were close. In fact even to this day if I run across another person who has worked at that ER ever I give them a lot of deference. I digress though.

I never thought twice about cutting off armbands then. In fact I would think it would be safe to say I never did it was not standard practice. Then all hell broke loose after someone did not cut off the ER arm band of a particular patient. When I say all hell broke loose I mean on a corporate level. I was working for a large corporation hospital whose interests lie over several states.

What happened was that someone from my shift (It could have been anyone of us) did not cut off an arm band. The patient and her family then packed up all their stuff and went to the little used strange corner of the hospital that was the "overflow" for the maternity ward. In my time at this hospital I never saw patients go up to this area. Sure you would walk through it to get to the other older part of the hospital, seriously though no patients or staff were ever assigned these rooms.

There in this semi-abandoned corner of the hospital was where this family stayed for a little over a week. By family I mean father, mother a couple of kids and a grand parent of some sort as well. "Preposterous" you may think certainly person from security would have picked up on this with their patrols. Um...no. Keep in mind this is a corporate chain of hospitals, security is low on their priorities, the security went to the lowest bidding security company and I hate to say this you get what you pay for. Our security personnel's primary focus was patroling the parting decks keeping all the cars safe especially where the corporate hacks cars were parked. This naturally caused probs in the ER later, that's another story though.

Well then a doc, nurse, tech or other hospital personnel would have noticed. Well not really, I'll get to that in a moment. In your daily wanderings in the hospital do you even pay attention to the people you pass in the hospital that look semi-normal. Also in the entire hospital's defense it was a couple of years post 9/11 in a part of the country NOT known for terrorist attacks and mass shootings. Noone thought twice and if they did ask they were promptly shown the patients arm band that was still attached to the discharged patient.

Finally after a little over a week someone noticed. It was a house supervisor who gave a fuck (another words who did their job) noticing this patient for the umteenth time and running over to a computer and running the record number and seeing that the patient was discharged over a week earlier. Security was called and since they were just really low level parking lot observers the local police were contacted and showed up.

As the police say "upon further investigation" they all found this family living in a room on this little used corner of the maternity ward that was nowhere near a nursing station that was in use. Turns out that the family was contacted several times by hospital staff but once seeing the still intact armband on the patient let them slide because they had an intact armband. The family made many visits to the cafeteria and in fact some how were getting trays delivered to the room. They had found a linen cart and were getting fresh towels and sheets from it and had even gotten toiletries (soap and toilet paper etc) from the hospital as well. I would even go as far to say that this was epic.

This got the attention of the hospital's corp types and then on up the chain to regional corp. Naturally the family got tossed out on their asses by the hospital. I don't know if they were homeless or not and it was all hushed up this incredible story never made it to the local news. Well shit went up in the air and landed right in our laps there in the ER.

We all got lectured to for weeks about the prompt removal of armbands from patients upon discharge. In fact they then went to different colored arm bands for the ER just in case. The admit clerks were to cut off the ER arm band if the patient got admitted. We had to keep up with the armbands and I'm sure someone some where was keeping count. It became policy in our ER to cut off armbands no matter where the patient came from and put on our own and that the armbands we put on patients in our ER were hospital property and to be retrieved. If you missed an armband and it was found that you neglected to collect it you were verbally warned then got written up for your lack of attention to this particular detail. Seriously, no shit.

Yup this happened. So that dear readers is why I cut hospital arm bands off of patients now. I'll even say you should too once a patient has been discharged from the ER.

Reality is quite strange sometimes.

Sixty One

Talking to a Paramedic after a particular stroke call a few weeks ago, I just heard that the call was coming in and did not know the entire story.

Crusty ER Tech: Dude what happened?

Paramedic: "Got toned to an elderly woman having a stroke. Got on scene to this woman who was all contracted in bed. Breathing like 6 times a minute. Family says that they decided to take her out of the nursing home she was in. After a night or two at home she starts acting altered. Family decides fuck it she's tired lets put her to bed. Ten hours later they check on her and she's like this. They had no clue about her history or meds. They acted like they did not even care, no one even asked what hospital we were going to. I asked them when they tried to get her up and they said 'We got her up when we got her up'. Goddamn that place was a hell hole.

Crusty ER Tech: They should have left her in the nursing home. If it ain't broken don't fix it.

Paramedic: This is my first call of the day on a 24 hrs shift. Humanity is not my favorite species right now. This family was something else.

Crusty ER Tech: Sorry bro, hard times, anything I can do for you?

Paramedic: Nope, we're a truck down today and I gotta get back in service ASAP.

With that he split. I've stated before that for the most part I like patients. Although sometimes there are exceptions. I have no way of knowing the whole story, it's just damn tragic no matter how you cut it.

Sixty

Wanting rib spreaders vs. needing rib spreaders

Since this small dysfunctional corner of the internet has made it to sixty  that's right folks 60 entries I decided to relate one story of a distant past. Plus crusty is a few strong beers in on a late weekend night. Forgive the typos and hold on to the popcorn cause this folks is a true doozy.

I was working a trauma shift in one of the trauma centers I had worked in my past. One of the responsibilities of this area that night was taking inventory of the equipment on hand vs needed for the night. The preference is for every trauma bed that there be a thoracotomy tray.

Before I go any further let me state a few things:

1) I know precious little about surgery
2) Although exciting it still to this day well over a decade later as a dumbass ER tech that surgery on a major scale terrifies me.
3) I have a LARGE amount of respect for anyone who takes knife to skin in hopes of healing
4) I am NOT an OR tech nor do I have any OR experience. I could not tell you the components of a thoracotomy tray but I can tell you once you get to that point that GODDAMN EVERYTHING IS IMPORTANT. I am an old EMS type who has seen a thing or two with a keen sense for shit really going sideways and figurung (drinking here remember) out how to dig out of the proverbial hole.
5) Many apologies to those of you who work OR who know what is going on.
6) I am terrified of surgery...did I say that already?! That is whether it's being done on me or not.
7) PLEASE understand I am talking out of my ass and way out of my comfort zone here.

So I do my inventory and find that for the night and for all our trauma beds I have exactly ONE thoracotomy tray on hand which perplexes me but I am told that "it's a week night nothing REALLY happens on weeknights' Cue foreshadowing music. I am working at a poor hospital and really we are lucky to have this tray on hand usually we have to beg one from the OR.

Now up until this point I've seen a few chests cracked. Been there when we needed to internally defib a patient and not have the paddles on hand. (how do you fix that? well open up another tray or grab a spare set if you are in a well funded hospital) So I know a little bit which is to say when the surgical team decides to crack a chest in a trauma room the pucker factor goes up a shit ton and the shit has hit the fan in a very major way. Which is to say when I hear the surgical types say "We're cracking a chest" I need to know where everything is at and then where to find things if shit ain't there another words when old murphy of murphy's law makes a very unwanted appearance.

Long story short and you dear readers saw it coming that night we crack a chest.

The tray is opened and lo and behold the tray has everything we need except for:

THE FUCKING RIB SPREADERS

For those of you not in the know rib spreaders  (eg, Finochietto) are one of those essential pieces of equipment you cannot get to the heart without them. This vital piece of equipment opens the rib cage enough for the surgeon to reach their hands in to do repairs to very vital organs, defib a patient or do a heart massage. These like most parts of this particular tray are important. Unlike most everything else in an ER you cannot just cobble together something that works you gotta have THAT piece of equipment.

Now I am sure there are folks out there way smarter than ol' crusty ER tech who know how to do shit like this. To them i will say in a situation like this I am by far the dumbest person in the room. I am not a trained surgical type. I will say that even surgical folks may not know how to over come this deficit of essential surgical equipment. I don't know I do not work in an OR.

So there are no rib spreaders. Since I slapped the tray down on the table and i'm standing there and fuck there are no rib spreaders all eyes rest on me. Now double fuck me. I should have insisted earlier on getting a second tray up ther just in case but i was waved off that thought for what ever reason. At that point the surgeon says "Fuck open another tray" Which the charge nurse and trauma nurse say "That's all we got" A silence falls over the room. We all know the surgeon wants to crack the chest in fact in the hurry to do it the rest of his team has already cut into the appropriate land marks and fuck blood is pouring out. The level one is going and suction canisters are filling up. Lots of blood in the chest cavity.

I look up and say "I'm going to run over to sterile supply and get another tray" I get told more than once before i leave the room to "Hurry the fuck up"

I am sprinting down the hall way. I am confident in those moments that the charge nurse is on the phone to sterile supply telling them someone is headed over there to pick up another tray. I know there is probably a resident calling the OR telling them of our predicament. Sterile supply is closer in a round trip than OR is one way. So I know if it's no dice at sterile supply I gotta call the ER and let them know I got fuck all. It's a monumental cluster fuck.

I make it to sterile supply, instead of seeing a rattled person standing outside the doors with the tray in hand I arrive at the door hearing their phone ringing. I start pounding on the doors with both fists screaming. I am having a controlled shit fit. The doors fling open and there stand a bewildered sterile tech looking at me all pissed off.

This is understandable. I can imagine the life of a night shift sterile tech being almost zen like. Night in and night out you listen to your music and clean surgical tools. You do the same thing night in and night out you may think "this is awesome, I'm all by myself and I don't have anyone hardly ever bothering me." Again I don't know I am not a sterile tech I can only guess.

I have disturbed this dude's zen and fuck now the damn phone is ringing off the hook, shit every line is ringing off the hook. I would guess that this dude has never seen this much action going on at his job ever. He's answering the door & picking up the phone. He's got me screaming at him for a thoracotomy tray and some other person on the other end of the line screaming for the same thing. This dude is in the eye of a horrible shit storm and he ain't use to it. I know it's the charge nurse asking for what i'm asking for because she ain't leaving anything to chance cause I could have dropped over dead running over to get the thoracotomy tray. In fact i'm a little surprised a surgical resident or another tech is not running up right after me.

Needless to say I am sweaty and wild eyed.

The sterile tech is able to focus enough through this abrupt cacophony of noise that I need a  thoracotomy tray. He has no clue I need it NOW!!! He tells me all our thoracotomy trays are being cleaned at the moment, that we'll have to wait until later to get them.

Clearly there is a misunderstanding here.

To his credit he hangs up the phone before I speak. The phone begins to ring again. He looks annoyed. I am one breath from pushing him aside and just grabbing whatever i need which would be a mistake since i have no clue where anything is in the sterile cleaning area. I calm down enough to tell him that we are cracking a chest up in the ER and that I need a  thoracotomy tray ASAP, Yesterday, NOW!!!! If I ask for rib spreaders alone it will be a fuck up. Better to ask for the tray in fact in my paranoia I ask for two  thoracotomy trays. He snatches up two quick that belong to the OR . I tell him if I have to come back for another tray that physical violence will occur. I mean it because what we need aint on these trays then I am fired, he is fired and other people are fired so why not kick someone's ass over this damn mess. I'll take the charge fuck it.

I make it back to the ER in just a few minutes (literally, yes LITERALLY!!!) The chest is cracked the rest of the way and surgical things happen. I won't go past that.

I don't know who fucked up the thoracotomy tray so badly that there were no rib spreaders in it. I was told rather sternly that I knew better and to have a back up tray in the future. I learned a powerful lesson there. The charge and trauma nurses were told the same thing. We all got angry glares from the surgical teams for months after that. A lot of memos and emails were exchanged over this very gross oversite. For as long as I was at this hospital that never happened again.

I had a triple extra large whiskey after that shift. It makes for a nice story but I've had a lot of sleepless nights over that one. So goes the life of the ol' crusty one.







 

Fifty Nine

"Don't do it."

A few years back a friend outside of my circle of EMS and ER circles approached me after he graduated college with a bachelors of some sort of science from a major private university then med school. He had worked as a ER clerk to pay the bills that scholarships did not cover.

ER clerks in the old days really had a tough job and were often the center of the universe in the ER. When we had paper charts they'd collate them track them make calls to any number of people and get calls from the same. Biggest part of the job was answering the near constant ringing phone. Very important because ER docs call other docs to consult with and vise versa. Depending on the hospital they ordered tests and arranged transport to other parts of the hospital or at least helped in it. Aside from looking at the old white boards the ER clerk is the person who you told everything to because they were the one constant in the ER. Since we have computer boards and pt charts are computerized as well the role of the ER clerk has greatly diminished. It's an easy way to work in an ER without getting involved with patient care. An ER clerks job is to stay behind a desk period. I give the old ER clerks mad respect.

I digress

So I got this friend who wants to be a doc they have gone through med school and is looking to specialize. He his wife and I talk about this over dinner one night and I'm asked since I am an EMS type and work in an ER what I think of emergency medicine as a specialty for him. This friends is a really loaded question. If you already asking this question you've already decided and human nature being what it is you are looking for confirmation that it is a good decision. I'm known for being blunt to the point of painful even more so when it comes to the job.

I've known some great ER docs and some real shit bag ER docs. Some are truly great human beings and sometimes the smartest people in the room hands down. Others just need to be strangled where they stand because of their sheer incompetence and lack of any social skills what so ever (I'm talking to you Dr. Klaus).

I said that and also told him this exactly:

"Don't do it."

I was asked why and I followed up with many things. Emergency medicine is constantly changing and it seems to me that the higher your education the less time you spend at the bedside with the patient. A lot of what we all do not is sitting behind a computer and checking boxes. Liability and responsibility is tremendous for the ER doc. They are the generals in the ER what they say goes and they have to be leaders. It can be rewarding but also more often than not is total drudgery. Which goes for most any job anywhere. There is a shit ton that goes on behind closed doors that the ER docs do that I don't know about. There is a ton of politics played in the private groups in hospitals. When I worked at a private hospital with a small ER group I saw it fairly close up. You can be a fantastic doc and still get shit out the other end because you were on the wrong side of an argument with administration. I saw it happen a few times and it was always sad. ER docs have a lot of power but not as much as you think. ER docs are in essence the middle man, the jack of all trades and master of a few. They treat a patient and if the patient is seeing another doc they gotta call them and see what their doc wants to do. Waiting on that call back can be an aggravating experience for everyone concerned in the ER. I've seen docs do nerve blocks for a patient with a tooth ache and turn right around and read a vastly complicated EKG and decide on definitive care for another totally separate patient.

Let me dig myself in deeper because I'm too stupid to shut the fuck up. To me it seems like the financial crush of loans and the way over the top commitment to become a doc before you specialize is an astonishing achievement, truly a pinnacle. With that said why waste that on working in a ER. I told him do any other specialty get stupid rich and do cardiology, neurology or open your own colonoscopy clinic. That way you are not at the mercy of a hospital administrator or senior members of a large ER group. Do something with your doctorate in medicine where you can have nights and weekends off and be able to send your kids to a great liberal arts private school and college. Not do something where your life is put in danger every shift or where you get nightmares from what you've experienced as a doc in the ER. Don't do the job because you'll get pushed around by every other specialty and get shit on from down below and from a great height.

I told him doing any kind of patient care in a ER will change you and in my experience not in a good way. Its a whole different universe from ER clerk to ER doc. He's a great guy and honestly I did not want to see him change or be hurt from the crush of what I know about working in a ER especially going through residency in the hospital I work at, oh man oh man it can be awful. In short I wanted to protect my friend.

I had one ER doc tell em that his dad who was an ER doc as well told him not to be an ER doc. In fact his dad was pleased as punch because his son was an artist. Well the son felt the pull of ER medicine and went through the whole pipeline to be a ER doc. When he got his residency his father told him that he was proud his son got his doctorate but that he was a total idiot for being an ER doc now.

I guess I did not get my point across well or explain it clearly enough. He applied for residency and got it at a major hospital in another state. We stayed in touch as much as possible due to the constraints of being a resident. Towards the end of his residency we crossed paths and had a lunch he his wife and I. He excused himself to go to the bathroom during our lunch. While he was gone his wife became very somber which is not her personality at all. She told me "Everything you said came true" she was going to stick with him and support him but there are easier gigs as a doc than working in an ER, they both knew that now. I didn't ask for specifics, i could see the change in my friend too and it made me sad.

I knew one ER doc who was fucking excellent. She was amazing with the patients, staff all the way down to the housekeepers and kitchen personnel. It was a fair sized hospital and everyone it seemed knew her. Plus she was a great doc to boot. We loved her, she got tired of the grind of being an ER doc and one day came in told the group she was working with that she was done and left to do public health in Africa. She sent us an email a year or so later telling us it was the best decision she ever made.

I'm probably sticking my foot into my own mouth rattling off about this but really there is an easier way to make a living with an advanced degree, I'm sure of it. For the most part everyone who works in an ER intentions are well, they have a good heart. There are a lot of lost souls who work in an ER and I'm always a little depressed when I see a new crop of ER residents or new grad nurses come into the department.There is a high mental price to be paid in order to do it though.

For those of us who were lucky to get through high school and go on to work on an ambulance after a few years it's all you know. Your career options are limited dragging drunks and junkies out of flea bag motels and out of the gutter makes for great stories but hardly pays the bills. Ambulances and hospitals are not happy places in general. What I am saying in my off kilter way is:

Don't do it.

What do I know, I'm just Crusty ER Tech.

Fifty eight

Nurse Bass strikes again.

Working triage and responsible for EKG. My job is simple stupid. Do EKGs and be damn sure I am available for "Cardiac Alert" EKGs. Do the EKG tell pt to stay put, find attending and have them sign off on the 12 lead. It is a new point of pride at this hospital we have this cardiac program and whiz bang awesome cardiac cath lab which is a sure money maker like colonoscopies, it rakes in the money and lordy the prestige esp with cardiac caths (see The Rape of Emergency Medicine). If you have read my previous posts then you know all the way down to my level that this is something you DO NOT fuck with. Especially if we can catch an MI early and get the pt cathed and save a life. I take this seriously it gets my undivided attention. It saves lives, can get ol' Crusty ER Tech in  a shit ton of trouble and makes the hospital money. It seriously has my attention esp when it comes to saving lives and staying out of trouble that I can avoid.

Seriously, full stop.

I make sure I stay in the area and hate to wander away from the EKG bay. Most of the time we have an EKG tech but on weekends and holidays we do not. Also when the EKG tech wanders off to do whatever we have to cover them. It happens.

Enter Nurse Bass. I have my head down doing EKG in the bay for a variety of patients. I'm plugging away and catching every EKG I can find in the system because I am VERY afraid of missing one. We have a different system of triage from every other place I worked it works well you just gotta pay attention to some small details and our system for ordering normal EKG and "Cardiac Alert" EKGS are very hit or miss. Basically if a "Cardiac Alert" EKG comes down a triage nurse who orders the test is suppose to tell me and have the patient there on hand. It rarely works like that. So I am constantly refreshing the computer and looking for new EKG orders.

Nurse Bass is charge nurse that day. Nurse Bass LOVES to delegate and is happy sitting in a chair behind the desk "managing" the area. By managing I mean looking at wedding and baby shower websites. I got my head down and have only left for five minutes to use the bath room I was gone for maybe five minutes. About 2 hours in the shift Nurse Bass spots me sitting in the EKG bay "surfing the internet" which is not true because the computer I am on has been blocked from internet access I was checking for EKG orders again, again and again. I had just finished up an EKG for a dialysis patient and directed the patient to the appropriate area a few minutes before.

Nurse Bass tells me that I don't need to be "sitting around" and I need to help her clean rooms and help her with her duties. I inform her of the policy which states that I need to stay in the area and be readily available for the triage nurse. She ignores me then proceeds to get cross with me and restates what she just said. I have no recourse.

As the fates have it a bunch of EKGs are given to me over the next 45 min to an hour. I'm plugging away doing what I am suppose to be doing. Then Nurse Bass reappears and talks to the triage nurse. Either Nurse Bass does not see me or is being passive aggressive and says...

"Have you seen Crusty ER Tech? I have not seen him in an hour, he's probably wandering off some place or hiding, I'm so sick of his shit." this is a direct quote folks.

I'm actually hurt by this statement because I am a stay at home type of tech assign me to an area and you can find me there. Again ESPECIALLY when it comes to EKG stuff.

Nurse Bass is standing right in front of me when she says this. I'm behind the EKG machine and look up at her in all her girth and glory and I say "Nurse Bass I'm right here and have been for nearly an hour doing one EKG after another for just as long like I am suppose to. If you do not belive me ask the Triage nurse and check the log on this EKG machine."

Nurse Bass is unhappy with my response, I think part of it was because she was talking shit and did not see me sitting there.  She tells me I am suppose to help her clean rooms. I say we have house keeping for that and if a nurse cannot wipe a bed and pull a film of paper down over a exam table then something is wrong. The bays in the triage area are not getting trashed because we turn them over quickly. Nurse Bass is not hearing any of this, she tells me that I need to help her clean rooms and do as she directs (meaning I need to clean rooms). I ask her about doing "Cardiac Alert" EKGs and other EKG as directed by the docs. She says "we'll cross that bridge when we come to it"

Another words I'll be thrown right under the bus for missing EKGs while I am out doing her bidding. I have no recourse and we are having this discussion in a patient care area. I look to the triage nurse for support who is usually supportive she shrugs her shoulders and says "She's charge"

I throw up my hands and have no choice "Nurse Bass believe what you like I could care less, I'll do whatever." at which point she turns on her heel, walks over to the desk and looks at the board (by board I mean a baby shower planning website)

For the rest of the day I am furiously running around like a maniac trying to do the "whatever" while trying to stay on top of EKGs. I'm doubly cranky and mentally exhausted by the end of the day. The day ends with a line from Nurse Bass:

"Well night shift is here, I want to thank all the docs and mid-levels (PA's and NP's) for their hard work today." At this point the triage nurse says "What about the nurses and Techs?"

Nurse Bass pretends she did not hear the triage nurse sitting beside her.

So ends another shitty day for Crusty ER Tech. I gotta find another line of work.