Number Games

In the world of nursing, there are a lot of numbers that you deal with.

And I'm not just talking about heart rate, temperature, and blood pressure. And I'm especially not going to get into lab values.

No, no, it's all about the equipment.

One day we'll talk about Foley catheters - the ones that go into your bladder - and the meaning behind their numbering system.

Today, we're talking about intravenous lines. IVs, for short, if you weren't sure.

With IVs, numbers are inverse to size. The bigger the number, the smaller the IV catheter. The sizes in common use are 14 gauge to 24 gauge, and like women's clothing, we go in even sizes only. They do get bigger than 14 gauge, but if you get to that point, you're working with older equipment or you're talking about physician-inserted central lines.

Again, central lines are for another day.

Today. IV's.

We often run into people who say, "Oh, I'm a hard stick," which means it's hard to get an IV started. Some of them are right, and some of them are full of shit.

The other day, though, the truly difficult stick was a theme. I think I only started one 20-gauge, which is one size smaller than you should generally be starting on your ER patient.

The 18-gauge should be standard. If you're sick enough to be in an ER, you're sick enough for an 18-gauge. When you give blood, they use a 16-gauge. A 14-gauge requires a hosepipe of a vein. Eighteens, sixteens, and fourteens are really a pleasure to use, whether you're a semi-sadistic ER nurse inflicting pain on your drunk or uncooperative patient... or you've got a trauma or other critical patient that merits the larger sizes.

But I digress.

The other day, I was mostly starting 22's, which should be reserved for kids. Absurd. I even started one in somebody's wrist. Not the back side, but the side right next to the palm of your hand. That's one of the most painful places to start IVs, and as a rule for conscious people, I try to avoid it. I started three there.

But the prize goes to one of our chronic pain patients.

Or one of our doctors, depending on your perspective.

The short version is that the patient had multiple health problems, needed pain medication, and on the off chance that she was admitted to the hospital, the doctor wouldn't settle for an intra-muscular pain medication. He wanted to start a line. We'd tried a few times, and we knew she was a truly difficult IV stick. So I told him the story, and he decided to start an IV in her external jugular vein.

Yes, that's right. Jugular. In the neck.

Don't worry - it wasn't the artery. No squirting blood.

EJs, as we like to call them, are first in line of last resorts for venous access. If you're going to get it, the bigger the better.

On the second try, all we could get on this woman was a 24 gauge.

Yes, a 24.

We try to reserve that for infants. The catheter itself is about a half-inch long. The others we use are 1-1/4 inch long, or longer.

Smallest EJ I've ever seen.

Fortunately, that was at the beginning of the day, and I started off the day with the worst. It did, however, set the tone for the day. I managed to successfully start IVs on most of my other patients, but they were all pretty damn small.

IVs are all about your training, and whether or not you can tap into your natural skill for vein location through your training. Judging by my experience, I fall somewhere in the middle according to both, but I felt ashamed starting so many damn 22-gauges.

It was somewhat redeemed, though, by the fact that the next day, everybody had lovely veins and I started plenty of 18-gauges.

The other side of this is what happens when you get home. My husband can tell you all about that - I palpate his lovely, large, hose-pipe veins all the time, thinking about the 14-gauges I could start in his hands

I could tell you about my veins, too. Where they are, what size IV would fit, but that would be boring.

Suffice it to say that little item on the "You know you're an ER nurse if..." list is true - you examine other people's veins in the checkout line at the grocery...

T is for Trauma

Before we moved to the midwest, I worked at a Level 1 trauma center, and for the year I worked in the ER there, I got truly excellent training and experience with trauma patients. There's always plenty more to learn, though, and you've never seen it all.

In the south, trauma season is summer. Well, summer is the height of it, anyway. Everybody gets out their motorcycles, ATVs, boats, jet skis, and what have you, and they get a little crazy. Here, winter is trauma season, because despite its annual recurrence, nobody seems to remember how to drive in snow and ice from year to year.

My current ER doesn't meet all the requirements to be a Level 1, so we're a Level 2. Basically, we don't have all the capabilities and resources of a Level 1. That also means you get fewer trauma patients, and your nurses have less training and experience.

So last week when the charge nurse pulled me out of triage and said, "We're getting two really bad traumas. I'm giving you the baby," it was a little disconcerting. Me? Are you sure?

Yep, they were sure. Fortunately, I also had a lot of help from the on-site EMS training staff and the trauma coordinator. We didn't get much of the story beyond that it was a car vs. dumpster at about 35 mph, and nobody was wearing seat belts. Two of the patients went to our neighboring hospital, and two came to us. They did it a little backwards, though - sent us the toddler and the pregnant patient, and sent the fifty-year-olds down the road. Why backwards? We don't have a pediatric unit or a mother/baby unit. Oops.

My patient was an 18-month-old girl who, instead of being in a car seat, was in her mother's lap.

Yeah.

Huge laceration on her forehead, another just below her nose, bit through her tongue, and a tooth missing. And that was just what we could see. She was crying inconsolably and really acting like she had more of a head injury than what we could see.

The ER doctor took one look at the laceration and had the secretary start making phone calls for a transfer to a facility with a pediatric ICU.

The little girl had been c-collared and creatively restrained in the big orange EMS car seat so that she was sitting upright instead of laying flat. Probably a good idea, considering the cut below her nose. We did the trauma thing, took off her clothes, put her on the monitor, drew blood, started an IV. I had her in the CT scanner 20 minutes later, and she had only been there for an hour and eight minutes when the helicopter landed to transport her elsewhere.

Now, she was the first trauma patient I've had to send elsewhere by air, but that has to be some kind of record. I'm just glad the doctor acted as quickly as she did, otherwise my patient might have lingered with us much longer.

She was one lucky little girl, though - no skull fractures, no bleeding in the brain, no other injuries. Just some nasty lacerations.

Looking back at it, though, the whole situation was pretty ridiculous. I mean, come on. First of all, who in their right mind takes the risk of not putting their child in a car seat? I understand they can be expensive, but isn't your child's life worth shelling out for the cheapest one you can find? And if you can't afford a car seat for your one child, why on earth are you having another?

I know, I know. They didn't think about it that much. Or plan. Or whatever.

I think that if I have to deal with the results of your poor decision-making, I earn the privilege of criticizing it.

Now, I realize that it wasn't all that long ago that it was common practice to put your baby on your lap, or your toddler on the bench seat next to you. Things change so quickly, though. Cars today go much faster, and we let a lot more people drive. Who, evidently, shouldn't.

I really hate it for that little girl, that she'll have that scar front-and-center. I guess the good thing is that right now, for the worst of the healing process, she's too young to care. And every time her parents look at her, they will, hopefully, be reminded of the importance of buckling up.

So in case you weren't sure about it, learn from their mistake. Buckle up.

Step into my triage box...

It's always an interesting night when I'm in triage, for two reasons. First, it means we actually have extra staff, enough that we can spare a nurse for out front. Second, instead of being a shit magnet, I'm a stupid magnet. Yes, ERs in general attract the not so brilliant, but sometimes I really have a special talent. Such was Sunday night.

A guy brings his two-year-old son, complaining of a cut on his head that was still bleeding a little bit.

I started doubting the bleeding part when it took the guy five minutes combing through his son's buzzed hair before he asked the kid, "Okay, buddy, where is it?" The kid points at the part of his head that apparently hurts, and we finally find it. A little round abrasion, right there on the top of his head, a whopping two millimeters in diameter.

Needless to say, there was not much blood involved.

"So, what's the problem? Why did you bring him in?" I asked.

"Well, he hit his head on the corner of a door this morning, and tonight when we were putting him to bed, he sad that it hurt," the man explained, looking at me expectantly.

I obviously didn't get his point.

"And did you give him any medicine for the pain, like Tylenol or Motrin?" I asked.

"No, I just brought him straight here!" the man said.

I promptly triaged him a level five, which is completely non-emergent.

I essentially had the same conversation with the parents of my next patient, except instead of a non-laceration and a headache, we were talking about an improving cough and a "really high fever" of 98.9F.

"So why did you bring him in today?"

"Well, he's already been on antibiotics for four days, from the pediatrician, but he's still having fevers. I felt like the Motrin wasn't working, so I stopped giving it to him, and just use the Tylenol, but now his fever comes back every five hours. It gets really high, too, like a hundred and ten degrees."

Right. I resisted the desire to ask how they measured his temperature to 110 and if his fever started coming back after she stopped the Motrin.

Seriously, guys? The FDA makes these medications over the counter for a reason - if you follow the directions, they're very safe and very effective.

Although sometimes, talking to these people, I wonder.

When we hit a lull around 10pm, I made my way to help out in the back. Fortunately, it was a pretty calm Sunday night, and we only had about eight patients. I was just considering asking if I should be sent home early for low census when the EMS radio went off.

My stupid magnet was working for the ambulances, too, apparently.

Over the radio, we received report: "We're bringing you a 40-year-old male patient, discharged from your facility yesterday with pancreatitis. Today he noticed his left wrist turning purple, and called us. He admits to drinking seven beers tonight..."

We stopped listening there. Everybody threw out names of our frequent fliers, and finally somebody mentioned the right one. I knew, because he'd been my patient the day before. We then speculated that he'd gotten drunk, fallen, broken the wrist, and not noticed until it started turning purple.

No such luck.

First, he had to peel off all eight layers of clothing he was wearing. Then we asked, "What's wrong today?"

He pointed to a big bruise on the inside of his wrist and said, "It looks like you guys messed up when you started an IV!"

"Well, that's what happens when you come in twice a week, drunk, with your pancreatitis. The alcohol thins your blood. You're going to have bruises."

"Yeah, but it hurts!"

"And what do you want us to do about it?"

We didn't get a clear answer to that one.

Sometimes I have trouble deciding whether I'd rather be a shit magnet or a stupid magnet. I lose patience very quickly with stupid. Although, watch tomorrow be a shitty day. Then I'll change my mind.

Welcome to the Emergency Room

Hi, my name is Becky, and I'll be your nurse today...

Oh, wait. I'm not at work.

I'm here for the storytelling. Because, let's face it, every day in the ER is another exciting story. As we often say, you can't make this shit up.

Now let me give you a little introduction. I tell all the stories - good, bad, hilarious, and disgusting. I'll do my best to censor myself on language and gory details, but I believe that some of it is necessary if I'm going to realistically convey some of my experiences. I work mid-shifts in the greater Chicago area, which doesn't generate as many crazy stories as the trauma center I worked at before, but it can still be highly entertaining. My goal is to keep the whining and complaining to a minimum, but fair warning, some will sneak through. The stories are worth it, though. At least, I think so.

So stay tuned for the first story, which should debut sometime over the weekend.