Fourty Four

Pt who is a mid-30's male is found unresponsive at local recreation center. Bystanders call 911 while others begin chest compressions. While waiting on ambulance arrive by standers attach AED to this unresponsive seemingly healthy male. The AED orders "NO SHOCK" no shock is given and  bystanders continue chest compressions.

Ambulance crew arrives (along with a fire engine a supervisor and a few police officers) pt is scooped up and placed into ambulance. Then the pt is assessed further by EMS crew. Pt is found to have a pulse with a GCS of 3 as reported by crew pt is breathing on his own. this patient is transported to us at BCH.

When the ambulance gets to the hospital (a very short trip from said rec center) the pt now has a GCS of 10. As pt comes into the critical care area of the ER the patient becomes more and more alert to the point of by the time we get him on the monitor we find out that the patient is deaf. When he does not want to talk to us any more he has another "syncopal" episode.

No one knows ASL in the ER. BCH has many many resources so in rolls a computer on wheels with a web cam on it. We dial up the ASL interpreter who pops right up on the screen and sees a room full of people around a patient who is now "unresponsive" the ASL interpreter is unaware her mike is on and the volume is on full blast on our end and she says:

"HOLY CRAP"

The room erupts in laughter.

The pt. arouses on his own again and begins signing with the interpreter. It begins a very circular conversation which frustrated the hell out of everyone. The patient was a poor historian. The only real complaint we get is the patient is having chest pain. Which figures because bystanders were doing chest compressions on him for a few minutes before the EMS response. Trust me if the AED did not stop the bystanders from shocking him he woulda gotten a 360 joules wake up call.

The patient was rapidly moved out of the critical care area into a regular room.  Never did find out why he passed out and was unresponsive. With intermittent episodes of responsiveness and unresponsiveness who knows what was going on. The patient of course got the million dollar work up. What can you do with these situations?

At least the system worked seemingly flawlessly and kudos to the bystanders:



Soon more mysteries of modern ER care in the dynamic urban environment will be revealed. I am just an old Crusty ER Tech trying to make it to the end of shift.
 

Forty Three

As we get on into the colder months the shelters fill up and we start to have our urban outdoors people begin to appear with more frequency, often in the damnedest places. Yes, yes we do get our fair share that come in complaining of chest pain or homicidal or suicidal thoughts. Which comes a small rub with me and some of my fellow tech and often nurses. I know it gets damn cold on the streets and shit the shelters are only moderately better (they're warmer).

My thought is that if you're in a bad way and homeless and come up to us and say that you're just homeless and need a place to crash til the bad weather passes then hey we are in the caring business, we'll find you a place to crash for the coldest part of the day or night. Just don't expect us to cater to your every need, be quiet in the corner and that will be that. It's happened once or twice and it happens once or twice per winter season. Just don't make a habit of it and by all means get to those shelters early.

One thing is that many don't know or really care that when they come in with the right verbiage that they will get the million dollar work up. Then since they are indigent and cannot pay the taxpayers of the city, county and state flip the bill or the hospital eats it which cuts into our operating budget which keeps us from upgrading from the monitors that are over 20 years old in some cases. It gets frustrating sometimes and sometimes it gets plain funny.

Awhile back I was in the habit of running stairs after shift not on one of those stair masters in one of the many stair wells of the high rise hospital I work at. I'm about on say 10th floor (which is about halfway to the top) and there is a "half" floor there which is only accessible to the facilities guys it's a crawl space where they can get to pipes and wires and such. this half floor con only be reached by stairs. The crawl space is locked with several locks and alarmed. The small 4-6 stair landing is super warm though.

That's where at around 0800 one morning I stepped on a homeless guy. I was in a half daze after working a long shift and wheezing my lungs out from doing stairs. He was surprised that I stepped on his outstretched arm and let out a yelp. I was surprised and let out a very undignified girly scream. At which time I ran up to the next floor and called our (seriously) crack security staff and they handled the situation. Story went that dude got discharged walked out the doors then walked in another set of doors and wandered around til he found a stairwell. He went up until he found a spot where noone really was and crashed.

Then there was the running gag for a run of shifts where a code would get called once a day by someone who could not wake up a homeless woman who was sleeping in the hospital. In a large urban hospital such as BCH if you are savvy enough you can hang out in our many waiting rooms for various clinics, watch TV, be warm and sometimes even get fed all without seeing a doctor. This particular woman just did not do that. She'd just fall asleep anywhere. In a hallway next to the freight elevators in a corner of the gift shop etc. Our hospital is divided up for codes the ER covers certain floors including the ground floor which is where this woman decided to fall asleep for this run of shifts. It's a total pain in the ass to go running with a monitor and drug box to a woman who is just being stubborn and playing asleep hoping to get left alone so she can return to her nap. It reminded me of the same phenomenon on the ambulance a commuter sees a homeless person sleeping on the side of the road and calls 911 which brings a crew out to wake up said homeless person. People mean well it's just that after awhile you wanna just well...scream. This woman got referred to social services and sent on her way. Never saw her again.

So begin the late fall and early winter months.

Forty Two

We've been getting a lot of EMT students through BCH as of late. For the most part they have been wall flowers with a sprinkling of capable ones and the occasional "I'm getting ready for med school and thought this would help me prepare" types. No one listens when I tell them that being an assistant manager or manager at a subway would pay more and that you'd only receive only about half of the abuse.

Alas my pleas for career change fall onto deaf ears of the phalanx of EMT students we see now. The wall flowers make me wonder how they get trained then I saw this video and I think I get it.

Not saying that my particular training was magnificent. My instructor got fired at the 11th hour because he made a racy banana joke to the wrong student. Fear not as long as I am the Crusty ER tech BBCOD will live on. That was a damn long time ago in a land far far away from where I am now.

If you're reading this and you're just starting out take the classes seriously. Also keep in mind to have some damn fun. The job is tough enough even with the humor.

In case you CNA or nursing types are in here looking I'll answer your question with a YES this is how EXACTLY how EMTs and Paramedics are trained. And if you believe that then I got a certain bridge or some beach front property in a land locked state that I can sell you.

Seriously consider working at subway. I hear that employees only pay 10% of the actual cost of a sandwich.

Forty One

Crusty has come out of his nursing school stupor (OB oy vey!) long enough to flip through the old blog. I decided to read some of the search criteria and this is what I got:

how to be a great er tech & helpful things for (an) er tech

Totally legit questions. Which are not simple questions to answer. I'll try to answer both at the same time. I'll only do 5 cause that's all I got time for.

1) Know your shit aka "educate yourself". Always work to educate yourself further don't get sucked into the "Well I don't need to know this cause it ain't in my scope of practice." thought process. Don't understand something and wanna know more? Write that shit down and look it up when you are not busy, better yet ask. Take classes ask to go on trauma, cardiac, ICU rounds or sit in on a M&M. You'll learn tons.

2) Know those mother fuckers aka "build relationships". Especially with the Paramedics, EMTs and Flight Medics & Flight Nurses. Most of us came from the field and need to remember it can really suck out there under a car in the snow and or rain. besides they can draw an excellent picture of what was going on with a very sick or injured pt. It can be tough as the tech you often go to places in the hospital and deal with the people in the hospitals that nurses and docs don't deal with. Getting in good with the CT techs can get a pt on the table a little faster or or have the XR techs run over for a muy importante CXR. The EKG tech can show you how to pull up serial EKGs when they ain't around. Go out of your way for central sterile techs cause they're the ones you'll need once in a blue moon and when you need what they have you're REALLY going to need it, like for instance a set of rib spreaders:
 

Needing rib spreaders and not having them is a monumentally BAD thing. That's a whole other story for another time.

3) Know how shit works. You are the "Tech" short for technician. Following that train of thought you NEED to know how pieces of equipment in your prospective ER works. Great example is the traction splint for a closed mid shaft femur fracture. I can't count how many times I have been pulled out of triage or from another area because I was the only tech around who knew how to use this simple piece of equipment. Also be familiar with more complicated pieces of equipment like the ultra sound and the I-stats if you have them. Know how to operate the level 1 infuser in your sleep.

4) This should go under building relationships it's just separate. Get to know the docs and nurses real well. I'm not talking on a social level either. That way you can anticipate what is going to be needed and get on it. Then when you have a moment ask what's going on with an interesting pt and why certain things are being done. That way you are building your knowledge and looking like a true professional that you are. I guarantee you if you do this long enough you'll have docs, nurses and everyone else wanting to teach you something every shift.

5) Last but not least don't be a goddamned social butterfly. Remember we are in the ER to take care of patients and not further our social agendas. In my book patients come first way before that stupid pot luck, what a really hot nurse is into this week or what happened on the reality show of your choice. Save that shit for lunch or break if you get one. Take care of the patients first!

  

Alrighty back to the "reality" of school for the Ol' Crusty ER Tech.

Forty

The tale of Nurse No.

Many entries ago I promised I would write the story of Nurse No. Well the time has come to put one of my fave stories of floor nurse idiocy down for the ages. After many years as an ER tech working west of the Mississippi I moved to the east and started working in BCH. I had cleared "orientation" and just started working the night weekend shifts. I was liking it so far, constantly busy with interesting cases. We were still using paper charts at the time which in hind sight was a horrific way for ANY big city hospital to have to operate.

I was asked to take a pneumonia pt up to the floor. The pt did not have any kind of funky PCP or TB for that matter, just a plain old case of pneumonia. The pt was a middle aged woman, she was one of the sweetest ladies ever no deficits, no drugs or etoh. Just one of those rare times in the ER where we treated a normal person. Her family and I chatted as I got her belongings together to transport her upstairs. They were all nice folks. After they saw that I was taking her upstairs they all left confident in the fact that she would be well taken care of by the nurses on the floor. This is around 0100 in the morning.

Heavens if they only knew.

I get the pt upstairs drop off the chart to the ward clerk and push the pt to her room at the end of the hall way. It's a semi private room and she has the bed closest to the door. I walk her inside get her settled, tell her I hope she feels better. I grab the stretcher roll back past the nurses station and head to the elevators. Naturally at BCH even on a weekend night halfway through the shift the elevators are slow. So I'm waiting and waiting then all of the sudden I hear feet running down the hall and the door bursts open and a very irate nurse says to me "You have to take that pt you just brought up back down to the ER!"

Clearly something has gone awry.

One thing the Ol' Crusty ER tech has learned in his ER tech career is that you NEVER take pts back down to the ER. The reasons are many:

1) The room or spot they were in is usually occupied by another pt.
2) The pt is no longer under the care of the ER doc they have been signed out and have orders written by a floor doc. The care of the pt is going forward by going to the floor.
3) The nurse caring for the pt previously does not want nor do they need an extra pt. especially one that JUST got admitted
4) It frustrates the HELL out of the patient. "Why am I going back to the ER?!"
5) Lastly and most importantly it REALLY pisses off a charge nurse.

Unless the floor nurses put a gun to my head there was NO WAY I was taking this pt back down to the ER.

I walk back inside the med/surg unit with my stretcher to discover and even more irate med/surg charge nurse. This male nurse immediately jumps up from his chair once he sees me and begins to scream at me (keep in mind this is at 0100) because I am the complete idiot who brought up an active TB pt to floor unmasked to an occupied semi-private room. I'm non-plussed, I looked at the chart and talked to the nurse before coming up, this is a simple pneumonia plain and simple I says. While I was waiting on the slow ass elevators the admit docs (a couple of first year and second year residents) tubed up the rest of the admit orders in which one of the boxes checked said this was an active TB pt.

This charge nurse is waving this chart all in my face and is demanding I walk down to the room and get this pt. At one point during this dressing down of my professionalism, intelligence and genetic back ground he grabbed my arm to encourage me along. I asked nicely that he release my arm while I call my charge nurse. He came to his senses for half a second and I was able to call from that nurses station. As soon as the ER charge nurse answered the phone the floor charge nurse got all riled up again. I could not even tell my charge nurse what was going on. I told the ER charge nurse I'd call back in a second.

At this time I made a point to show this floor charge nurse my badge "My name is 'Crusty ER Tech' I am trying to solve this problem, it's not my fault there the chart is screwed up. If you don't quit screaming at me and leave me the hell alone this problem won't get solved. I'm going to the other side of the nurses station and call my charge nurse again, please this time sir don't scream at me while I am on the phone." I said it in the nicest tone possible, I wanted to explode. Getting into a screaming match on the floor with another co-worker is a sure fire ticket to get paper on you especially when you are not on your home floor, it's an easy way to stand before the man.

I was able to call down stairs to the ER charge nurse and I explain the situation. That I got this male charge nurse going bat shit over the situation and trying to intimidate to get me to bring a pt back down which I know is a total no-go. I don't go into detail, it's clear I'm in a jam. The ER charge nurse says alright stay RIGHT there at that phone, she KNOWS this is not an active TB pt just in any case she'll get an isolation room on another floor so things can go forward and whatever I do, DO NOT BRING THAT PT BACK DOWN. She says she'll call back in less than five. I hang up the phone quickly because the floor charge nurse is running over and I'm thinking he's going to jump into my ass again and this time I won't be so pleasant.

The floor charge nurse demands to hear what she had to say. I'm to the point I tell him we are getting another room on another floor, that I'm camping on this phone for the next five minutes. Naturally he does not believe me and wants to talk to the ER charge nurse. No problem says I. I look on my badge and give him the number to the laundry, a phone I know that won't be answered at 0130 in the morning. I do this because he needs to be occupied with something other than leaping into another temper tantrum. I'm confident that situation will be handled. In the mean time ALL the floor nurses are glaring at me like I just kicked a puppy or some shit.

Less than 5 minutes later I get a call back. ER charge nurse says take the pt to such and such isolation room on another floor. Now is when things get REAL interesting.

I walk back down to the room with the chart and stretcher, walk inside to see that the pt is not in her bed. I do see that a nurse (Nurse No) is bracing herself in front of the room's bathroom door like she is trying to keep a ferocious zombie at bay. I ask Nurse No "Where is the pt?" and she says in her broken english (turns out she is from china) that the pt is being isolated in the bathroom because she is infectious. "You no take pt out of rest room." I tell her that the bathrooms in this hospital are not negative air pressure, and even if the pt was and active TB'er that you Nurse No are not wearing a mask, now let me get this pt to a floor where there isn't crazy dripping from every surface. Nurse No reluctantly unblocks and opens the bathroom door.

I find this sweet normal female pt sitting on the toilet with her knees drawn up to her chest.Oh and since the floor thought she was an active TB'er they did not put a mask on her, obviously keeping her trapped in a bathroom was the best choice. It was a pitiful sight, she then asked me "Am I contagious?" I assured her that she was not and that there was a mistake with some admitting paperwork. I further explained that she lucked out and gets her own private room up on a floor where it is nice and quiet.

I get her back on the stretcher and head back out to go to another floor without incident. I was rather surprised by that. I get the patient up to her new room get her settled and it's all good. the nurses on this floor are much less crazy that the other ones I just dealt with. I head back to the ER sure that I was going to have to deal with another irate charge nurse this time though it was going to be my boss. I was sure I was going to have paper on me cause this whole episode from beginning to end took over an hour. Naturally I get stuck on the shitty elevator for 10-15 minutes.

I get back to the ER and find the charge nurse. I ask her if everything is cool. She looks at me strangely and asks "What happened up there?" I tell her in vivid detail of my life of the past hour. When I get to the part about Nurse No trapping the pt in the bath room I get a face palm reaction and hear "Oh no they didn't!" The charge nurse then finds the admit residents and asks WTF? They reply "Ooops oh my we made a mistake she is just a regular pneumonia pt." This gets a face palm from me and the ER charge nurse gets visibly angry calls those residents into the med room "talks" with them about their error and storms out of the department.

The ER charge nurse walks back into the ER about 15 minutes later. With a rather smug look on her face, turns out she went up to the med/surg floor and raised all kinds of hell. She even came back with a list of names. She assured me that I did the right thing and that those people up there are all sorts of out of control. I fully expected a follow up to this episode. Nothing came of it.

About one year later.

I see an orienting group of nurses for our department and who do I spy with my little eye. Nurse No. I immediately grab a N-95 mask and hand it to her and walk away without a word. I doubt she got the joke or refrence. Somehow the word quickly spreads about Nurse No's unique form of isolation. Nurse No to her credit stayed on in the BCH ER for around a year and then left for greener pastures I imagine.

And dear readers was just one night and one patient. Sheesh.

Thirty Nine

E.R. Tech week

Well it gets remembered once every couple of years that's ER tech week. This is the poor cousin to EMS week and Nurses week. This is when ER techs are suppose to be thanked for all the hard work they do in their prospective ERs. For the cynical Crusty ER tech it's more about the free food (usually pizza) that everyone else gets to scarf down leaving me with 2 cold slices of black olive and jalapeno. (who eats that shit anyways?)

The clincher was this said at the beginning of shift by the charge nurse:

"There are gifts for you ER techs, no I don't know what they are, they will be unavailable until next week and in limited supply all of you probably won't get one."

On the other hand there was a surplus of really nice bags during nurses week:

"It looks like we have too many bags for nurses week. NURSES if you want a second bag just come by and see the me (the charge nurse)"

I never did find out what the ER techs got for ER Tech week. I took some time off the following week and never got my gift. The gifts for other "Tech weeks" over the years are of note:

1) A zippy badge holder with hospital's name on it that broke halfway in shift.

2) A leaky snow globe of the hospital I was working at.

3) A pen that quit writing after 2 shifts. It was not only me every other techs pen too.

4) A ten dollar gift certificate to the grocery store down the block.

5) A handful of old stale chocolate candy that was under the unit secretary's desk. Seriously that's all we got one year.

That's the shit I could remember. I think somethings were left over from nurses week's of years prior and got found in some store room or in a back office cabinet. Gifts that would be appreciated would be:

1)  Pens that work

2) Coffee shop gift cards of 10 dollars.

3) Trauma shears

4) Cool nalgene or aluminum bottles.

5) A raffle for the techs only for an electronic device of some sort like a small tablet of some sort loaded with medical apps.

That friends would take foresight, imagination and a budget. Most places I work have none of those things. Usually tech week is usually an afterthought and coincides with Nursing assistant week. I have been told in the past "Well you guys are paramedics and EMT's so you're included in on EMS week." Thing is that EMS week is for the ambulance crews. I know when I was on the ambulance I would have killed someone from the hospital for stepping into my "week"

That's how another "ER tech week" went. So it goes.

Thirty eight.

Been awhile since Ive written, Here is a little bit of advice, When you pull out your trauma shears to cut clothes off a pt watch what the fuck you're doing, Cause goddmanit you are gonna cut the pressor that is keeping the patient alive. Fucking heads up. The damn pt coded does not need to be a nutso situation. Pt coded and coded again up in the ICU,

Go figure.

Don't get so fucking so scissor happy. Chill the fuck out for christ sakes.