All hospital nurses know about that silence in the parking garage after your shift, the one where you shut the door and sit in your car and just zone out after your shift.

Here’s a little known secret that the ER holds dear.

Waiting for a helicopter to land is AWESOME.

You take the gurney out, stand by the wall, and wait as the noise of the rotors grows louder and louder and the little dot becomes larger and larger. Sometimes leaves and gravel blow against your face and exposed skin and it stings but you don’t even care. The noise of the chopper makes everything else obsolete. You can’t hear alarms beeping. Or your radio. Or the call lights or the phones or that family member that’s put at the desk again.

Hi there everyone!

Soooo sorry for the lag – it turns out finding a new and cheap (yet good! and functional!) email service was harder than I thought.

This is our first ‘to everyone’ test email – and this will be our new provider, over here at buttondown, which is a smaller operation but seems to be ethically sourced ;). (And I never thought I’d be in the business of needing to find an ethically sourced newsletter provider but here we are in the year of our Lord 2021, heh!)

I’ll be making a post from substack tomorrow, to sweep up any people I might have missed, and also to remind people to cancel their subscriptions to us over there.

Hey people, sorry that it’s been a bit — L’Erin’s still on her well deserved vacay, and I’ve been recuperating/happily dealing with book release things.

Unfortunately, recent news has come to light about substack (this newsletter platform here) secretively funding anti-trans authors to make their platforms appear bigger than they are and/or giving them advances to generally help them to survive authorially and….

EFFFFFF THHHHATTTT.

Cassie again!

I know y’all follow L’Erin and I for the exciting hospital action, but the entire reason L’Erin and I even know each other at all is because we’re both writers off shift, outside the hospital.

What do we write in our free time, when we’re not at the hospital, you ask?

Well…what write…is REALLY GOOD (and also v. steamy) paranormal romance — and just came out today!

This is Cassie, and I’ve prescheduled this post to go live on 3/14, which is the first day I took care of a covid patient at my hospital last year. I know it was 3/14 because I made it my pinned tweet on twitter, the same twitter thread I made walking on my way into work that day.

This is likely going to be a mess of a post, so bear with me.

Have you ever died before?

(Jesus wept, Cassie, you’re a morbid fuck, you think. WHELP THERE’S A POINT TO IT…this time.)

((Also, I have recently had my Wellbutrin dose upped, thank you very much.))

So I’ve kinda-sorta died three times.

Cassie here again (and I’ve prescheduled some posts and L’Erin’s on vacation soon, so the next few will likely be from me, too.)

Had my first real interaction with a family under non-covid circumstances yesterday.

They were only allowed to visit because their loved one was dying, and our visitation procedures are still really hard core…but eventually there were four strangers in the room with me, along with their loved one.

It’s been so very, very long since I’ve seen a ‘normal’ death, that I’d almost forgotten what to do.

So here’s the link to pt one of my EKG overview for laymen, in which we covered the P wave on the EKG, which indicates atrial action.

Now it’s time to talk about ventricles! (Remember, again, I’m not your cardiologist ;))

Let me start by saying this—mental health care and substance abuse care in this country needs a MAJOR overhaul. Inpatient psychiatric beds are extremely limited, outpatient and aftercare programs are hard to get into, and funding just keeps getting slashed and beds eliminated.

I could go on and on and on, but I really want to talk about acute crisis and why emergencies departments struggle to meet the needs of patients suffering acute psychiatric and substance abuse issues.

They often go hand in hand—people self medicate because their brain is on fire and they don’t know how to make it stop. 

So, you have a lot of “dual diagnosis”, or depression with a side of alcoholism. Both problems require treatment, are complex and difficult to treat in an emergency setting, and often require lifelong care and attention. 

Hi all, Cassie here, and it’s been awhile since I’ve neeped out on a particular teaching topic. This one is near and dear to my heart (*ba-dum-ching!*) so here we go, with the usual caveats — I am neither your cardiologist, nor am I a cardiologist, this is just an armchair overview for people who’ve wondered what the hell EKGs show and how the heck they work.

(Someone has told me this is especially timely now, given how many personal heart trackers, etc, there are out there on the market, so hooray! Happy to be of service.)

My last few posts have been pretty heavy, so here’s some lighter reading fare today. The black cloud phenomenon. It’s a real thing, just like Murphy’s law. You know, the one that says if something can go wrong, it just definitely will. The one the Emergency Department runs on. If nothing ever went wrong, we wouldn’t have jobs. 

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Recently read a post on a nursing Facebook group bitching about floor nurses not taking report because they were on a lunch break. In fact, one poster said it happened to her coworker and her coworker told the nurse “well, we don’t get breaks in the ER so your patient will be up shortly.”

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Banging this drum one last time!

If you’re a writer, a nerd, or both (like me!) — I’m giving a free talk (although donations accepted) for Dream Foundry (a non-profit org for new writers)!

Injuries in Fiction and Writing About Other Medical Topics — via zoom, 1 PM PST today!

Tuesday was a shit day, from start to finish. 

It was bitterly cold, 16 below zero when I left for work. The roadways were frozen solid. I almost hit a car that spun out on the highway and came back heading directly at me. I dodged that bullet and made it in and I KNEW this did not bode well. 

We had something like 17 car crashes in the first two hours as well as a pretty horrific trauma unrelated to the weather. The biocom (radio that EMS calls to notify us of incoming patients) was barking nonstop. This is medic so and so coming to you with two patients, rollover at highway speed, airbag deployment, no seatbelts, heavy damage. And on and on. 

Thankfully no one died, and most had minor injuries, but they just kept coming. And coming. And coming. 

People on twitter say this to me ALL THE TIME when I brawl about masks and hypocrisy.

Like they think they’re going to hurt my feelings.

I started off with a (very short) career in sales before I went to nursing school. This was before Air BnB was a thing — the place I worked for had a business model based around renting out people’s unused vacation homes in Cabo San Lucas. There were twenty of us in the office, and we all worked for one rich guy who had several homes himself.

It was an interesting experience — I doubt they’re still around now — and it taught me a lot about how to be circumspect.

You see, I’d never been to Cabo personally.

We had a DOS program, where you’d put in how many rooms people needed, and dates, and we could go off of available inventory, figuring things out — and there were photos I could look at, and that I could send to the clients, online.

This is a 100% true story — but let me preface this by saying I don’t actually like geraniums.

I love a ton of plants, but geraniums don’t do it for me — I don’t have the patience to deadhead them when I’m supposed to so they always wind up looking scraggly.

But I still have a bunch in my front yard, from this home’s prior owner. I had my gardeners cut them back when I was going All Succulent All The Time…but the effers grew back anyways. Around my succulents. So now there’s a whole hostage situation going on, where I can’t water one without watering the others, and on some level I have to respect that.

All of us!!!!!!!!!

Went to bed at 10, up at 3. Story of my life. Don’t sleep much between shifts anymore thanks to COVID related and capacity related stress. Thinking about what a resident once said after listening to me and my coworker talk about going to dinner after work, maybe thirty minutes after a bad trauma. It was probably his first grotesque experience, but for us it was just another Tuesday. And he turned around and said “Jeez, does anything ever bother you guys?”

He was only half kidding. And I thought something along the lines of ‘boy, you’ve got a long road ahead of you if you don’t learn to compartmentalize a little bit, bud.’ This isn’t even going to be the worst thing I see this week. Sure, they might be missing a few pieces, but they’re going to survive.

Cassie again, with a fun (depending on your definition of fun!) opportunity :D.

I love to do education, I love being a nurse, and I love being a writer — and this is where those things all get to intersect!

I’m doing a Webinar with Dream Foundry about Injuries in Fiction and Writing About Other Medical Topics on 2/20 at 1 PM PST!

My coworker said this after a patient threw a full urinal at her because his meal tray hadn’t arrived yet. He ate dinner at 5 every day and it was 5:15. Never mind that she had no control over meal tray delivery and had spent the better part of an hour giving multiple units of blood. He was also angry because he’d spent over a day in the ER because there were no beds upstairs. 

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Even more Cassie ;) —

In going back and rereading the question that the subscriber asked (but after having already made my LOVELY PLANTS POST, because I love my plant-children) — I kinda missed their point, so here goes on that — let me quote KB here:

Cassie again!

Awhile back we asked paid subscribers if there were any questions in particular they wanted answered, and someone asked how we got back to normal after shifts, and I thought I’d use this slot here to talk about how I do that that with y’all.

(TL:DR, scroll down to see photos of my garden that I’m inordinately proud of)

Ok, so if you follow me on Twitter you might know my most famous tweet ever was about butt stuff. 

Yes, people put stuff in their butt and lose it. No, we don’t really care that you do it anymore that we care that you put a ladder on top of a lawnmower to reach a chandelier and fell off it. People do dumb shit. They end up in emergency rooms. 

Ok, so you already knew about that? Cool, let’s talk about other weird shit.

Hey peeps, Cassie again!

I just finished off a 12 hr shift (although I’m pushing this post out into the future some for HIPAA-adjacent reasons) and I thought I’d give y’all a summary(ish) of what went down while it’s fresh in my mind

So, first off, my patient was a 1:1 patient, which meant that I was their only RN (although I happened to have a new-hire/gopher that day, which was great.)

The reason they were a 1:1 was because they were actively dying with covid.

Ok, so the ERs are overwhelmed, right? You’d have to live under a rock to not see images of ambulances waiting to unload and patients in hallways and hear about record wait times and how people are being sent home on oxygen because in some areas there are no rooms, right?  

Yeah. It’s real. Everything sucks right now. November/December was really fucking awful in the Midwest—January has not been as awful, though we are still at 90%+ capacity in most facilities and ICU beds are pretty hard to come by. It’s the “new normal”, a phrase I first encountered after my son passed away, and this is the second time I keep hearing it used regularly. I can interpret that as this is just how it is, it’s gonna suck forever, so get used to it.  

A few days ago one of my coworkers said “remember how pissed we used to get when we came in if there were ANY inpatient holds and now you’re just like “YAY THERE ARE ONLY TWENTY” and I was like YES THOSE DAYS WERE THE BEST. The BEST. I wanna go back.  

Hey there, it’s Cassie again!

Thought I’d take a moment to go through and explain what ‘life support’ really means, since it’s a term that gets tossed around a lot but if you’re not a medical person you might not have a great context for it.

At its broadest, life support is anything that you require to survive — makes sense, right? It’s any therapy that if you didn’t have — you would die.

Before I get into the explanatory weeds here — sometimes we’re taking care of people’s grandmothers, who’re writing them notes on facetime or sending texts, and they’ve got breathing tubes in or they’re on 3-4 pressors (blood pressure medication, more later) to keep their BP up, and they are very much alive!

“You signed up for this.”

“Well, you’re getting paid a lot.”

That’s just some of the things people have said to medical professionals who have voiced how difficult healthcare is during this pandemic.

COVID-19 really has done quite a number on our headspace, especially in the ER. We’re not only treating acutely ill patients with a highly contagious virus, we’re holding record numbers of admitted patients, and while most of the public is pretty chill about wait times and hallway beds, some are definitely not. 

Sometimes I’m like why am I still doing this?

And then I have to remind myself. 

Head on collisions and partial amputations, 

Hey there, it’s Cassie, sorry it has been a bit between posts! Both L’Erin and I were swamped with work and general malaise.

I got my second vaccine shot last weekend. Felt out of sorts for a few days, unsure whether that was my shot, work, my mother's continuing poor health (due to her having covid), or being an American, heh.

My mom went back to the hospital a few days ago and they X-rayed her, found out she'd gotten pneumonia and a UTI. They've blasted her with antibiotics since, and she feels better again. I hope it sticks. (For the record she's been fighting this since Christmas...and I can't say I TOLD YOU SO until she's all the way better, heh.)

So about a month ago, an Oregon nurse was put in leave, then fired after she posted a TikTok video about traveling maskless, encouraging play dates, etc. There was a tremendous backlash from Twitter users and the Internet sleuths found her real name and her job, and she was subsequently dismissed from her hospital. Also, she was an oncology nurse, which is just....so fucked.

Right after that this other idiot in Florida did the same thing, and get this, she was a PEDIATRIC nurse who worked with special needs and immunocompromised children. Same outcome. 

We’re going to talk about some recent racist incidents in medicine today and what I’m going to say is important.

The first one I want to talk about is FarmerNurse. FarmerNurse aka Wee Key aka some chick in one of the Carolinas, a Registered Nurse, flashed the “ok” symbol affiliated with white power while fully gowned in PPE on TikTok. She was promptly fired after multiple people reported her, even though she shut down TikTok and other social medias. But there’s a lot to unpack here.

I was scrolling through Facebook when I caught a glimpse of a photo from my friend Sara. It was Sara holding her son’s hand., with an ambulance cot behind the bed. That wasn’t what caught my attention. The picture didn’t show his face, just their hands and a small glance at his chest—where I saw what looked exactly like a Ballard closed suction catheter. 

My heart stopped for a second. He’s intubated? How did this happen?

(This is going to be long, bear with me and settle in.)

As a lifelong nerd with a writer’s morbid side-interest in all the ways people can die and a habit of following all sorts of people on twitter, I started seeing the news about covid out of Italy, straight from Italy, at the end of Feb, and very early March.

I couldn’t tell what the Italian broadcast I was watching said, but I didn’t need too — they were inside an ICU, I could tell from the ventilators and the pumps. And the second I saw multiple people flipped over on their bellies, I thought, “Oh, no. This — this is bad.”

This is our first ‘subscribers only!’ post! (Mostly, because we believe in large part that information, especially on health-care related things, should be free right now.)

But we very much appreciate your support (and in fact you’ve already funded a purchase of brand new nursing shoes for me, thanks! ;))

I’ve just finished lining up this upcoming week’s posts for us, but I’m too brain dead from working back to back 16s to be otherwise functional right now. (I’ve worked 104 hrs this pay period, that includes five 16 hr shifts and two holidays. I remember my name, and that’s about it.)

I still thought I’d reach out and check in though, as we enter the new year — do you have any questions or thoughts, no matter how random, weird, or mundane — that we could answer for you about nurse stuff, hospital things, or covid madness? Or just something you want to get off of your chest and have us amplify?

Just don’t.

I’m putting this placeholder post in here now, and we’ll see if I get a chance to change it between now and the 31st.

I have every intention of coming back here and writing something moving and thrilling that makes you totally reconceptualize your view point and gives you the munition you need to explain to everyone else in your life why you’re staying home as much as possible — and not only that — but something SO MAGICAL it CONVINCES THEM TOO to stay home, like some ‘I clap for fairies!’ fever dream that flows outwards from all of our well-meaning hearts to somehow inspire and heal our nation and get everyone who is currently a dickwad to stay home and not breathe on anyone else in the new year.

Let’s talk about what happens when hospitals begin to reach capacity! High bed occupancy is defined by some as reaching 85% capacity. This is significant for mortality rates increasing in the neighborhood of 9% according to a 2014 study.

But why, you ask, would being at 85% capacity mean increases in mortality?

Because capacity takes a whole lot of things into account. For example, “ghost beds”. There are hospitals that utilize semi private rooms. Due to COVID-19, these have been made private for infectious disease control purposes. But that bed still counts towards capacity.

How to behave in a pandemic when your local hospitals are at and over capacity in order to decrease the strain on the healthcare system and workers.

1)      Utilize the emergency rooms for emergencies. If you’re calling to ask if the ER is busy, if we’re full, or what the wait time is, your needs can probably be met by an urgent care.

2)      Insert photo of things for urgent care cause ER

3)      Don’t call to ask if we have COVID patients. Everyone has COVID patients. Sorry.

I hope everyone had a safe holiday at home with a minimal amount of people and no one outside your pod!

Work’s cray. Some of you all follow me on twitter, so you’ve seen my ongoing messages from the staffing office, but if you haven’t, here was my weekend:

Today I'm going to explain oxygenation and ventilation in layman's terms, so y'all can play the home game! (This is a recap of a prior post based off a viral tweet I had in spring. I sent it to my author mailing list a bit ago, so if you’re on both lists and this feels familiar, that’s why!)

At the time I wrote it it was more to explain why NYC needed so many vents so quickly — I’ve tweaked it now to explain more about why people with covid might be on a vent.

This is by far the most frequent complaint in the Emergency Department. Why does everything take so damn long? It even SAYS Emergency in the name, so shouldn’t everything happen just lickety split? How come I’ve been waiting here an hour and that person was whisked back to a room right away? Why haven’t I gone for my CT yet? The doctor said they would come back and discuss my test results and I haven’t seen them once? Why can’t I have food if I have to wait this long?

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Once I got interviewed & asked if I was a character in one of the stories I wrote, to describe myself. I said I was a woman hovering on the edge of middle age who was sick of everyone’s shit. This was in 2019. As 2020 draws to a close, I *think* I’m officially middle aged (40), l’m fucking done with everyone’s shit, and I’m mad as hell.

My next post was supposed to be about violence towards healthcare. (Hey kids, do you like violence? Work in the ER!) but now Marco Rubio, Mitch McConnell, and Lindsay Graham have received the COVID-19 vaccine. 

Countless ER, ICU, and other frontline staff are still waiting. I’m lucky—I was vaccinated Wednesday, December 16th and I was proud and honored to receive mine. I worked my ass off for that vaccine. I need it, not just to protect myself and my loved ones, but my patients and my community. 

I know what you’re expecting. Some bloody traumatic injury, bones and gristle all exposed. Severed limbs. Open chests. Eyeballs on the cheek. Maybe a Christmas tree being extracted from a place it shouldn’t be. And I have those stories, dozens, if not hundreds of them. I’ve been doing this a loooooong time. Say I saw a terrible thing a month, so 12 times a year. Multiply by 18. Somewhere in that neighborhood. Probably more because of the law of threes and sevens. If you’re not familiar with that piece of superstition, it’s a common belief that bad things in our world happen in threes or sevens. So, if you have two codes in the department on day shift, there’s either one or four more to go before the cycle is broken. 

But you can find the gore in any horror movies with good special effects. We’ve seen that, up close, and it’s really not that cool. It’s disturbing and traumatic and horrible, so those aren’t stories we revisit very often. It’s more along the way of “remember that cop that threw up after he handed you that arm in a grocery bag?” I have seen every body part opened and every organ, or part of it, up close before. I’ve been there when chests are cracked open and seen more blood than I thought was possible, gouged myself accidentally on an exposed shattered bone, and seen things turned inside out that weren’t built for that.

Hey there, ICU RN Cassie here. Let’s break down how ICU capacity works and what effects it, m’kay?

BECAUSE I AM SEEING THINGS ON TWITTER THAT MAKE ME WANT TO STRANGLE PEOPLE.

(I’m usually brusque with idiots, but this is a very special late night ‘I’ve worked two very long 12s and have another long-ass 12 to look forward to tomorrow’ so there’s going to be extra curse with curse-sauce.

I have a (mostly) private journal that I write my thoughts and feelings down in sometimes, as I have them, and that’s important because other than anger I don’t often let myself have feelings anymore.

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The other day, a trauma surgeon and I were having a lively discussion about whether hangings meet criteria for trauma activations. See, back many, many years ago when trauma criteria was a new deal and lists were being made, a lot of hangings had cervical spine injuries and vertebral artery dissections. These are interventions that have a high probability of requiring surgical interventions, hence the need for trauma team activations. This is because many of the hangings studied were judicial, which is a fancy way of saying “executions.” There was certain way the noose was tied and there a significant fall prior to the noose “arresting” or stopping the fall, which had a much higher chance of death or causing the kind of injuries that require surgery. Most of us will never see these kind of events.

Suicidal hangings tend to be much more common and not performed from a significant height. This results in much less “trauma” to the structures in the neck, and injury/death occurs from asphyxiation; or suffocation. In this respect, I told him, they were much more like a drowning, something that isn’t a trauma activation. At which point, he said, “well what if I strangle you? Is that traumatic?” (Note: we have a good working relationship!!! This was not threatening or uncomfortable!) And I said “I don’t know, are you buying me dinner first?” And he just shook his head, and said “ER nurses. They always have something else to say.”

Hey peeps!

Some cool/interesting/poignant stuff caught my eye in the past 24 hrs and I wanted to share:

First off — check this tweet, it’s AMAZING. I recommend sound on!

It’s around 3 pm. I’ve been at work since 6:30 am. I haven’t eaten and have peed once. I gave up on getting everyone their 30 minute lunch somewhere in the last hour and everyone’s getting fifteen minutes, one at a time, to step away and grab a bite to eat. I’m walking down the first hallway to check on the staff in the back; I’m avoiding the second hallway because there’s a patient is extremely upset about being in the hallway. I’ve explained we are utilizing hallway space to make sure people receive timely treatment, rather than waiting longer for a private room to open up, that this way we can manage pain and nausea immediately rather than delaying treatment.  There’s also a very sweet elderly lady on oxygen, who needs the next open room because she has a significant cardiac history and needs telemetry monitoring. As I walk down the hall, I’m asking myself why the hell I’m still doing this ER thing anyway.

It’s a question I ask myself a lot these days, along with how much longer I can continue under the current circumstances. Our hospital has been packed since August, the ER is constantly full and holding admitted patients, and seeing a higher volume of sicker patients. Patients are unhappy, staff is exhausted, space is an ongoing problem. 

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I’ve been a nurse for 19 years, the last eight in the ER. I’ve had a love hate relationship with my job the entire time, which matches up pretty well with my romantic relationships, but that’s another series of stories. I love the chaos, the fast pace, the madness, the trauma and the codes, that one day everyone is critical and you’re saving lives one after the other. I hate the sense of defeat that comes with some shifts, I hate failing to save a life, I hate the way necessity dictates some people wait for a very long time because while their matter may be medical and require care it is not life or death, and mostly I hate the lack of control I have to fix everything in a timely fashion.

I meant what I said, and I said it because it’s true.

(So much for the soft launch, let’s just dig right in here!)

I’m writing this right now from my car in the Safeway parking lot near me, waiting for a prescription to be filled. I live in Oakland, CA, and my Safeway is on Fruitvale Ave, the same Fruitvale you may remember from the amazing (and sad, and anger inducing) movie Fruitvale Station that came out awhile back.

Many of my coshoppers – if not the majority – are black.

Welcome to twonursestalking’s newsletter by L’Erin and Cassie. We’re nurses who also happen to be professional authors, and as you can imagine we’ve got a lot we’d like to get off our chest right now.

We met on twitter, where the both of us have been continually frustrated by the limitations of the character count against an unrelenting tide of bad takes and covid-related stupidity.

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So, who are we?