A Feather in Your Cap

On overnight shifts, nursing homes are the bane of my existence. If you have been reading for a while, you probably have noticed that I actually tend to favor geriatric patients, particularly those with dementia. The problem with nursing home patients on an overnight is that we are on a strict time limit. In this city, while there are plenty of ambulance services to get patients to the hospital, once a bed-bound or even wheelchair dependent person gets here, if we are ready to send them home, there are no transport services available between the hours of 10 pm and 8 am.

This is appalling.

What it boils down to, is that if I can't get my geriatric patients dispositioned by about 9:30 pm, then they are stuck in the Emergency Department until the next morning as "Overnight Guests". Imagine being 80 years hold with dementia and being stuck on a plastic lined mattress for over 12 hours, with all sorts of screaming, bright lights, and not to mention bad smells surrounding you. A sleepless night certainly isn't going to help any, as a lot of dementia patients tend to decompensate at night. Sure, there's a call bell at their bedside, but for someone who can't remember their address or thinks that Harry Truman is the president, how do you expect them to remember to call for help? It's difficult on our staff too, to have to go in and reassure these patients every 15 minutes when they cry out for help.

So, when I see a nursing home patient in the rack on a night shift, there's always a ticking sound going off in my head to get the labs done, and get the x-rays back in time to arrange for a ride. On overnight shifts, the deadline has already passed, so any patients that come in are guaranteed to be stuck until morning. We have tried all sorts of creative options ranging from calling local family members for transportation to taxi cabs, if the patient is able to be transported sitting up and can fit in the backseat of a regular vehicle.

Unfortunately, some of the staff members at these facilities seem to be aware of our transportation problems and take advantage. If grandpa or grandma is being particularly cantankerous, one phone call gets them transported to the ED for "changes in mental status" and gets them off the hands of the night staff, sometimes even for a day or two. While some of these assisted living places are great about sending paperwork, too many times I walk into a room and meet a senior who not only can't tell me if anything hurts, they can't tell me anything about why they are in the department. This leads to what we call the Granny Grope-o-Gram, a workup including lots of tests that are probably unnecessary, but rule out major bad things... head bleeds, hip fractures, pneumonia, etc.

The other night, I walked into Room 4 to find a nursing home patient who was sent in for "purple, pulseless feet." She was very with it mentally, but when I asked her why she was there, she said, "Frankly, my dear, I haven't the foggiest idea." I examined her feet: they were not swollen, and were warm and pink. She had great pulses. Nothing hurt. After calling three different numbers and paging the provided "staff nurse" someone finally returned my page 3 hours later, to verify that my patient had just been sent for a foot evaluation. By this time, it was 4 am. So, I tucked my friend in, ordered her a breakfast tray, and sent her home in the morning.

The other night, I was amused to see a complaint of a rattlesnake bite listed on the board. There are no rattlesnakes here, and it is winter, so there should not be anyone getting bitten by anything other than a pet snake. As it turned out, the patient was from a nursing home. He was a creative guy, and had an old Stetson hat that he had decorated with several feathers and the head of a rattlesnake. This thing was at least 10 years old, but apparently during the day, he had scraped his finger on one of the fangs of the snake. No way he had been envenomated, but the facility had sent him in for evaluation after-hours. So he was an overnight guest too.

I guess these sort of transport issues are why some departments have opened observation units for people who don't have any active issues going on, but either they can't be set home (too intoxicated, no available psych beds, etc.) either. It's easy to see how having 3 or 4 patients stuck in rooms indefinitely causes waiting room overload, and eventual department closure to ambulances as we have no space for more patients. It's a frustrating thing. Hopefully, someone will eventually start up a transport service in the near future, but until then I don't know how to fix it.

Hard Day's Night

I just finished a string of overnight shifts. Fortunately, last night was slow and I was able to catch up on all of my dictations. For two blissful hours in the middle of the shift, I actually didn't have a single patient. I saw a nursemaid's elbow early in the shift. Nursemaid's elbow is subluxation of the radial head. It occurs in small tots when they get picked up by the arms or sometimes from sudden pulling forces. It is one of my most favorite things to fix because it is so dramatic. Usually, the toddler comes in with one arm hanging limply by their side, and they refuse to lift it. All it takes is some slight pressure in the right spot and a quick twist, and you get a satisfying click. When you check up on the kid a few minutes later, they suddenly have full function of that arm again. I guess I just like quick and easy solutions.

I was glad to have a catch-up shift after the frenzied pace of the previous nights. In our hospital, there's typically an attending on the pediatric side until about 2 am, and after that it goes down to one attending covering both the adult and the pediatric sides until 8 am. As as 2nd year resident, I now work overnights by myself on the peds side, or with one intern and usually no senior resident on the adult side. The decreased coverage at night is usually adequate, but we can get overwhelmed in a hurry. Discharges can get slowed down as each patient has to be seen by the attending before they can go, and they are often busy with more critical patients on the adult side.

For some reason there is this phenomenon on overnights where parents will awaken their children from a dead sleep and drag them in for the silliest of things (runny nose, rash, etc.) thinking that there will be no wait to get Tiny Tim evaluated at 3 am. This stuff is all pretty benign, but it clogs up the works, and when we actually are busy in the middle of night, people get pissy pretty fast at having to wait.

Things that stalled me up on seeing the rashes in a timely fashion on some of the overnights included: a teenager shot in the neck (the bullet went right through the spinal cord and he's now paraplegic), four teens involved in a rollover (none of them wore their seatbelts), and 5 stab wounds that presented on the adult side all at once. The stabbings didn't involve me directly, but they resulted in a riot in the lobby. It was bad. At one point, parents were asking me if they were safe, and I had to tell them to just stay in their rooms with the doors closed. Apparently, there was a metal detector malfunction.

Last year, we had a metal detector that didn't actually work. Then they put up a "No Guns" sign. Finally, we got a working metal detector. When the thing goes off, the entrance door to the waiting room automatically locks. Apparently, the lock malfunctioned, so there was suddenly a horde of people in the waiting room, and people fighting in the street. We have our own security guards, and PD was there quickly, but we basically had to go on internal disaster and completely shut down until the lobby could be cleared out. All of my sore throat and fever kiddos had to be police escorted with their parents to the parking lot.

It didn't help matters either that I'm still getting over my stupid respiratory virus. I was feeling much better, but then started to lose my voice. It was so bad that by the end of one of my shifts, the parents were having trouble understanding me. My voice kept cracking like a 13 year-old boy's. I can only imagine all of the blanks that will be showing up on my dictations.

Today's Headlines

Sorry I haven't posted in a while, thanks to those of you who have stuck around.

Lately I have been doing the overnight shift. The bad thing about the overnight shift is that you walk into a messy department. The good thing is that by sunrise, everything has pretty much calmed down.

I have been involved in no small amount of trouble over the past week. There have been shootings, stabbings, and the usual strokes and heart attacks. For the size of this city, we do pretty good. One of my attendings says that working on the pediatric side is pretty much like practicing veterinary medicine, because the infants can't tell you what is wrong with them. I think the same is pretty much true of trauma patients.

I generally don't get much of a story from them. It's usually something along the lines of, "I don't know what happened, I heard gunshots and then I realized I had been shot." Or the more classic, "I was walking to church when this guy just walked up and stabbed me in the chest."

It is generally the next afternoon when I wake up that I get the full story. There's nothing like hearing that the guy you spent 3 hours resuscitating was part of a string of retaliation while you sip your coffee. Or that the guy that died got stabbed because he called his girlfriend a "fatty". Hell hath no fury like a woman scorned, I guess. But then I guess it's better that we don't know what happened... easier not to develop a bias and all that.