Drug Pusher

Must be new ...

2011-04-04T08:18:00.005-05:00

"Spook, lab's holding on 5-oh".

I immediately rush over from the emergent-foot-pain-for-four-months-at-3-in-the-am patient to take what could be an important call with life altering critical lab values.

"ER, this is Spook how can I help you?"

Excited hyper-voiced lab dude: "Good Day Spook! I have a critical lab value for you!"

Who the hell has critic... oh wait!
Only person I'm expecting anything to show up on is drunk-hooker-chick who comes in about once every other week, for the past 8+ years, for the same reason - acute alcohol intoxication (sometimes with SI thrown in for variety).

So without any preamble, I ask "so what's her BAL (Blood Alcohol Level)?"
Excited not-so-hyper voiced lab dude: "Oh! How did you... anyway, it's 299!" [roughly 3 times the legal limit].
Me: "That's it? *snort* Business must be hard... Thanks lab dude."

Poor kid! Getting all excited about a BAL of 299 ... on drunken-hooker-chick no less! Obviously he hasn't met our other heavyweights.

I give the kid 2 weeks...

I set the phone down and walked into the med room to procure some STAT Motrin to administer to the emergent-foot-pain-for-four-months ...

Informed Consent

2011-03-18T04:58:00.002-05:00

"Sir, your mother is very sick. Her Troponins came back elevated. The question is do we need to admit her to the ICU where she may need pressors or ..."

The son turned and looked at me. I could already tell that he was lost.
The admitting doctor had just walked into the room and after her assessment, had let loose...

He didn't understand a word beyond "your mother is very sick".
He managed to nod at the 'appropriate' times; while looking politely dumb otherwise.

The admitting doctor carried on and I was called away to another patient who was having trouble with their heart rate.

When I managed to figure out what was going on with my other patient and had intervened to stabilize the problem, Ms. "elevated troponins" was still 'stable' and was being admitted to the ICU with orders for "pressors" among a myriad others.

As I walked into the room, with bags of meds, tubing and IV pumps; the son was sitting at the bedside, caressing his mother's hand while talking in a whisper to her ear.

While I was setting up the IV pumps and meds, I made small talk with Mr. Smith, the son. Are you the oldest son? How many siblings do you have? etc.
"Mr. Smith, I know you just had a serious discussion with the Doctor about your mother's condition. Do you have any questions?"

Scarcely had the words left my mouth when out poured a torrent of questions!!! It was like the Johnstown flood!

Why is she going to the ICU?
Is my mother dying?
What the **** is pressors?
Why are her lab results abnormal? What the hell does that mean?
Why is she so 'sleepy'?

So on and so forth...

I did my best to answer his questions, in layman terms as much as I could. "Pressor is just a fancy word for medicine that helps raise blood pressure. As you can see on the monitor, your mother's blood pressure is too low. If it stays low, her brain and heart and kidneys won't get enough food and oxygen and that'll cause damage." etc.

I ended up spending a good bit of time explaining things to Mr. Smith - and in the end, I had the admitting doc paged back into the room [while I was present] to make sure he had his questions answered.

Mr. Smith wasn't an idiot - he was an engineer who managed a successful business.
He was just clueless about "medical issues". Just like John Q Public with no medical background.

All he knew and cared about was the fact that his mother was sick, literally comatose ... and that's it.

Walking into this room and talking about "ICU" and "pressors" - how the hell is he supposed to understand any of this? Even with a 'medical background' such issues are difficult to comprehend.
Now put yourself in this man's shoes - we're talking about your loved one here. If someone wearing hospital scrubs or a white-coat walks in starts mouthing of "ICU", "pressors", "heroic measures if her heart stops" - what would you think? How would you feel?

Yes, there are mitigating circumstances. "Look, at her condition now, she will definitely die. The procedure we're looking to perform has a chance of success but it also carries the risk that she'll die from the procedure. What are you're wishes?"

Ms. Smith's case certainly wasn't that dire. Critical, yes. Unstable, no.

But even if she was - doesn't the family/kin/PoA deserve that little bit of knowledge? In PLAIN TERMS that they can understand?
Instead of saying "we need to put her on pressors and admit her to the ICU" can we not say "We need to put her on medication to help maintain a good blood pressure that will help her heart and we need to admit her to the ICU so that she'll be more closely monitored" ??

What does that take - an extra 30 seconds of speech?

It just really makes me wonder - how "informed", is 'informed consent'?

Holy Crappy Week Batman!

2009-06-13T02:21:00.002-05:00

Walked into work and as I was swiping in, an unfamiliar face dressed in scrubs with an unfamiliar ID badge approached me and asked, "excuse me but are you a nurse in the ED?"
"Yes I am" I cautiously replied, "how can I help ya?"
"Do you know the code for the tube system?"
"Are you new here?" I asked. I thought we weren't hiring anymore??
"Oh yes. I'm an agency nurse and I haven't worked here before. And they haven't assigned me a code"

OH SHIT!
That's what my mind said the instant she said "agency nurse".
When management is desperate enough to call in agency nurses, you can bet your last dollar that the fecal matter has well and truly hit the air recirculation device!!

I wasn't mistaken either.
Last three shifts have been pure chaos and unadulterated mayhem. You know all the amount of drama they manage to squeeze into one episode of ER? Well, try compressing each episode to 15 minutes and repeat for the entire shift and the next shift and the next shift and the next... that's how it's been down here in The Pit.

A combination of "work everyone up no matter what" doctors, combined with semi-indifferent/downright-lazy support personnel, staff callouts, a downed CT scanner, temperamental tube system, malfunctioning lab software and an erratically performing computer charting system... all conspired to transform an ordeal into the perfect and most horrific nightmare.

If that wasn't bad enough, the patients seeking our services were all the "borderline" kind: Sick enough to die at any moment... but they just ain't dead yet. Which means long, drawn out (and sometimes repeated) codes. Add to this mix, the more than usual amount of violent drunks, actively psychotic and abusive psych patients and more than the usual amount of attempted suicides.

You name it, we ran out of it:
* Pre-filled saline flushes? Check
* Primary IV tubing? Check
* Wrist/ankle restraints? Check
* Hospital beds for admitted patients? Check
* Pre-filled Dilaudid and Morphine Carpujects? Check
* 16 and 14 french foleys? Check
* Blankets (warm or otherwise)? Check
* Food trays (even simple sandwiches)? Check
* 20g IV catheters? Check
* Batteries for portable monitors? Check

On and endlessly on.
Everything from Dynamaps to portable EKG machines kept switching off because there was just not enough time to plug them in to recharge! At one point, our supply of Percocets, Zofran, Ativan and Propofol got so low that Pharmacy had to raid ICU stock for our supply!

I'm just thankful that our water supply didn't run out!

Nobody is yelling at anyone else... yet. But morale is strained. There is definitely a sense of "Us (staff)" Vs "Them (patients)" amongst some of the staff. Management is trying - and failing gloriously! - in trying to perk up flagging team spirit. Instead of support in the form of more staff/better equipment, meaningless platitudes are being offered (again!).

I mean, in what kind of "First Class ED" do I need to hunt high and low for a frigging thermometer??!!

We've been on continuous "Bypass/Divert" status since Monday but it seems to make not one iota of difference. Wave upon wave of the sick, the wounded and the dying keep crashing against the thin white line of ED staff... and we're just barely holding on.

We have not slowed down at all from the winter.

Just yesterday I walked into work at 1100 hrs and there were 19 "holds" (pts. who have been admitted to the hospital but are hanging out in the ED because there are no beds available). NINETEEN!!! Psych, Tele, ICU, Med-Surg, Stroke... you name it, we were holding 'em down here. Close to 40% of our ED bed capacity was being occupied by admitted patients - which meant that triage and bed flow was a complete disaster all day long.

We've been getting slammed like crazy. Last month, we shattered all previous volume records.

I've been consistently working over 44+ hours/week! I was supposed to work 1100 - 1900 yesterday but ended up staying till 2230 to help out because we were so busy (crashing patients left right and center).
And it was on my day off!!!

I mean, it's freaking JUNE; not FEBRUARY! What the hell people??!!

Untitled

2009-06-01T22:26:00.007-05:00

I try all I can, what more is there to do?
Why, lets intubate! And get a ventilator too!
One Pressor, Two Pressor, Three Pressor, Four
There's nothing left to pump into you any more
Five fluids, six fluids, seven bags and eight
yet your foley output shows naught all night.

You lie there listless in bed
and here I am at my wits end.
Surrounded by all of modern medicine's marvels
and with nothing to show for all our travails

The only saving grace, if any
Was that you passed from this world surrounded by family
As cruel and abrupt as was your passing
I can only hope the final battle was worth the living.

I'm tired. My feet hurt. My back aches. My mind is fatigued.
And yet, the thought remains - "what if I'd done this or that or something more?!"
A wise colleague imparts sage advice
"Hindsight never resurrected the dead"...

... and then after a pause, added:
"Go home! Get some sleep. I'll see you back tonight..."

And so I go home to toss and turn
and snatch fits of sleep
For return I must in the morrow
back to earn my keep.

To dance that dance once again
Against that ancient and final foe
We may win or we may loose
But the dance is one we cannot choose

- © Spook, RN [June 2009]

Die erste Pistole

2009-05-14T19:11:00.006-05:00

About 10 days ago, I walked into my local shooting range and put down 500 smackers for this little beauty:

The Smith & Wesson M&P 9 9mm semi-automatic pistol. Truth be told, I wanted the Beretta 92fs but apparently there's a serious shortage of Beretta pistols. I also liked the CZ but going by the advice I was given (stick with "tried and true" brand names for your first pistol) - I decided on the M&P. And I gotta say, them interchangeable back-straps was a big selling point to me. The ergonomics of the pistol is superb (which is another reason I really liked the Beretta and the CZ - the "feel").

So yesterday, I went over to the range and sent 200 bullets at this target:

Yes, yes. I know. My aim sucks (12 yards). But that's the whole point of buying the pistol - gotta work on that aim!

All in all, I'm one happy little boy.

Next up:
M1 Garand
Beretta 92 fs

Gotta start puttin' in some overtime at work! :-)

I curse the fact that ...

2009-05-06T22:03:00.008-05:00

... my iPhone can't record video and I didn't have my camera around.

I was walking out of the locker room headed toward the ER (ED if you are... well, you ought to know by now) to start my shift when I heard the unmistakable sound of a piano! Our hospital foyer has a grand piano but to date I always thought it was just for show.

My curiosity piqued, I mosied over. And what a sight to behold!

One of our Urology docs was belting out a kick ass rendition of "Bloody Well Right" by Supertramp! Right there in our hospital foyer. He had this big, silly grin on his face as his fingers danced over the keys.

I just had to walk over and ask... I mean, I couldn't believe my ears!

"Hey Doc! 'Bloody Well Right' by Supertramp, right?!"
He just looked at me and nodded, that grin still plastered on his face. He was obviously enjoying himself :-)

So that's that. Along with Uro Doc, that makes 6 other people (other than myself) that I know of, who have heard of Supertramp and who obviously like their music.

Holla at all you Supertramp fans out there!

Confession...

2009-04-25T11:57:00.006-05:00

I just rediscovered "Swervedriver"... and fell in love all over again.

The live version of "Duress" absolutely kicks ass.

That is all.

Notice to all current owners of handguns...

2009-04-23T09:58:00.007-05:00

EDIT TO ADD:: All future readers of this post, disregard the "(note: concealed/open carry is not an option in my State)" part of the following post.

In other words - I'm looking towards your opinion regarding your recommended "carry" weapons (be the concealed or open); or otherwise.

Thanks!

In any case, here's the original post ------
... that means YOU AD! And LawDog! and... all others :-)

My permit has finally arrived.

Here's the deal -- I'm having a SUPER hard time picking out what I'd like to own (note: concealed/open carry is not an option in my State).

I'm looking for something self-defense-ish (but not limited to). I've shot/tried the following -

* S&W 14 6" barrel 38 special
* S & W M&P (both the 9mm and 0.45 - I prefer the 9... didn't like 45 wasn't too comfortable)
* Colt M1911
* Springfield XD
* Sig Sauer P220 (have to re-evaluate this one)
* Glock 19

That's about it... I have a 90 day window period.

Please recommend your favorites and why.
Oh and anyone who can recommend a place I can get my hands on a good M1 Garand, please let me know!

Thanks!

The Med Error

2009-04-21T06:03:00.008-05:00

My first med error (and as things go in ones career, the one I VIVIDLY recall the most) happened when I was orienting on days, my first job as a brand spanking new RN on an extremely busy ortho-neuro-gyne-med-surg floor (years later, my co-workers and I took to calling our unit 'The Dump'. Anyway...)

I had an absolute KICK-ASS preceptor who'd been working there for decades. She was smart, talented, hard-working, dedicated and blessed with a dry sense of humor She rode my ass mercilessly all shift long, every single day at work. Her simple rationale: "I'm not trying to be a 'nag' but I'm trying to give you an idea of how really hard this job is. Make use of me, my time and expertise the best you can NOW... because in 6 weeks or less; you'll be ON YOUR OWN".

She scared me poop-less.... but she also made me sit up and take notes.

Now, all "background story" aside:
I was on my last shift of week 3 of orientation. I had a 79 year old post-op ORIF of the Left ankle. I'd gotten through the initial 4-hour period window of post-op patients with their constant monitoring... heck, I'd even gotten 70% of my documentation done. I grinned to my cocky self and thought 'this is going good'.

As are many patients who are post surgery, pt. developed nausea and vomiting. There was a standing order for Droperidol (Inapsine). I drew up the right amount, checked it against the MAR, and showed it all to my preceptor before walking into the pts. room to administer it.

I administered the dose with no hassle, flushed the port and after reassuring the family that the medication should help, left the room to chart.

15 minutes later, as I'm walking by the pts. room, I notice that she seemed drowsy. "Maybe pt. is just tired." I told myself; "After all, pt. has had a long day." I congratulated myself on the quick intervention to resolve pts. nausea/vomiting and my head ballooned with grandiose ideas of what a 'kick ass nurse' I was going to be.

Well, as they say - pride commeth before a fall.

Half an hour later, as I was walking by rounding on my patients, I noticed that the pt. I'd administered Droperidol to seemed to be in a REALLY DEEP SLEEP.

My "still-cocky brain" somehow managed to tarry a tad bit longer to ogle its fine work. Ahhh, she's resting so comfortably....
That was when the "other" brain's screams became more audible.... "she's not breathing! She's not breathing! She's not bre...." (and so on)

!! PANIC !!

Klaxons went off in my "cocky brain" and my bladder did it's best to burst past my sphincter and empty itself in a glorious waterfall onto my shiny new white scrub pants...

I somehow managed to "rush into the room" while also not outwardly appearing to "rush into the room". My mind was racing the speed of light and winning, while all my lungs could do was echo the "Oh my god! Oh my God! Oh my God" chorus... as my heart proceeded to jump out of my mouth and take off for parts unknown.

Outwardly, while I did my best to not appear to be the nervous debris that I was, I attempted a feeble smile at the family as I managed to croak "I'm just here to make sure XYZ is all right"... while my stomach was doing somersaults worthy of an Olympic gymnast medal.

The pt. was a 'little hard' to arouse. But to a noobie nurse like me, anything less that "full arousal" was = "comatose". Even though my heart was incognito, I could feel its rate climb into the Ionosphere. A cold, icy ball materialized in what was left of my stomach....

"Cocky-brain" had been replaced by "Panic-brain". "I killed the patient" seemed to be the medley of the moment - interspersed with "you are an idiot" and "how stupid of you" and various other choice epithets [I'm omitting a few phrases (ok, LOTS of phrases)]....

Miraculously, from somewhere in the depths of my foggy (non panic-ky) brain, I latched onto an idea. I walked outside and brought back a portable pulse-ox machine. This way I'd have an idea of the pts. heart rate and oxygenation while I manually counted the respiratory rate and the blood pressure.

My initial readings were fairly "normal" (i.e. not too deviant from pts. known baseline and previous vitals)... save for the respiratory rate. For the rest of the shift, it hovered around the 12-14 mark (while the other signs stayed stable).

For the remainder of my shift (6 hours), I was in that room as often as I could (sometimes as often as every 5-10 minutes).

Throughout all this drama, my preceptor kept mum - except to encourage me to check in on that patient as often as I could while also hounding me about my other patients.

By the end of that shift, I was a wreck. I was convinced I'd nearly killed the patient. I had worse than a "lowlife no good slacker" opinion of myself. My report off to the night shift was very somber and gloomy.

As I plopped my weary butt down to chart after the shift, my preceptor mosied over and nonchalantly said "you want to talk about it?"
Dejected, head downcast, I mumbled "I'm so sorry. I don't know what happened. One minute pt. was fine but the next minute.... well; I don't know what to say!"
She simply asked "Well, what do you think happened? What do you think caused the pt. to become that way?"
"I really don't know", I stammered. "I wish I did!"; I said, somewhat emotionally.

"Walk me through it. Walk me through your interactions with that patient during the shift".
And so I proceeded to describe it all, in painstaking detail.

"Do you think any of the medications you gave the patient over the shift might have caused that?"

*Blink* *Blink* "Why, now that you mention it, the whole damned business started after I medicated the pt. for nausea!"
"Well, what did you give?"
"Inaps.... wait a minute!"
"How fast did you give the Inapsine? Did you give it slowly over a good 1-2 minutes?"

I thought real hard. And then it hit me - in my eagerness to relieve my pt. of nausea/vomiting; I might have slammed the medication in too fast. 0.625 mg didn't seem like "a lot" to my dumb-brain... but I'd forgotten to take other criteria into consideration. Not to mention the cardinal sin of administering a medication I wasn't too familiar with - especially with regards to effects AND side-effects.

My face turned a beet red: "I... uh... might have... ummm ... given it a little too fast".

My preceptor smiled and winked at me and said: "Lesson learned".
I was thunder struck!! "WAIT!", I sputtered; "you KNEW all along??!! WHY didn't you tell me???!!!"

"Because I'm here to teach you and you're here to learn. Knowing you, I'm rather confident that after today - you will never give any medication without knowing what it can and cannot do... and how to give it appropriately. Being a nurse is more than charting meds and giving them as ordered - as you've no doubt learned today."

She then reached over and patted my back and said: "Don't beat yourself too much over it. I was observing the patient all along too. Your subsequent reaction to the patient's status is commendable - if a little inefficient. But, you're learning and you attempted to do the right thing; which is what counts any way. Someday, I'll share my own 'learning lessons' with you. But for now, finish your charting and I'll see you tomorrow".

It has a mark left in the only place that counts. No matter how old or how experienced you get...
You never forget it.

"Old Lady With The Low Heart Rate"

2009-04-11T02:50:00.007-05:00

I think this one is one for "the books". Y'know? The 'stash' of interesting patients/encounters that you file away some place?

Last week I was assigned to one of our two "Acute side" pods [2 nurses to deal with a theoretical 8 beds.] Naturally, given the state of Emergency Departments these days, those "8 beds" can 'stretch' to 12, 14 or 16 (this is the "acute side", mind you) depending on how many patients you can cram in before you're 'forced' to go on Divert... and of course, you don't get any additional "help" when you're over loaded. Management seems to think that it's ok to staff 2 nurses to 8 beds even when 6 of those patients are on vents...

... but I digress.

Anyway, my partner and I are already dealing with 13 patients (6 in rooms, 7 in hallway stretchers - some "sharing" hallway assignments) when we're curtly informed by the charge nurse that one of our room patients needs to come out because there's a lady out in triage with a "low heart rate and no discernible BP".

My partner and I look at each other and practically play 'Rock, Paper, Scissors' to decide which one of our "critical patients" in our rooms has instantly become 'less critical' so that they can sit out in the hallway while we treat this new patient emergency....

Ok, Ok. Just kidding. We pulled one of our semi-stable chest pain patients (the one we deemed to be at the lowest risk of all our patients) out of his room to open up a spot for our new patient (but we DID play rock-paper-scissors to decide who would pick up the new patient and I DID lose...)

So I walk into the room as the triage nurse and a tech assist the patient to the stretcher. I introduce myself to the patient and her husband (they're both about 90+ years old) and I note that the patient can still walk, albeit with assistance... and that she's still talking.

Triage had told me that the patient's HR was about 30 bpm and she couldn't get a BP.

Not the kind of behavior I'd expect from someone with such a low HR and no BP!, I thought to myself.

As she was settling in, getting undressed and hooked onto the bedside monitor; I asked my questions while surreptitiously assessing the pt. Radial pulse indicated a HR of 28. To confirm, I checked a carotid... also about 28-30 (with super-long pauses between beats). I used my stethoscope to check out her lungs and heart sounds - nothing exceptional other than her irregular bradycardia, with long pauses.

I did a manual BP - she was 55/20!

But she's sitting up and talking to me! Her only complaint is "feeling a little dizzy, like I've been feeling off and on this week except tonight it got worse".

Well, I'll say!

Of course, while this was going on; other things were stepping into high gear. Someone showed up with the EKG machine, someone else started hooking her up to the bedside transcutaneous pacer and a paramedic student started looking for a vein for an IV in her arm. I requested that he get an 18 gauge in her Right A/C and to come grab me if he had any trouble.

The patient shoo'ed all us 'men' outside (especially her husband) as we were trying to get her undressed for the EKG/monitor. She managed a wry smile and said "even after all these years, I'm still modest about myself around him". That elicited a chuckle from the two female techs and a grin from me.

"Well, you got nothing to worry about from us M'am. We'll make sure he doesn't catch a sneak peak", I said with a grin; which elicited a good belly laugh from her.

I figured it was time for me to step outside and talk to the husband.

"Hi Mr. Smith. While we're getting your wife settled in, I'd like to tell you what we're planning to do. First we'll hook her up the the bedside monitor so that I can keep an eye on her heart and other important signs even if I'm not in the room. Some of my colleagues are going to do an EKG, a simple electrical "picture" of her heart to see if there is any abnormality. Other colleagues are going to start an IV on her and draw some blood at the same time to test and see if she is or has suffered heart damage in the near past.

Do you have any questions so far?"

"No, I don't", said Mr. Smith.

"What I'd like to ask you though is your perception on things", I continued; "What made you bring her to the ER tonight. Has anything changed over the past week or was it something that happened tonight? Were you engaged in any activity which is not the norm for the two of you? Any strange/different food or drink? Medications?"

When I mentioned medications, Mr. Smith calmly tells me, "I think she took one too many of her BP meds. That explains her symptoms and her bradycardia. I don't think it's anything serious but given her bradycardia, I thought it best to get it checked out".

Now, normally, I don't have 90+ year old gentlemen use the words "symptoms, bradycardia and BP meds" in the same sentence... much less articulate them in a manner as to suggest a medical diagnosis!

Before I could ask the husband where he learned them neat words, out comes the paramedic student with a grin on his face as he hands me a bunch of vaccutainers containing blood samples. "Here you go Spook! 18G in the Right A/C, just like you requested".

As I was thanking him, the student turned around to face the husband and exclaimed, "Mr. Smith! Say, you wouldn't be the same Mr. Smith who was head of cardio-thoracic surgery at Sprawling Metropolis Trauma Center, would you?! I've heard so much about you! My Dad was a paramedic and he used to talk about you all the time!"

I swear I saw the old gentleman in front of me *blush* and mumble, "Yes. I was. But that was a long time ago".

Well, that probably explains him knowing all them words, eh?

Right when I was about to say something, the tech walked out with the 12-lead EKG report. I quietly stopped her and took the paper copy of the EKG to show it to Mr. Smith. I let him take a quick look at it, before I hurried over to the ER doc to show it to him.

Both the ER doc and I now approached the patient and her husband, to explain things as to where we stood. The ER doc was convinced that while her condition was serious, it didn't warrant an immediate pacemaker implant or surgery. Her lab work seemed to indicate no emergent abnormalities and he was inclined to agree with the husband that the pt. had probably taken one too many pills by accident.

The plan was to admit her to remote telemetry overnight - just in case.
While the ER doc was talking with the admitting consultant over the phone, I saw Mr. Smith quietly sneak into his wife's room.

They held hands for a while. Looking into each others eyes. Saying nothing... and yet 'speaking' all that need to be 'said'.

A little while later, I saw him get up, gently lean over and give his wife a heartfelt kiss. He brushed her hair off her face, while they were still holding hands. Then they said something that I couldn't hear and her bent over to kiss her again.

The look they had on their faces was just... well, indescribable.

[I did feel guilty that I witnessed what was obviously meant to be a tender, intimate, private moment between the two of 'em].

Mr. Smith slowly shuffled out of the room, taking care to close the curtains and shut the sliding door. He ambled over to me and said "Thank you for all your help today son. I'm loathe to leave but she insists I do. She says that I need my rest and that the dogs would get antsy without us."

He paused.... and looked down...

"Trust her to be more worried about me and the dogs even as she's lined up in a hospital!"

I walked over to Mr. Smith and bent down on my knees so that his eyes could see mine. I took his hands in mine.

"Mr. Smith, you're wife is as concerned about you as you are about her. But at this point in time, there's not a whole lot else you can do for her. I won't dare to presume to tell you how how things ought to be, but Sir; this hospital has strict visiting hours. As much as I'd love to bend the rules, you and I both know I can't."

He looked up slightly. A striking face; worn by the ravages of time, worry and care. A mist occluded his bright grey eyes.

"I've never been away from her. Ever. She'll be terrified. I know she will!"
That last response sounded less like a statement and more like a plea...

It nearly broke my heart.
"Hold on Mr. Smith. Let me see what I can do to..."

Just like that, I saw him shake his head. Take a few deep breaths in. Then he looked down to meet my eyes - his steel grey fiercely boring into my liquid brown.

"You take good care of her. She's all I have left!" I felt his hands clench mine, as if reinforcing his desperate plea.

"We will, Mr. Smith", I mumbled; "I promise".

He nodded assent, and then slowly shuffled off.

Leaving me all alone, to contemplate the loving bond that is shared between a man and his beloved wife....

Spoke my mind

2008-12-21T07:12:00.005-06:00

Sent to me via email:

[Click image to zoom]

If you created this image, lemme know so I can credit you.

Be careful when taking walks

2008-12-21T04:29:00.002-06:00

One of our ER docs told me this story:

Many years ago, when I was doing my residency near The Other Big City, police brought this elderly gentleman in to the ER. They said that they'd found him wandering around and when they stopped to question him, he responded with incoherent words and neither one of the officers could figure out what the man was saying.

And neither could we. His vitals weren't normal but they weren't off the wall either. One of the nurses thought she detected some AoB (Alcohol on Breath) but for the most part this guy appeared benign. Lungs clear, good heart sounds, no apparent signs of trauma.

Then, one of the cardiology residents who happened to be down on a consult happened to pass by the ER room while we were trying to figure out what the hell to do. He stopped, poked his head in and asked one of the nurses what was going on. Upon being told the gist of the story; the resident shook his head and said: "He's not mentally confused or unstable. He's speaking a different language. I don't know what it is but I know it's not gibberish." Apparently this cardiology resident was of Indian extraction and had heard it before.

This set of a flurry of activity... and before long, they managed to find an Indian-American nurse who was called down to help translate.

Apparently, this gentleman had recently arrived in country; visiting his son's family for the holidays. He'd had a glass or two of wine in the afternoon and had decided to stretch his legs with a walk and take in some fresh air. That was when the police found him and the poor man spoke not a syllable of English. Fearing that he'd been injured/lost and wanting to make sure he was ok health-wise, the police brought him in and that's where all the fun started.

What's in your RSI box?

2008-11-26T18:11:00.004-06:00

Nurse K posted a random bleg a while ago about RSI boxes. I must admit that when she mentioned that her ED didn't have a RSI (Rapid Sequence Induction) box, I was slightly surprised. I thought all EDs had something similar - I mean, having one makes a lot of sense.

But then again, my old hospital's ED didn't have one either.

So Nurse K, here's what we have in our ED:
- Meds in the box:
* Atropine Sulfate (1 mg/10 ml) prefilled syringe X 1
* Etomidate (2 mg/ml) 10 ml vial X 1
* Ketamine Hydrochloride (50 mg/ml) 10 ml vial X 1
* Lidocaine Hydrochloride 2% (100 mg/5 ml) prefilled syringe X 1
* Midazolam (2 mg/2 ml) vial X 2
* Succinylcholine (20 mg/ml) 10 ml vial X 1
* Vecuronium (10 mg) vial X 1

- Dilutants:
* Sterile Water for injection (10 ml) vial X 2

- Tools:
* 60 ml syringe X 1
* 20 ml syringe X 2
* 10 ml syringe X 2
* 3 ml syringe X 3
* BD 18G 1.5 inch IV needle X 2
* Easy Cap II Carbon Dioxide detector X 2 (no longer used. Now part of intubation bag)

- Misc:
* Alcohol swabs x 15
* Controlled substance documentation form

Some piccys:

RSI Box against a standard computer keyboard (to provide scale for sizing).

Closer view of RSI (notice the red pharmacy lock indicating a stocked, ready to use box).

Naturally, no nursing job can be complete without "documentation". A typical pharmacy use/waste form. Two RNs (or an RN and Pharmacist) to initial waste/use before restocking and locking the box.

We have 3 such boxes in our ED. Our airway/intubation kits are separate (they usually hang out in the trauma/code rooms near our crash carts). A while ago we decided to switch out CO2 detectors from the RSI boxes to the airway boxes. There are separate kits for peds intubation (in separate boxes as well). We also have our own anti-platelet/thrombolytic boxes (tPA, tnkASE, Integrilin).

Once a box has been used, a nurse (or tech) walks the box down to pharmacy and it gets re-stocked.

So, what's in your RSI box?

The Vent

2008-10-05T20:12:00.002-05:00

Quoting another ED nurse:

Ok,..was gonna try to stay out of this,.but I just can't help myself! I agree that this is a great place to vent. This is supposed to be a safe place to vent. A place to let out all my frustrations away from patients and co workers. A place to verbalize all those thoughts that I would NEVER, EVER say to someones face while at work! A place to voice my opinions to other health professionals who understand where I'm coming from.

I don't expect solutions to my frustrations. I don't expect someone to tell me how to fix everything and make my job a day at the park. It just makes me feel better to write it all down and get it out! It makes me feel better for someone who understands to say "yeah, I'm with you there!". If occasionally I learn something in the process of venting then good for me! If commenting to someone else's vent makes them chuckle or breathe a little easier that's great.

I've been a nurse for a long time and I do understand that those who aren't in the medical field don't always understand what I'm venting about. I've often whined about something to my husband (a non medical person) that seemed like an obvious situation to whine about and he looks at me like I'm crazy! I then have to go into more detail about my complaint and sometimes he will understand.

That's why I come here! I shouldn't have to explain to any of my fellow nurses how it makes me feel when a 22yr old tells me he has abd pain 14/10, can't keep anything down, while eating Cheeto's and coke, talking on his cell phone! There is no need to explain my initial thoughts when he then tells me he has no medical hx, takes no reg meds and is allergic to Tylenol, toradol, haldol, vistaril, naprosyn, ultram, and phenergan!

I come to this site because we are all in the same boat. We are all caring, compassionate, well educated, professionals who are trying to do the best we can for our pts. We get frustrated when, because of situations beyond our control, we can't do our jobs!

I would never, ever, tell a new Mom, who is worried about her 8mo olds 2hr temp of 102 that she is wasting my time and resources by coming to the ER instead of running to walmart to buy some tylenol! I would never, ever tell the man with back pain for "about 2yrs now, no one can figure out what's causing it" that he needs to loose 100lbs and find a family doc to take care of these "flair ups".

BUT,.when that same Mom comes up to the triage desk and complains that they have been waiting "almost an hour" and "people who came in after us have already gone back" and then gets nasty with me when I explain that the sickest pts go first, I'm gonna come to allnurses and VENT! I would so love to take that Mom by the hand, take her back to Rm 3 the 6yr old who was found in the bottom of the pool, then to Rm 5 the 18yr old unrestrained driver of a roll over MVI who was ejected, then to Rm 8 the 60yr old who suddenly couldn't speak and has a L sided facial droop, Rm 24 the 22yr old ruptured ectopic with a BP of 54/20 who is bleeding out faster than we can put it in and of course OR is full! I would so love to put everything in perspective for that Mom,..but alas,..I can't,..I won't.

I come to this site to vent to other nurses! To those that know exactly what I'm feeling. I don't vent to my neighbor or my hairdresser. I'm not directing my vent to any patient or family member. I'm here to talk to other like minded professionals!

If you have stumbled in to this site as a non medical person, just looking for an interesting read, or free medical advice you should be prepared for what you might see. Nursing can be a very unpleasant job at times. We see people at their worst. We see things on a regular bases that most people will never witness in their lives. We are expected to leave the room of a dead 3yr old and smile and ask Mrs Jones if "there's anything we can do for her, I have the time".

We are expected to understand that when the doc orders 100 of Morphine, he really meant Fentanyl. We understand why our pt with SOB really does need an 18g in the AC. We understand why a pt with abd pain must stay NPO. We know how to do our jobs and we do understand that non medical people don't understand!!

I find it insulting for a non medical person to make judgments on how I do a job that they couldn't do. I don't argue with my mechanic about the best way to fix my car. I don't argue with the electrician about how to fix my furnace. WHY WHY do people think it's ok to not only argue with us, but accuse us of being cold, and uncaring when we are doing a job that many people say they could never do?

I must stop,..if you are a non medical person and are offended by what is said on this nursing site,...it's simple,...see that little red box with the white X in the top right corner of the screen? Click it!

You ROCK lady!

Apparently I'm a libertarian...

2008-09-30T09:43:00.006-05:00

Saw this little "test" over at Respiratory Therapy 101 and decided to give it a shot.

You are a
Social Liberal
(88% permissive)

and an...
Economic Conservative
(80% permissive)

You are best described as a:

Libertarian

Link: The Politics Test on Ok Cupid
Also : The OkCupid Dating Persona Test

Friedrich Hayek's Road to Serfdom and lewrockwell.com - it's where it all started folks!

- Spook (proud Paul-ite)

Paul Newman has passed on

2008-09-27T12:03:00.003-05:00

Ya know, I'm not usually one to get all weepy and mopey about celebrities.

But I've always enjoyed Newman's work - be it something silly like "Slapshot" or iconic such as "Hustler" or "Cool Hand Luke". He was a humanitarian to boot with charities benefiting children.

So long Mr. Newman and thanks for the fond memories.

Healthy ER abusers are a "myth"

2008-09-19T03:46:00.006-05:00

A recent article in Slate claims that the uninsured without a PMD and the insured folks who have PMDs both visit the ERs (or ED if you are Dr. WhiteCoat ;-)) in roughly the same proportion:

If you believe the conventional wisdom, the E.R. abusers of our nation are especially responsible for many problems in health care. They fill up E.R. waiting rooms and because they can't (or won't) pay their medical bills, the insured patients who prudently wait for weekday appointments to see their doctors end up bearing the costs of the abusers' in the form of higher insurance premiums. The oft-repeated claim is that if we can just find a way to get the abusers out of the E.R. waiting rooms, we'd eliminate many of the high costs associated with health care in the United States.

The problem is that this story of the healthy, cavalier, uninsured E.R. abuser is largely a myth. E.R. use by the uninsured is not wrecking health care. In fact, the uninsured don't even use the E.R. any more often than those with insurance do. And now, a new study shows that the increased use of the E.R. over the past decade (119 million U.S. visits in 2006, to be precise, compared with 67 million in 1996) is actually driven by more visits from insured, middle-class patients who usually get their care from a doctor's office. So, the real question is: Why is everybody, insured and uninsured, coming to the E.R. in droves? The answer is about economics. The ways in which health information is shared and incentives aligned, for both patients and doctors, are driving the uninsured and insured alike to line up in the E.R. for medical care.

Click here for the full article

Hmmm...

The "Nursing School" Car

2008-09-07T06:10:00.008-05:00

I worked two jobs during nursing school. I bought a beat up 1995 Plymouth Neon - stick shift and a pretty decent radio. It had 2/40 air conditioning (2 windows rolled down driving at 40 mph). The only thing I cared about was the heater, since I lived in Buffalo.

The gauges worked when they felt like it. I once drove an entire stretch from Ohio through Illinois with a non-working instrument panel - I had no idea how much gas I had left or if the engine was overheating etc. The only thing that worked faithfully was the tachometer - so I used to guesstimate my speed based on engine revs and which gear I was in (e.g.: 1800-2000 rpm in 5th gear was roughly 35 mph).

Since the instrument panel worked erratically, the odometer didn't always run either. I had no idea about the true mileage of the car. These things sorta start to matter because you start to imagine scenarios like where your pistons ram through the camshaft because of a timing belt that wasn't replaced at the 'appropriate mileage' or busting a strut because of not having a safety inspection done at the 'appropriate mileage' so on and so forth...

It took me on several 1000 mile trips (and helped me move between two apartments. How I managed to cram my clothes, utensils, computer, stereo system and books and transport them thousands of miles, I alone know). It lasted through some of the worst winters Buffalo threw at us. It saved my ass during a real bad 75 mph spin out on the I-55.

That piece of junk lasted till 2007. I was driving home after my 4th 12 hour night shift in a row. I entered a school zone and with kids around, hit the brakes to slow down. Pedal went all the way to the floor but the car kept going. I used the gearbox to slow down to the point where I could yank the emergency brake. Thankfully, it worked and I was able to stop the car. By then I was wide awake and terrified.

I upgraded to a Honda within 2 weeks after that incident.

So, that was my "school car". What was yours?

Secret Santa

2008-08-28T09:40:00.002-05:00

Yeah, I know it's a little "early" to be making posts about Santa Claus and Christmas, but I just ran across a post from Terry over at Counting Sheep (check her out y'all) that reminded me about something.

You see, I do not observe the holiday, but it sure is important to most of my coworkers.

I have the exact same opinion about this holiday. I'm not a religious person and don't observe any religious holidays - the only holidays I actually care about, for sentimental reasons are Independence Day and New Years...

...And my birthday - well, it's not recognized as a holiday just yet but I'm working on it :-p

But I know how important this holiday (and Thanksgiving) is for many of my co-workers. My experiences with my first job at a Mennonite hospital in a smallish town in the middle-of-nowhere-midwest-America just solidified the whole thing.

So I always volunteer to cover someone else's shift for Christmas and Thanksgiving - even if it's not my turn.

The way I see it: I get paid time and a half and someone gets to stay home and spend that time with their family/loved ones.

It's a win-win solution as far as I'm concerned. :-)

The more I think about it...

2008-08-28T08:53:00.002-05:00

... the more I realize what an awesome thing it was for me to push off from "The Toxic Environment" (aka Old Job). The people I worked with were awesome but the job in itself sucked the life outta me.

I sit here nursing a beer, thinking about all the amazing things I've done since I left that job - all the while knowing that I've barely scratched the surface! I sit here thinking about how I'm working a much busier and more intense environment (my feet hurt like they've never hurt before) and yet don't feel as desolate and run down as I used to.

There exists a greater scope for teaching - be it patients, new grads or EMS students - something that I greatly enjoy.

I'm challenged here - both physically as well as mentally/professionally and I'm surprised to find that I like that. More is expected of me and I find that a little exciting.

So yeah, I guess I ought to thank my sister-in-law (was her idea for me to come down here).

Only in the ED?

2008-08-26T09:15:00.007-05:00

ER Nursey blogs about "The naked man in the church" and discusses her sentiments about the episode, wondering if her years in the ED (Hey! I'm learning Dr. Whitecoat!) trenches haven't dulled her sensibilities to shocking human behavior.

Her story reminded me of a shift barely 3 nights ago. Along with the rest of the ED staff, I was treated to the spectacle of a drunk busy jerking off despite being placed in a visible room for observation because of 'suicidal ideation'. He knew he could be seen by others but he just didn't care (no, he wasn't that drunk either).

By the end of the shift, drunk guy and frequent-flyer-drunk-screamer-~~bitch~~ girl in a near by ~~hall~~ close view bed were overheard sharing tips on scoring easy dope and evasion tactics. One of the senior ED nurses stopped and said (in a voice dripping with sarcasm): "Awww! Love is in the air. Those two are hooking up. Isn't that sweet?"

Of course, what I'd witnessed was within the confines of the ED while ER Nursey's was on decidedly more public (and if you wish 'hallowed') grounds. Still, I couldn't help but think .... "only in the ED."

Bugs

2008-06-08T00:21:00.002-05:00

I don't like creepy crawlies.

It's not like I get freaked out over 'em.
But they do disgust me.

Mightily.

Over the past few weeks, I've been noticing a few creepies around my apartment. And the incidents seem to be increasing each week...

Usually, I simply find a sandal and quickly squash 'em to death. And then dispose of 'em.
But it annoys me that I have to do this.

Again - I DO NOT like creepy crawlies.
I know they serve a purpose in nature and all that - but they can serve their purpose outside my apartment thankyouverymuch.

Ugh! Blech! Urk!

Working short handed...

2008-06-07T23:57:00.002-05:00

We had six call-ins today.

Six.
With a heat-wave passing through the region, I kinda figured it was gonna be "rough" today anyway... but with the call ins ... man! Heat stroke, chest pains, MI, severe dehydration and others ... you name it, we got it.

At times I was tackling 10 patients at a time.
And I'm just a rookie!!
If it weren't for the expert (and often silent) assistance of my preceptors and colleagues; I'd have never made it through the day! I'm SO in awe!! There's a couple of 'em especially that... someday... y'know... if I ever become 1/10th the nurse they are; I'd consider my nursing career in the ER a success.

Cool.
Collected.
Know everything.
Seen everything.

Can do anything...

Wow! And I mean "WOW!"

Feeling hot hot hot!

2008-06-06T19:49:00.001-05:00

Was a rather hot day today and it's only gonna get worse over the weekend.

I suspect a rash of AMI/heat strokes to pay us a visit.

Only gonna get busier...

Gallows Humor

2008-06-06T18:45:00.004-05:00

911 Doc over at MDOD made a post about the O sign, the Q sign and the dotted Q sign.

Reminded me of this list:

Most of the definitions on the following lexicon of medical slang appeared a few years ago in the National Lampoon. Some of the definitions are funny. Most are sick. All are used in respected hospitals.

===========================================================================

BOBBING FOR APPLES: Using the finger to unclog a severely constipated patient.

F.L.K.: "Funny-looking Kid."

F.L.P.: Parents of an F.L.K.

CRUMP, GORK, VEDGY: A patient requiring intensive care, incapable of movement, and apparently unaware of his surroundings.

HORRENDOPLASTY: A difficult and time-consuming operation.

BAG, BOX, COOL, STIFFEN, X: To die.

CROCK: Hypochondriac.

MARRIAGEABLE MONSTER: A young female patient who has successfully undergone major plastic surgery.

GOMER: A senile, messy, or highly unpleasant patient.

FASCINOMA: A "fascinating" tumor; any interesting or amusing malignancy.

DROOLER: A catatonic patient.

CUT AND PASTE: To open a patient, discover that there is no hope, and immediately sew him up. Well, almost immediately. Sometimes young surgeons practice surgical techniques for a while first.

FOUR F-ER: A gallbladder patient. "Fat, forty-ish, flatulent female."

PINKY CHEATER: Latex finger cover used in gynecological and proctological examinations.

ROAD MAP: Injuries incurred by going through a car windshield face first.

A HOLE-IN-ONE: A gunshot wound through the mouth or rectum.

THE "O" SIGN: The letter O as formed by a patient's gaping mouth.

THE "Q" SIGN: A patient giving the O sign with his tongue hanging out.

THE DOTTED Q: The "Q" sign, with a fly on the tongue.

SIDEWALK SOUFFLE: A patient who has fallen from a building.

LOOSE CHANGE: A dangling limb in need of amputation.

BULL IN THE RING: A blocked large intestine.

GONE CAMPING: Reference to a patient in an oxygen tent.

EATING IN: Intravenous feeding.

BORDEAUX: Urine with blood in it.

SCRATCH AND SNIFF: A gynecological examination.

ANGEL LUST: A male cadaver with an erection.

HIT AND RUN: The act of operating quickly so as not to be late for another engagement.

CAPTAIN KANGAROO: Chairman of a pediatrics department.

ROOTERS: Indigents and hangers-on who gather in big-city emergency rooms in order to be entertained by legitimate cases.

SHORT-ORDER-CHEFS: Morgue workers.

LOOP THE LOOP: Flamboyant surgical rearrangement of the intestines.

BUGS IN THE RUG: Pubic lice.

HEY DOCS: Alcoholics handcuffed to wheelchairs in big-city medical wards who, at the sight of a white coat, bleat out in chorus, "Hey, Doc!"

BLOWN MIND: Gunshot wound to the head.

ICING ON THE CAKE: Lethal tumor discovered in the X-rays of a heart attack victim.

THE GARDEN: Neurosurgical intensive care ward, so called because of the "vegetables" found there.

BOOGIE, GOOBER: A tumor.

THE DEEP FRY: Cobalt therapy.

ROASTED GOOBER: A tumor after intensive cobalt treatment.

HEALTHY GOOBER: A dead patient.

BURY THE HATCHET: Accidentally leaving a surgical instrument inside a patient.

SILVER GOOSE, SILVER STALLION: Proctoscope.

SQUASH: Brain.

GAS PASSER: Anesthesiologist.

CRISPY CRITTER: A patient with severe burns.

There! I just gave away our trade secrets! :-p Y'all got any more additions?

And as usual there were some folks who couldn't:
1. Read
2. Take a hint

... and complained about what a bunch of evil, uncaring bastards we were.

Meh!

I think I'm gonna like it here

2008-05-31T12:45:00.003-05:00

Pt. came in c/o of severe vag bleeding over the past 2 months or so. Was feeling weak, nauseous and generally "ill". ER doc talked to OB and had pt. put on their list. She was going to be admitted to OB.

As I am still orienting, I asked my preceptor "C" for help as I was about to go into the pts. room. As I was about to enter, a lady walked out and in passing told me, "Oh, her pads were soaked. So I cleaned her up a bit and changed her".

As I'm setting up supplies to draw more blood for lab work, I casually asked C "So, who was that?"
"Dr. O. She's an OB attending".

*Blink Blink*

"Did you say attending?"
"Yeah. Why?"
"Nothing", I stammered; "I'm just not used to having docs - especially attendings - clean up patients... I guess".
C shrugged her shoulders, "It's different down here".

I guess it is. I think I might actually like working here...

Speaking of different and cleaning people up, The Chief Complaint of the day award goes to:

"Soiled himself. Here to be cleaned up".

No, it wasn't my patient and I wish I had the time to look up further details [or not. HIPAA violation, non?]- but that really was the "Chief Complaint" as entered by the triage nurse into the system.

And no, I'm not making that up...

The Things They Carry

2008-05-17T13:02:00.004-05:00

"Hey Spook! You're back so soon?", teased J.
I snort. "I live here. I eat out of the vending machines and shower in the ER decon room. Didn't you know that?"
J rolls her eyes. "Yeah right! Seriously though, you need to take it a little slow. Don't be no hero Spook. I don't want you burning out on me".

I chuckled at that. Those were the exact words I used to admonish J, chiding her for working too much overtime.

It wasn't that simple - or maybe it was and we were just too young, too naive and too dumb to see it. Working night shift on our floor was dreadful - since we were always understaffed, constant calls from managers and charge nurses begging us to work an extra shift (or two or three) was "routine". Neither one of us bothered to make out a schedule since it kept getting changed every other day. Nor did we bother asking for time off because we'd be treated to the whole pouty, whiny drama of our chronic staffing problem. In fact, staffing is so bad that over 90% of the time, HALF the nurses working nights on the floor were float pool nurses.

"Yeah well, not before your wedding anyhow. I mean, someones gotta eat all that ice cream!"
J poked her tongue out and made a face. We both laughed.

I took a quick look at the assignment sheet and compared with the patient board. We were both split and had patients all over the floor. Not only that, but I saw that the patient assignment was patchy - people had simply been put into whatever room was available. I let out a short whistle, "Wow! This is nuts. Musta been really busy today"

RM, one of the second shift nurses answered in a tired monotone without looking up from the computer screen, "15 surgicals, 14 discharges so far Spook. We're not done yet, since 3 of 'em are still down in PACU. It was a freaking revolving door up here today".

"Damn! We're full." I sigh. "I bet that makes the suits happy... wait! MS is back??! Didn't she just get discharged last week?"
CM, another evening shift nurse looks up and says "she was my patient. Didn't listen to report yet? Just want me to give a verbal?"
"Yeah sure. Lemme grab my stuff and I'll be back".

I hurry over to the staff room and get ready. CM plops down on the chair in front of me. She looks beat. Tired. That’s a bad sign – no matter how bad the day got, she was usually very cheerful.

“C, hang on a second”.

I get up, go over to the counter and get a glass. I fill it with cool water and hand it to C.

“Here, drink this”.

She looks at me. Her mouth forms no words but the gratitude in her eyes is genuine.

Glass of water never felt so good huh? When was the last time you had an uninterrupted 10 seconds to have a glass of water? Musta been a real bad day…

“C, listen to me. I want you to give me report, put your stuff in your locker and go straight home. Don’t worry about if you did this or that. Leave it to me. Clear?”

C nods her head, too tired to argue or protest.
Quietly, I take report.

There’s a lot to be done. 3 dressing changes and two IVs that need to be started... besides the other assorted "usual stuff" - assessments, med passes, chart checks etc. etc. etc.

A couple of hours into the shift and progress was bitter and slow. Soon as I finish one job, two more seem to appear. It seemed more and more likely that I wouldn't be able to leave on time at shift change.

I was scurrying back to the nurses station to gather supplies to try and start a line on someone else’s patient when I passed MS’s room. I thought I heard quiet, muffled sobbing. The door was barely ajar and the room was dark. I paused.

There it is again! What’s going on? I knock softly and tip toe into the room.

MS is lying in bed, with tears streaming down her face. Crying and sobbing. The trained professional part of me quickly analyzes her for any obvious signs to explain her discomfort. I see no obvious signs. I quietly walk over to her bed and sit down at the edge. I take her hand in mine and give it a gentle squeeze.

We exchange no words. I sit quietly while she cries.
Finally, she blows her nose on a tissue and looks at me with bloodshot, tired eyes and a worn, haggard face.

“I’m sorry”.
“For crying? Don’t ever be. Human beings cry.”
“I’m scared. I’m hurt. I don’t know what to do”.

Silence. A pause.

“I just got off the phone with Dylon. My older son. We had a fight…”
The tears begin again.
“We had a fight and he hung up before I could soothe things over. It was over *sob* a stupid cell phone bill. *sob* Now I’m trying to call him and he won’t answer his phone. I just want to tell him that it’s OK. That I still love him. I want to hear him say it. I want hear him say it. I want to hear him say that he still loves me.
I’m lying here and my kids are by themselves out there. I’m such a bad mother!”

She’s crying again. I don’t say a word. Just slowly stroke her arm. My pager starts vibrating. I hurriedly turn it off.

“MS, kids are resilient. He’ll turn around.”
“I know he will. He’s my boy after all”. A wry smile. “But will I have time?”
We both look at each other. The anguish on her face is unmistakable. I lean over, wrap my arms around her frail, disheveled body and give her a gentle hug.

And I just sat there as big fat tears rolled down her cheeks and wet my shoulder as MS cried her heart out.

After what seemed like an eternity, she slowly pulls away and wipes her tears.
“M, nobody knows the answer to that question”.
A wan smile. She nods. “Yes. That’s true, isn’t it?”

“Thank you for sitting with me. I know you have other patients who need you”.
I squeeze her hand and smile. “I’ll be in shortly to check on you, OK?”

I slowly turn around and walk out that room.

Here lies MS. A woman barely into her 40s. Trying bravely to raise her children the right way, all by her lonesome self in this world full of people. Who has just been told today that her cancer is terminal and has spread to her liver, lungs, pancreas, stomach, intestines … everywhere. Who despite her constant physical pain and the suffering brought about by cancer treatment, still worries about being a bad mother.

A tear rolled down my cheek.
Then a second.

How wretched is human suffering!

I walked to the desk on autopilot and sat own. Put my face in my hands and closed my eyes; trying to clear my head. Somewhere in the distance, a part of my brain is trying to tell me the phone is ringing but I’m powerless to act.

I feel a hand on my shoulder and look up.
“You ok, Spook?” asks J.
I smile and nod my head. “Allergies”, I lie.
She smiles. She knows it’s a lie and that I have no allergies, but lets it fall for now.

Deep breath. A shake of the head.
Back to work…

Update: MS finally passed away on September 8th. She was at home, with her family and friends.

Reap as you sow

2008-04-04T16:30:00.006-05:00

Had to happen, sooner or later.

It is the 410-bed hospital in Blue Island that nobody wants. Even for free.

In a stunning development underscoring the plight of non-profit hospitals struggling with the increase in uninsured patients, the Catholic ownership of St. Francis Hospital & Health Center on Wednesday said it will shutter the hospital because nobody would buy it.

The religious order of nuns that oversees St. Louis-based SSM Health Care said it could not even give the hospital away to other health facilities "for free."

Saddled with tens of millions of dollars in losses from uninsured patients who could not pay their medical bills, St. Francis would be abandoning its core mission of caring "for the people of its communities regardless of their ability to pay." SSM will seek a closing application with the state, a process that could take several months.

This particularly strikes close to my heart because the earlier institution I was working for was a not-for-profit institution. Supported by an extensive parish and network of churches.

Brings me back to the argument that as bad as things are, who really loses if hospitals continue to run in the red? The answer obviously is "we all do". Not only are employees laid off, but now the community has to travel farther in search of health care.

TANSTAAFL - There Ain't No Such Thing As A Free Lunch.
Immutable law of economics.

[RANT!]

A fact all those clamoring for "universal care" (etc.) do not seem to understand: you can't force someone to provide anything - be it a product or a service - for free. The insurance boondoggle is bad enough as it is... without the added stupidity of government rationing (which is what will happen under ~~socialized medicine~~, er sorry; "single payer healthcare").

[END RANT!]

Dr. WhiteCoat at WhiteCoat Rants. Y'all head over there and check it out...

First impressions

2008-03-31T21:11:00.002-05:00

Took a "quick look" around at my new job site today.

Patients lining the hallways. Folks bustling about, in and out. Didn't notice the phones going off the hook constantly. Seemed chaotic but orderly at the same time.

Welcome to the ER? I guess.

Still have paperwork and stuff to do. Orientation doesn't start for a couple weeks.
Everyone's warned me - this place ain't no cake walk. Very busy. Sees a high volume of patients all the time.

I understand the concern, but deep down inside, I'm confident. As long as I have adequate support, I'm confident I can hack it. I know there's lots of "adjustment" and "learning" I have to go through; and I'm willing to give it all I've got.

The good thing is that everyone seems to like working there, as busy and chaotic as it gets. Hope I fit right in :-)

Moving is a pain in the butt

2008-03-31T20:24:00.005-05:00

Seriously.

It took me a freaking week to clean up my one bedroom apartment, load all my crap into my car

and drive it all over 1500 miles to my new job.

Oh and there is one thing I re-learned (I guess I forgot after my last move) - when driving long distances, there is only so much music you can listen to! Sheesh! Talk about boredom!

And speaking of car - I love me new car! :-) After driving a 14 year old, crotchety Plymouth Neon with non-working guages worn out brakes and tires and pathetic fuel economy... me likey the power, zip, handling and 500-miles-to-the-full-tank aspects of the new car. Not to mention safety features and gizmos up the wazoo!

Getting back travelling: I will say this though - if one is so inclined to go "off the beaten path" every once a while, this wonderful country will reward you. Not only did I get to see breath taking scenery on the way, but I also had the pleasure of running into some absolutely outstanding folks on the way: from the owner of a breakfast diner who gave me a meal on the house after looking at my tired, bloodshot eyes and weary face to the kind folks who let a complete stranger (me!) into their home (and outta the rain) so that I could stop someplace dry till the weather cleared up.

THANK YOU! :)

I couldn't fit everything into my car, so I packed some of it and sent it with UPS. Still awaiting some of my boxes to show up. Staying with extended family for now.

Time to find an apartment, yes?

Stuff White People Like

2008-03-20T20:35:00.005-05:00

I about wet my pants laughing.

NOTE: It is 'humor' of a different kind. Not for the overly sensitive or bashful. It's definitely not PC. Don't say I didn't warn you...

D minus 11 and counting...

2008-03-03T07:34:00.002-06:00

March 14th, 2008.
My last day working my soul killing job.

I need to haul ass and start cleaning up my apartment ... and stuff. But I just don't have the motivation ... for now. I just want to relax, take a deep breath, catch up on some sleep.

But yeah, it was like a huge weight being taken off my shoulders. Actually manage to smile and be cheerful at work these days.

And in other news, I met someone who kinda said and did something that totally made my shitty week seem less shitty. Stay tuned for that story...

The 2 weeks from hell

2008-02-22T12:39:00.007-06:00

Man! Shitty assignments all around. Really sucks at work right now. My ass is dragging trails in the snow.

Plus the two teeth I did my root canals on last December have been hurting like a son-of-a-mother. I've been popping Motrin like crazy. I can't get an appointment at the dentist sooner than next month (perfectly coinciding with what I anticipate to be my moving time to my new job. Super!)

The last time this happened, I had a colossal infection in my gums and needed 3 weeks worth of antibiotics to clear up. I am really not looking forward to a repeat episode...

Not that it makes any sense - I thought when you did a root canal, the root is desensitized - permanently. How the hell can it possibly hurt there, I'll never know.

All I know is that even a sip of "below room temperature" water sends shooting streams of agony throughout the jaw and the right side of my face ... and this being winter, I can't even let cold air hit that side of my face. I've been warming everything up and tilting my face to the left and drinking/eating in small morsels at a time.

Bah! I can't eat. I can't drink. Hell, even breathing cold air through my mouth hurts.
Tooth aches and ear aches suck! Suck! Suck! :-(

I'm beat. I'm back tonight for another 12 then I'm conking out. I'm gonna turn my phone off this weekend and go on a real bender. I hurt and ache in places I didn't know existed.

Woo Hoo! Go me!

2008-02-07T03:56:00.000-06:00

I got that ER job I was looking for.

It's in a different state, so I need to transfer my license. And while that's going on, I'm still going to continue working (hey! I need the money!)

It means I have to re-locate (again!).

But it also means I won't be working my soul-killing, strength sapping job anymore!

My charge nurse was absolutely devastated when she found out I'd found a new job. Guess the old saying "you don't know what you've lost till it's gone" is true after all! Now if only they'd appreciated my work all along, this might never have come to pass. Oh well!

I feel a twinge of guilt for leaving some of my work buddies behind. I'll miss them.
I'm a little nervous about moving - will I make it? Will I be able to hack it?

Truth be told, I'm sorta looking forward to it. It's been kinda lonely here in the boonies.

Why the hell didn't I do this sooner?

2008-01-13T04:01:00.001-06:00

I updated my resume on Monster.

Within like a day or so, I have concluded 4 different interviews for jobs ranging from ED to ICU and OR. I even spotted an opening for a flight nurse out in Juneau, Alaska!

Left me scratching my head - why the hell didn't I do this any sooner? I was so dumb for sticking with my stressful, deadbeat job. For some stupid reason, I wasted months trying to change departments in my hospital - never occurred to me to look elsewhere!

I think I just overcame my resistance to moving again (I've been here just a year and half). Health and sanity won out over temporary comfort and aversion. Besides, I've been thinking about it - I need to go back to school and get my masters (or beyond!) I need to get cracking - or life's just gonna pass me by.

No time for losers, You make the call
Believe in yourself, Stand tall!
Another day, it's in your hands
You can be the winner, in the end.

Keep runnin' don't look back
Keep movin' paint it black
Keep goin' don't ever stop
There's time to rest the day you'll drop
-- Klaus Meine, Mark Hudson

Ciao! Of to watch the Sabres game I recorded on DVR (whilst I was busy making sure confused old ladies with new hips didn't injure themselves falling out of bed).

A Day in the life

2008-01-07T07:52:00.001-06:00

Whoooooooooooooooa!

What a WEEK!

Tuesday noc (noc=night)- 16 hour shift. 7 patients (6 post-ops + one confused/agitated, non-restrained patient). One tech.
Wednesday noc - 16 hour shift. 7 patients (3 post ops + 2 admits + same confused dude). NO TECH!
Thursday noc - 16 hour shift. 7 patients (5 post ops + 1 admit + still same old confused dude). One tech (who is so useless, might as well be considered NO tech!)
Friday noc - 12 hour shift (I was scheduled for an 8). 6 patients (5 post ops + confused and now "combative" dude). NO TECH!

And to top it all - we have no "charge nurse" for night shifts.

So.

Anyway.

Tuesday night was the first time the Day Shift charge nurse (we have charge nurses from 7a-7p) handed me the "charge nurse phone and keys". Floor nurses carry pagers and narc keys ("narc keys" are used to unlock PCA (Patient Controlled Analgesia = patients get to push a button when they think they need some pain medication and a pump set up within controlled parameters delivers medication as needed) pumps. Charge nurses carry a phone accessible by anyone and from anywhere in the hospital and special set of keys (for elevators, supply cabinets, sure med, crash cart alarm unlock etc).

Turned out to be a good thing too. Because we ended up having to call a "Rapid response" (instantly call upon an RT [Respiratory Therapist] and an ICU nurse with standing orders and leeway to treat patients) on a freshly admitted patient from PACU [Post Anesthesia Care Unit ... where folks who've just had surgery are stabilized before being sent up to the surgical floor] - who ended up becoming "unresponsive" just as she was being wheeled out the elevator to the floor.

Wait, it gets better. I marched over to assess situation. It was tense, but we were handling it... but I had an uneasy feeling about the whole deal. Clinically, the patient was in "distress" but my gut was sending me all kinds of funky signals.

So now, of course; patient chooses to slip into "unresponsive to pain" status....
Lovely!

R-Triple-D! {Army talk for "Really-Deep-Doo-Doo}.

Called a Code Blue. Ran over and dragged the damned crash cart all the way across the floor and by the time I reached the floor, RT and the ER doc were there. Hung around to document till House Supervisor showed up (poor girl, was already tied up with a Rapid Response on medical floor!) Handed over charge to her and then raced back to pass meds on my post-op patients (Antibitiocs, HS {HS= Latin for 'Hora Somni' = bedtime} meds, Accuchecks {checks blood sugars} and HS insulin) all the while fretting about my confused dude. Mercifully, he was confused and naked but apparently had decided to stay put in bed for the moment.

By the time I got done with all this, my code patient had been successfully intubated and revived. I arrived just in time to see her being wheeled down to ICU.

Naturally - this left me playing catch up all night long. I don't know how I managed, but I managed to stay on top of patient care (while neglecting charting) till I could tape report.
Ohhh, did I mention that I had to go to a staff meeting at 0730 in the morning? And at this TWO HOUR (#*&&*^Y$) staff meeting, we were literally "read" power point slides. What a colossal, monstrous waste of time! Did they really think we couldn't read from handouts? What is this, grade school??!! Here I am, atleast 2 hours of charting ahead of me, wasting time listening to this nonsense! &*!^&$@!#!

I managed to stay awake through charting and somehow drove home. I don't remember what I ate (or if I ate at all! I was beat!) but I do remember that I couldn't sleep - damned lawn mowers kept me awake!

I finally managed to sleep 3 hours - and I was back that night.
Other than the fact that there was no "code" or "staff meeting", my night was a repeat of the night before. Too many sick patients, not enough staff.

Once again, dragged myself home.

Thursday night, post 4 hours of sleep. Not entirely bad - except for one of my post op patients who has some kind of weird fixation with his Codeine allergy. Pt. is a fresh Total Knee Artho (total joint replacement of the knee), with a measly Femoral block in place running Ropivacaine 0.2% @ 10/hr. Naturally, he starts complaining of pain into the noc. I try to convince him to take the MSO4 (Morphine) PCA as ordered. He refused - along with refusing the Dilaudid, Fentanyl and Toradol. He became infuriated with the "scheduled" med times and proceeded to fling a book across the room in anger, called me an "good for nothing, idiot SOB who doesn't know a thing in the world", threatened to leave AMA and/or sue/complain about the hospital and his "substandard level of care".

He wasn't thinking rationally nor clearly. He wasn't altered mentally in anyway - but it was patently obvious he had received little to no pre-surgical counseling (and given his surgeon, I was not surprised!) or he was a general insufferable idiot "know it all" (or a combination of the two).

I was close to blowing a fuse myself, but somehow maintained control, managed to calm the pt. He ended up calling the surgeon's office in the morning and lodging a personal complaint! Long story short, I made sure I documented the heck out of that incident and made sure I had collaborating evidence of my numerous attempts at making him "try" alternative medication for pain control (along with supporting statements from other floor nurses).

During all this time, did I mention the fact that I had 6 other patients? Including Mr. ConfusedandIwouldlovetoclimbouttabed ? Who did, end up rupturing one of the lines in his dual lumen PICC thanks to his constant meddling and poking?

Dragged myself home. Got about 6 hours sleep. Back on Friday noc.
Thankfully had "just" six patients. 3 post-ops and 3 others. One tech to stay with mr. confused.... which meant no tech for the floor. But I didn't care. Had to go down to the CCU (Critical Care Unit) and insert a foley in a patient and set up a CBI because apparently none of the nurses there (nor the house supe(ervisor)!) knew how to set up a foley with CBI (links to a PDF document) infusion! Most bizzare!

That's about my story of the week. Just had to get it off the chest.
Been super stressful.

Oh - and work wanted me to consider "coming in for 4 hours to cover 7p-11p". I practically told them to 'shove it' (politely of course!)

What it is....

2008-01-02T22:43:00.000-06:00

I've been a fan of Mark Knopfler and "Dire Straits" for longer than I can remember.

In fact, Dire Straits' album: "Making Movies" - was the very first rock album I heard (even before "Dark Side of the Moon").

I've always appreciated the songwriting/storytelling nature of their work (e.g. Private Investigations, Telegraph Road, Tunnel of Love, News, You And Your Friend, Local Hero, Single Handed Sailor, Brothers in Arms etc.)

What/who was the first artist you remember listening to as a youngster (an artist you have formed a life long affection for?)

Rage Against The Vending Machine

2007-12-30T09:00:00.000-06:00

Dear Designated Outside Contractor Food Supplier:

I must give you high marks for the excellent selection of above-average foodstuffs in our cafeteria. The portions are sensible, the service is wonderful, and the prices generally reasonable, except when it comes to snacky bits. $1.25 is not market rate for a bag of M&Ms. A brace of PopTarts at $1.29 is overpriced by almost 40%. This sort of madness drives me to our building's vending machine emporia... which in turn are driving me to madness, and to authorship of this screed.

Who is the crack-smoking numbnuts incapable of competent repetition in the maintenance of a vending machine?

I'm not talking about keeping the damn things online (although the snack vendy just around the corner from the cafeteria is suspiciously "out of service" frequently). I'm also not complaining about the slings and arrows of outrageous Fort.: the bag of chips stuck against the glass, the HoHos clinging, mockingly, to the wire spool exp'lled them. These are merely the manifestations of bad karma which we all experience, the dark cloud which only reveals its silver lining when additional coins are inserted to knock free said HoHos with the resounding thunk of a descending MilkyWay bar. Satisfaction, and twice the snacks.

No, my complaint, thunderous, and my indignation, righteous, is aimed at the methadone sampler whose job is simply to restock the machine with snacky bits and change. Let us start with the change, for as everyone knows, change is good.

If it were me, which it is not, I would value every snack in multiples of 25 cents. Acknowledging that candy prices have risen ridiculously since I was a lad*, surely chips could be 50 cents, candy bars 75, and the Big Hangover Cures (PopTarts, Pound Cake, Danish) a dollar. This sort of price management would mean Quarters-only change. The US Quarter-Dollar being the only reasonably sized and weighted coin o' th' realm, it makes sense to only stock the change mechanism thusly. But no. This being The Big Fancy City, you will have your premium, won't you? 85-cent candy bars. Now you have to involve dimes and nickels... hell, why not just invite the pennies? Or do you have a problem with coins of color?

Having all this Numismatic Affirmative Action going on just results in a bloated system* filled with jams and errors. Many times I have found the vendy on the second floor demanding exact change. Many times I have been so craving a Twix that I have crammed in a dollar bill, here, take it you fiend, keep the extra 15 cents, it's worth it! And been denied. Then there's the fifth floor vendy, which simply lets the dimes fall through, like a hot lesbian sitting alone in a bar. "Nope," says fifth floor vendy, "you can go. My candy is not even for sale."

And that's even assuming the stupid labels are right. I've noticed they're on a little wheel... so that your Depleted Uranium Cranium simply has to turn the price to match the price programmed into the machine. Why then, do the vending machines take on a slot machine air when I buy my Butterfingers? Why is the price 85 cents on one day, and 95 cents on another? Sure, one day it was 45 cents, but that was the day I helped the old lady cross the street AND I think someone else just forgot their change. Probably because they were injured bashing their skull into the glass in frustration.

While I'm discussing labels, why is the burden on me to determine the row and number of my selection? The cafeteria machine, you know, the one that rarely works? Several of the labels are missing... specifically E3, F5, and H0. And why is there a "zero" column, anyway? Are you planning a Vending Expansion that will jeopardize your supply of positive whole numbers? Or are you just showing off your integers, but think negatives would be audacious?

The fifth floor vendy even has some labels misapplied. Yes, I should be able to deduce F3's position between F2 and F4, but it has a E3 sticker on it and goddamn it, I eat out of vending machines... I'm probably hungover and need coffee. Throw me a fucking bone! There is nothing less savage than spending your last 85 (?) cents on a 3Musketeers, only to be rewarded with Good N Plenty.

Why does bottled water cost more than soda?

Isn't water a component of soda? Doesn't it cost more to process that water, add cancerous qualities and caramel color to it, and bottle it under pressure? Whither the price of sugar? Doth it not be high?*

Read more

I've got tears in my eyes and an achy stomach from laughing so hard.

Read more "Best of Craigslist..."

The Dark Knight...

2007-12-26T09:43:00.000-06:00

Which Action Hero Would You Be? v. 2.0
created with QuizFarm.com

You scored as Batman, the Dark Knight

As the Dark Knight of Gotham, Batman is a vigilante who deals out his own brand of justice to the criminals and corrupt of the city. He follows his own code and is often misunderstood. He has few friends or allies, but finds comfort in his cause.

Batman, the Dark Knight

71%

Captain Jack Sparrow

67%

Indiana Jones

67%

Maximus

63%

Neo, the "One"

58%

The Amazing Spider-Man

54%

Lara Croft

54%

James Bond, Agent 007

46%

The Terminator

46%

William Wallace

42%

El Zorro

33%

Heh. Just so happens that he is my favourite (yes, I spell favourite with an "e") super-hero.
He's all human.
He's flawed.
Hence why he's completely believable.

Might come in handy someday...

2007-12-26T05:32:00.000-06:00

Nicht es?

Not what I was expecting at all

2007-12-25T11:37:00.000-06:00

I just got home from vacation.

It wasn't a vacation.

At all.

Well sort off.

I saw a cousin get married. To a wonderful, wonderful, wonderful guy. It was a wonderful, happy time.
Marriages back home are a HUGE event.
Literally thousands of people attend the function. The entire function itself spreads many days. Fantastic food! (I've probably gained 10 lbs just from the 5 days of wedding food alone! It's impossible to resist I tell you!) Plus, the added bonus is that since the extended family gets together, you get to meet everybody - from great aunts and uncles and grandparents to the tiny tots (I discovered to my everlasting astonishment that I was an "Uncle" to half a dozen kids... ME! At my tender young age! An Uncle! Holy smokes! When did I get that old! LOL!) There was a good deal of humor over the fact that so many people assumed that I was my brother! I literally had to produce ID cards and drag my Father in to prove my identity! I had changed so much in six years - folks couldn't recognize me! Haha!

And then, the other HUGE plus point was that I finally got to meet my sister-in-law (my brother got married almost 2 and 1/2 years ago... but I was unable to attend the wedding because of nursing school). My sister-in-law is adorable - I'm so happy she is a part of our family. I even got to enjoy the hospitality of the in-laws. They have some 'characters' in their family too - all the more fun now! I had a great time! :-)

But on the other hand....

I had an acute attack of Gastroenteritis for about four days.
Preceded by the "head cold from hell" for about four days. All I could feel, smell and taste was phlegm. It was horrible.

My Mother was sick for half the time I was home - mostly stress related. Yet she refused to take time off from life in general - insisting that she couldn't. From her PoV she was right, and I knew it... but I hated it no less. I detested the pressures that "life" put on my Mother. My Mother has sacrificed a lot for many people... and many a time, I feel that she is not been acknowledged nor appreciated for that. My desire is for both my parents to retire and live a life of comfort - all the while knowing that such a desire is foolish... both my parents are work-a-holics. They'd go crazy if they had nothing to do!(and it seems like I have inherited some of it!)

My grandma passed away (my Father's mother. My maternal grandma passed away when I was in nursing school and I couldn't attend her funeral. As of now, my maternal grandpa is the only grandparent I have alive - my paternal grandparent having passed away years before I was even born).

My Father didn't take the news well (hell, is there ever a right time to lose your parent?) He has been sick on and off for a while now. I'm worried about him. My dear Father is a reserved man, he doesn't speak often... especially on matters of the heart. He is calm, quiet and reserved [the exact opposite of my dear Mother!] But he is a very sensitive man. Very loving. His anguish at the loss of his Mother was hard for me to bear - I may have lost a loving, dear grandmother, but he had just lost his beloved Mother. In the wee hours of the morning, I was called upon to be a nurse again. My Father had recently lost a mother-in-law and an elder sister. Outwordly, he attempts to be calm and measured - but I know he's hurting. They are a close knit bunch, my Father's family.

Did I mention that I needed 3 root canals? Yep, not one not two... three.

In the midst of all this chaos, I missed the comfort and company of some of my dearest friends. While I am a very friendly, approachable person by nature, I don't make friends that easily (sure, everybody is a "buddy" to me. But true "friends", I'm pretty selective). Despite uprooting my life and relocating half the world away in my teens, I adamantly spent a fortune keeping in touch with my friends. Yeah, I managed to meet some of them... but I missed seeing a couple.

And they hurt.
Because they hadn't seen me in many years.
And I hurt too - for the same reason.
There is still a longing in my heart.

*sigh* I need a vacation to get over this vacation...

Working Christmas

2007-12-24T12:04:00.001-06:00

Every year, at Christmas time; I always volunteer to work.

I'm not a "believer" and hence don't celebrate the holiday.

To me, it's a simple equation - since I don't honor/celebrate the holiday anyway, why not let the person who does... have the night of so that s/he can spend it with their loved ones?

I've noticed that Thanksgiving and Christmas are two VERY special holidays in the United States (Easter comes close ) ...... despite the overtly crass commercialized versions on display .... and I always figure: "These are the only few times when families get together once a year. Be it religious or otherwise - why not help them at this time?"

Hence why I volunteer to work these holidays.
My only caveat? (I want 4th of July and New Year's off! ;-))

But when all is said and done ...

I wish you all a very Merry Christmas. :-)
This coming year - may we all see a new era of peace amongst all mankind.

cheers,
Spook

Takin' a break...

2007-12-02T11:36:00.000-06:00

Finally!

Nearly missed a flight at O'Hare. Had to make a mad dash through Heathrow...

.... but I made it all.

It's technically day 5 of my 3 week break.
I'll try and play catch up while I can...

Woman with only half a brain

2007-11-18T12:01:00.000-06:00

Doctors treating a Chinese woman who complained of feeling weak discovered she only had half a brain.

The woman, 39, from Wuhan city, has lived a perfectly normal life and only came into hospital after she complained of feeling weak and stiff.

Zhang Linhong, director of Neural Rehabilitation Department at the local hospital, said: "On the MRI scans we were surprised to see that she only has grey matter on the right side.

Full story.

Now that is just plain plumb weired!

A new hope....

2007-11-10T07:00:00.000-06:00

... maybe? I dunno.

I talked to the new director of the ED yesterday, asking her about RN jobs in the ED. She seemed receptive. Apparently there's a bunch of people leaving the ED - many of then NPs who have now graduated.

Will know in a week.

Status: AWOL

2007-11-08T05:29:00.002-06:00

Haven't been blogging as much lately.

Since that co-worker quit, I've been pulling 68+ hr weeks at work. Money's been good but I honestly don't think it's worth it. Been badgering other department heads about jobs/openings but none seem forthcoming. I might have to re-locate.

Discussed the issue with some other folks (especially my Dad). Some big cities were discussed as options (indeed, some good jobs are open at present) but the whole "cost of living Vs income" discussion is where we're stalled at. I'm still hoping for a local job but I've made it quite clear that I'm not putting up with this anymore...

Besides that, there's been some personal stuff going on. Been trying to save money for my coming vacation at the end of this month (and funnily enough - spending that money like there's no tomorrow buying gifts and presents for folks back home).

I'm holding out for my vacation - hopefully three weeks will give me time to recharge. But I'm not staying at this joint forever. Nope. I maybe young and naive - but I'm no fool.

Guess who is here all week?

2007-11-08T05:06:00.001-06:00

I don't need to give specifics, do I?

Case in point: It took me 20 fucking minutes to give a patient some insulin yesterday?
"Why", you wonder?

Because it took me that long to locate all the fucking keys! Yes - KEYS!

There is now a separate key for a locked drawer that holds the syringes, a separate key to a locked drawer that holds all the needles, a separate key to the lock on the fridge where the insulin is stored. On top of that, I now need two RNs: one to sign off on my computer MAR that I am indeed administering 2 fucking units of insulin and one to make sure that I indeed administered the medication as documented.

Everything has a lock on it now - IV bags, antibiotics ... even the blasted plastic cups you use to collect piss! The entire damned supply room is locked! Housekeeping is locked at night - big bad spill or blood all over the floor? Too fucking bad - because all the cleaning supplies are locked and no one has the keys!

Oh and did I mention that I can no longer leave myself signed on a computer - even if I'm stepping away just to administer a medication and will return right after? Of course not, there are shifty, shady characters hiding in the fucking ventilation ducts just waiting for me to step away so that they can pounce and read all kinds of privileged medical information ...

All this bullshit because you know who is in the facility. GAH!

I owe! I owe! So off to work I go...

2007-10-18T05:01:00.000-05:00

Dang! It's been ages since I posted anything worthwhile.

One of our regular staff members handed in her notice. Remember how I stated night shift staffing was in dire straits before? That out of a total of 37 slots, we only had staff covering 17? That even with float pool picking up some of the slack we were still left short?

Well, it is only gonna get worse.

The past two weeks I've worked 6 days a week... my regular 3 12-hour shifts plus and extra 12 and an extra 8. Of course, I can say "no" - but I still have college debt to pay, my car loan, my rent, my utilities...

*sigh* In a way, I guess I'm lucky I don't have to provide for anyone else besides me or that I don't own property with a mortgage...

But what ever doubts I might have had about leaving this joint, the past month has erased it.
Completely.

Besides a couple episodes where I was chewed out for absurd reasons, management's rather "nonchalant" attitude about staffing the floor has convinced me. All I've heard are empty promises ("We're hiring new people" - well, instead of hiring 4 nurses, all we got was 1) and window dressing ("We're shuffling the shifts nursing techs work to provide better coverage" - sounds good and may actually help a little, but the elephant in the room is lack of adequate nursing staff).

The only thing the unit has going for it is the incredible camaraderie the nurses and techs on the shifts have for each other - despite the occasional back biting that goes on. Remember my buddy George? Well, he pretty much promised to hunt me down and kill me if I ever left him here at this joint all by himself. I think our bonds are formed out of the common sense of despair and of being shit over all the time by management. When I had a hard time getting management approval for my vacation this year (my first in over 4 years) - my co-workers on the 3rd/2nd shift, even though they were already short staffed and over worked; were the first to step up and offer to help.

I admit, that every time I think about "moving on", I have a twinge of remorse and guilt. I've enjoyed working with my co-workers and they are for the most part a fantastic, wonderful bunch. I mean, even through our horrid staffing and working conditions; we manage to have some fun along the way. Smile. Share a laugh. Commiserate over hard cases. Cover for and support each other.

But yet, I also realize; that my tolerance of current working conditions is morally unjustifiable. I've gone through the "proper channels" in-house in search of resolution... but the prevalent attitude seems to be one of "deal with crises as they come" rather than "why are we having constant crises?" As such, I'm convinced that trying to "change policy" in this instance is futile (and I'm usually the last person to say that - besides, I tried... and have been doing that for a while).

I never really wanted to work what I am working today anyway. Don't get me wrong, I have learned TONS and I mean TONS since I started working here. I love the challenges and what might seem perverse to some, I actually like the train wreck cases I'm assigned. But my heart was never into taking care of "adult" populations anyway - I've always wanted to work Pediatrics. Especially if it's "emergent pediatrics" (read: ER in a Pediatric Hospital)... but I don't mind working the floor in a Peds hospital or even a Peds ICU (not sure about NICU, but I suppose I could give it a crack).

So I've thought about new jobs - and relocating.

I know I'm going to relocate - but it's not going to be now. Not at least until summer of next year anyway.

And by then, who knows....

Doogie Howser on PCP?

2007-10-07T01:43:00.000-05:00

NameThatDisease.com - Test your disease knowledge

NameThatDrug.com - Test your drug knowledge

Click the results - test yourself.

Ways to maintain a healthy level of insanity

2007-10-06T21:25:00.000-05:00

--At lunch, sit in your parked car with sunglasses on and point a hair dryer at passing cars. See if they slow down.

--Page yourself over the intercom. Don't disguise your voice.

--Every time someone asks you to do something, ask if they want fries with that.

--Put your garbage can on your desk and label it 'in'.

--Put decaf in the coffee maker for 3 weeks. Once everyone has gotten over their caffeine addictions, switch to espresso.

--In the memo field of all your checks, write "for smuggling diamonds".

--Finish all your sentences with "in accordance with the prophecy".

--Don't use punctuation

--As often as possible, skip rather than walk.

--Order a diet water whenever you go out to eat, with a serious face.

--Sepcify that your drive thru order is to go.

--Sing along at the opera.

--Go to a poetry recital and ask why the poems don't rhyme.

--Put mosquito netting around your work area and play tropical sounds all day.

--Five days in advance, tell your friends you can't attend their party because you're not in the mood.

--Have your coworkers address you by your wrestling name, Rock Bottom.

-- Get on the elevator & insist that everyone call you "Admiral."

--When the money comes out of the ATM, scream "I won, I won!"

--When leaving the zoo, start running towards the parking lot, yelling, "run for your lives, they're loose!"

--Tell your children over dinner, "due to the economy, we are going to have to let one of you go".

How I spent my "Bonus Pay"

2007-09-29T15:39:00.000-05:00

Hospital had a windfall the previous fiscal year. Since we are a "not for profit" organization, management instituted a "Revenue sharing scheme" to distribute a share of the windfall (the other part being used for hospital upgrades etc.).

~~So, being the responsible, prudent young adult that I am, I salted it aw...~~

So being the fun loving, young adult that I am, I went out and bought myself:

Even had my first lessons yesterday too :)

My dream has always been to be able to play one instrument each from: the percussion, the wind and the string families. I already know how to play the drums (percussion), so the choice was between the violin or the saxophone.

I'm all excited now (and busy annoying my neighbors as well!)

Now THERE's a sports fan!

2007-09-24T10:40:00.000-05:00

It's the AFL (Australian Football League) Grand final and a man makes his way to his seat right on the wing. He sits down, noticing that the seat next to him is empty.

He leans over and asks his neighbour if someone will be sitting there.

"No," says the neighbour. "The seat is empty."

"This is incredible", said the man. "Who in their right mind would have a seat like this for AFL Grand final and not use it?"

The neighbour says "Well, actually, the seat belongs to me. I was supposed to come with my wife, but she passed away. This is the first AFL Grand final we haven't been to together since we got married in 1967."

"Oh ... I'm sorry to hear that. That's terrible. But couldn't you find someone else, a friend or relative, or even a neighbour to take the seat?"

The man shakes his head "No, they're all at the funeral."

Heh! That's dedication, wot? LMAO!

Up the Irons!

2007-09-24T02:13:00.000-05:00

I’m rediscovering my love for this band.

All over again.

A tiny selection of their extensive discography:

"Running Free" - live at Donnington, UK:

"Wasted Years" from their Somewhere In Time album:

"Fear of the Dark" performed live at Rio de Janeiro, Brazil:

(I just love Bruce's evil laugh in that last video!)

Is "free" healthcare, really the best healthcare?

2007-09-24T02:01:00.001-05:00

John Stossel does an exclusive report for a new "20/20" segment.

Check it out:

Check out the whole deal (it's a 6 part video) : Part 2, Part 3, Part 4, Part 5 and Part 6.

I love John Stossel. Sometimes, I wish he wasn't the only lone voice of sanity in the wilderness.

It really is an "eye opening" report and provides a different take from the usual drivel about the need for "universal" health care. Folks who've had socialized medicine all their lives don't know any different - I know, I used to be one of those. Folks who have private health care suffer from the "Grass is greener" syndrome and wish for universal care, not knowing what they are liable to get.

Does health care in America need fixin'? Sure! I'm not saying the current scenario is healthy. I just don't think eliminating competition and choice by switching to universal care is the right way to go about it.

What we need is more competition, not less.

Y'all been talkin' smack 'bout me?

2007-09-23T12:59:00.000-05:00

Meh! My reputation precedes me, yeah?

The CT scan

2007-09-23T11:27:00.000-05:00

Well.

Had the CT. Good thing I took the night off because I didn't feel "ok". I wasn't nauseated or anything... but I just didn't "feel ok".

So I drinks my prep with my dinner the night before.

Pitch, toss and turn in bed trying to get some sleep during the night - my usual "awake time".

Get up all grouchy after three hours of sleep when my alarm goes off. I've given myself an hour and half to shower/get ready and drink my morning cat-scan prep.

All goes relatively smoothly (warning to anyone considering/needing a cat scan in the future. If you don't hate Banana, take the Banana flavor smoothie. The Berry flavored one sucks!)

I drive meself over. Pre-registration goes fine.

I'm taken down to "pre-scan" area. Requisite health history is repeated. I see a very nervous CAT Tech student hovering around. She asks if I don't mind if she started the IV on me. I smile and say "not a problem!” I remember being a student once - we all gotta practice, right? And who better to practice on and build confidence than on a young feller with tree trunk veins? :)

Right away, while she is prepping, I notice ... well, "technique issues" (My tourniquet is not too tight, she's trying to "see" the vein rather than "feel" it, and when she thinks she's found one, she doesn't try to see/feel it's direction etc.) I generally try and keep my mouth shut - I don't want to come across as a smartypants. The only suggestion I offer is when she does the skin prep - gently I tell her with a smile: "Ma'm (though she is probably 18 years old), it works better if you really rub and scrub it during your process".

She blushes and proceeds to vigorously scrub my skin.

At this point she is ready to cannulate me and I can tell she is dreadfully nervous. I'm used to seeing folks poke my veins (I donate blood Q 2 months and watching an expert nurse drop that 16 G needle into my vein is one of the highlights of the whole process :D)... but I figure that my gawking on would probably be counter productive.

In stead, I try and play the "usual patient" routine and pretend to 'close my eyes in anticipation of the "painful stick" that is to come'.

I feel the poke and I feel her digging around. It isn't painful yet, just a tad bit uncomfortable. I crack my left eye open on the sly to see what's going on. She is digging around, her forehead knotted in concentration, trying to get that magical "flash" in the blood chamber signaling a successful IV stick.

After a dozen seconds of digging around, she flips over her shoulder to look at her preceptor - as if to plead for help. Preceptor says quietly, "Pull it out. Let me take a crack at it".

So she pulls out. Disappointment writ all over her face. She tapes my failed site down with LOTS of gauze and too little tape.

I bite my tongue yet again rather than do some 'constructive criticism' about the need for "pressure on the wound", "elevate the site over the heart for a few minutes" and "fold a piece of gauze over to form a square and use a good amount of tape (especially on males because of abundance of coarse hair) and use pressure when applying the tape/gauze combination to ensure restriction of blood flow".

I make a mental note to talk to the CT department about their preceptorship of students. I note a distinct lack of guidance and encouragement from the "preceptor".

For some reason, I figured this might be a 'nice' time to step in.

I volunteered that I'd be willing to have the student have another crack at my other arm for sticking a vein. The whole flurry off "Are you sure?" type questions followed and each time I answered in the affirmative - I was willing to have the student take another shot at cannulating me.

The student looked like any student would at this point - grateful that they were being given a second chance... and yet horrified about facing her past while trying to achieve a positive outcome again!

(I know precisely what the student was feeling - not too long ago, I too was a "student preceptee" but in a Trauma ER. There, I was schooled in the fine arts of "IV cannulation" by a kick ass ER nurse who had been at that job for 22+ years. She rode my ass unmercifully on all aspects of the job (but her forte seemed to be IVs) - but it is all thanks to her that I picked up some of the salient points of IV insertion.

And boy! Am I thankful she rode my butt back then! Where I work right now, I am the "go to guy" for starting IVs - never mind that I'm not exactly "Mister 20 years of experience!")

But anyway, I extended my Right Arm. Stretched it out good.

As the student (let's call her "ST" sat down with her supplies, I talked in a low, calm, assuring voice:

Me: "You're gonna do great this time. Trust me, I know"

ST: (half laughingly) "Yeah? I hope so"

(Tries to tie the tourniquet on my arm. Ties it on too loose again)

Me: "Pardon me. I don't mean to be a jerk, but I think you might get better results if you tied that tourniquet on a lot tighter. Now, don't worry about 'discomfort' - remember, it's important that you get the IV in, right?"

ST: (Looks at me a bit quizzically but decides to follow through) "Ok. Let's try that again...

Me: (As ST is re-trying) "A little harder... a little more... that looks about good!" I smile

ST: (Smiles) "Ok then! Let's get a vein. Ope....."

Me: And before she can begin her sentence, I'm pumping my fist. "Ready when you are", I grin.

ST: (blushes) "Ok, Let me take a look".

At this point, her preceptor is curious - I've been giving an awful lot of feedback to her student. I'm pretty sure it's something she doesn't expect her average CT scan patient to give...

...so her question doesn't strike me as something out of the ordinary:

"So, are you a CT scan tech? Do you work around here?"

Me: "No M'am!" I grin. "I'm a registered nurse. I work upstairs. I send folks down to you guys for their CT scans all the time."

I quickly turn my attention towards her student, who is still furiously looking for a vein. As gentle as I can, I tell her "try to feel for one. When you push/bounce on a good vein, it should feel spongy. Looks are not all they seem - sometimes a vein that looks good is probably not the best one to hit".

Probably not the best description - but given the circumstances, it should work. I have very good veins on both my arms. She just needs some pointed guidance. I try to guide her, gently; towards the rope of the vein in my AnteCube...

Me: "Little more medial.... little more... just a tad bit more... ok, you're close. You should able to feel a spongy, thread like structure. You're roughly close to the middle of my inner elbow."

Gently, I reach over and grab her index finger... and guide it to my Median Cubital/Basilic vein (for a clickable look at the anatomical position of this vein/site - click here! (WARNING: "Graphic content" of human cadaver used for illustration purposes!)... and gently press on the site.

"There... feel the spongy nature? You try it"

ST: "Ohhh! Ok! I feel it! You're right! It's nice and ... and... 'spongy'!"

Well! I wish every one had veins like I do! But that's a lesson you're gonna have to learn on your own. First things first though...

Me: "Ok. Now try to see which way that vein goes. Try and get a 'feel map'. Is it going straight up and down? Is it going off at an angle? Is it straight for an inch or so or does it get crooked?"

ST is busy trying to concentrate and palpate my vein. Judging by the pressure exerted by her fingertips, I can tell she's arrived at a decent understanding of the direction my vein takes.

She announces excitedly: "Ohhh! You're vein is good and straight! But it just goes off at an awkward direction in your arm!"

I tell her that while anatomy textbooks try and provide a good terrain map, human beings are individuals and are thus bound to be varied. I tell her to get her "stuff" ready (tape, Tegaderm, saline lock). She vigorously rubs the IV site (Hey! She's learning already! :)) in preparation.

As she's about to insert the IV, I tell her to pause and take a good, deep breath. Then I look her in the eye and say "You can do this. Just remember the position you just found, the direction the vein took, spread the skin before you poke and remember to start at a low angle and go slowly. Don't worry about hurting me - you won't. I know you can do it right".

I then turned away and closed my eyes.

I felt the poke... and felt her digging around some. I resisted the urge to look ... just maintained the calm demeanor. Suddenly I heard a yelp:

"Blood return! BLOOD RETURN! Blood Return!"

I felt her clumsily retract the needle - while forgetting to put pressure on the IV site.... almost instantly; I felt blood flow down my elbow through the IV site.

ST: "CRAP!", she swore. But in a frenzy of activity, she managed to hook up a saline lock in no time. As she was wiping up some of the blood, I opened my eyes and winked at her...

Me: "So, it wasn't that hard was it?", I said with a grin.

ST: *blushing* "It was! But I still made many mistakes!"

Me: "Well, those weren't critical mistakes. And you did choose to overcome you fear and failure to give a good attempt again. I'd call this one a "decent try". :)

ST: *still blushing* "Really?! Wow! I thought I'd screwed up major time!"

Me: "ST, nobody is a born IV sticker... except me, of course!" I grin. "But you did well, given your circumstances. Just remember: Dependent arms, tight tourniquets, feel the vein and stick it with confidence", I said with a wink and a smile.

And with that, I was ready to head over to the CT scan....

So, I walks into the CT scan unit.

Facing that big "donut like thing", I quietly tells myself "this is it Spook. Hope the results come out all ok!”

I take a good deep breath, walk over to the counter and take off all "extraneous items" - watch, keys, cell phone, wallet, dog tags, and my belt.

I quietly lie down on the bench. They cover me with a blanket and ask me to lower my pants to my knees. I comply. Then they ask me to raise my arms over my head.

First we "shoot" my abdomen "without" IV contrast [IV contrast consists primarily of Iodine solution]. I 'travel' in and out of the donut - being asked to "inhale and hold my breath" every so often while they take pictures of my abdomen before being told to exhale.

The night before (and this morning), I have swallowed what's known as "Redi-Cat" - a solution that primarily consists of a Barium Sulfate suspension. This solution has been swimming around in my body for a while and now they've taken pictures of by innards - the Barium Sulfate helps identify certain body organs and innards.

Then comes the "Pictures with IV contrast part".

During this session, they "shoot" (literally deposit about a 100 ml of solution real fast. This is the primary reason why CT scans require "good" venous access) Iodine contrast solution directly into my veins.

I was told to expect "feeling warm all over".

Lemme tell ya, it ain't nothing like you think it would be!

When they says "warm all over" - they means "warm all over". And not a "slumber-party-under-the-comforter-warm".

WARM! As in "hot"! You suddenly feel freaking HOT all over. From you head and shoulders, your chest.... to your belly... then in a very awkward way... your genitals too (men - by that I means your testicles and penis!)... before it reaches down to your feet and toes.

All of this happens within seconds! So while you're there feeling semi-assaulted; you're 'drawn' into the CT machine again. Again the command comes: "Breathe in.... Hold your breath".

They did this once and I felt semi-nauseated. Still trying to fight off/get used to that funky, hot, warm feeling between my legs and in my gut, I was slid into that machine again.

Once again, I was told to "Breath in.... Hold your breath".

However, this time... something was wrong! My stomach basically decided to call it quits! This wasn't an 'ordinary issue of stomach issues' - my stomach pretty much just up and quit!!!

I felt stuff regurgitating up my throat!! I felt myself being dragged out of the scanner... all the while trying desperately to hold my position as requested - hell, I didn't want to screw up the damned test and have to do it again!!!!!

As I was being mechanically pulled out of the scanner, I frantically waved my arms, and began pointing fingers into my mouth in the sign of "I'm gonna puke right now!"

I waited for back up. In fact, no back up came...

I ended up turning myself onto my side to mimic the "Recovery position" and proceeded to spew vomit onto the side of the scanner-bed and onto the floor. I vomited about 100 cc worth of my morning CT prep of Berry flavored Redi-Cat (*yuck!*)

Almost as soon as I was done puking, I began analyzing myself: "Ok, respiratory rate seems fine and other than the nasty shit I regurgitated as I was puking, my airway seems to be ok. My heart rate seems a little high, but we're not way up there yet. Ok... looks stable for now".

I leaned back/semi-sat up in that cat-scan-bed/stretched.... breathing through my mouth, retching the last of my vomit, trying to clear my nasal air passage...

"You ok, sir?

Where the HELL were you lady when I was puking?!! Do you realize that in the position I was in, I could have choked/aspirated in my own vomit??!!

"No I think I'm ok. Just have the residual effects of vomiting. I'm not nauseous. I'm actually pretty sure that I tolerated the Iodine IV injection just fine but when you asked me to "Breathe in and hold your breath" was then I started having a problem. I'm pretty sure it's gas related."

[I intend to follow this up with Radiology. It's fine and dandy that I am a young buck, trained in healthcare that was able to look after himself....

.... but what if I was an 85 year old vomiting on that scanner?!! Heck, no body rushed in! And when they did, no body bothered to turn me over to my side lest I aspirate my own vomitus! Me thinks a tad bit of training is due here!]

"Ok, Sir. Why don't we get you up and get you cleaned".

I pretty much proceed to get myself cleaned - including rinsing the highly irritating vomitus out of my nose *blech* *ugh*. Once I'm done, the tech lady (who was also the pre-ceptor earlier on), simply pulls my IV out and slaps and (inadequate) gauze dressing on top. I instantly put pressure on the spot, raise my hand about my head and politely ask for two strips of long 1 inch tape. A minute later, I bring my hand down and swiftly pressure tape my IV site dressing down.

"Ok Sir! You're free to go!"

... and that's it. No post procedure teaching. No "discharge instructions". No "discharge sheet". No 'basic' monitoring (like a short set of vitals signs. In fact, no one took my v/s either before or after) after a procedure like that - hell, especially after I showed an adverse (even if it maybe a "common") reaction!

Like I said, there are multiple issues with Radiology that I need to address....

"I just hurt all over! I feel like I'm going to die!"

2007-09-18T13:08:00.000-05:00

Last week was a little rough at work - Friday was the pits. I had an incident with a patient in the wee hours of Saturday morning.

I didn't like the way it was handled.

AT ALL!

Mr. Z is essentially a post-op Day #2 of a knee replacement. We've been having "issues" with his urine output - so PM shift inserts a Foley in him (around 2100 hrs). When I assess him at 2300 (that's when I pick him up from PM shift), he's alert, oriented, talking about his family and an otherwise pleasant gentleman. I see some clear urine in the Foley drainage bag - not much, but some. I figure it'll pick up soon.

While I was walking my rounds at the other end of the floor, I though I heard someone calling out for help. Part of me wanted to dismiss it saying "you're hearing things". But my gut thought otherwise ... and I respect what my gut tells me. Figuring it can't hurt to check; I quickly walk over to Z's room...

... where I find him half-naked, with his hips and legs (including that post-op knee!) off the bed and on the floor... and his upper body obeying the Law of Gravity by slowly inching its way downwards and towards the floor.

Dadgum it!

I do a mini-dash into his room, reach over across his bed, hook my elbows under his shoulder and hold him by his shoulders to prevent him from crashing onto the floor. Straining and grunting with effort (Mr. Z weighs about 200 lbs. I'm about 150. Right now, Mr. Z isn't co-operating and he isn't supporting his weight either i.e. he is "dead weight"). I quickly realize that I can't win this tug-of-war and with my knee, somehow manage to hit the call light button.

"May I help you?"
(with a strained voice) "It's Spook! I'm in room 80. I need some help here, NOW!"

That produces a determined response - I hear sprinting of shoes down the carpeted hall and a nurse and a tech burst into the room. They quickly recognize the gravity of the situation (no pun intended) and help me maneuver Mr. Z safely back into bed. Crisis (and not to mention the paperwork) averted - for now. Mr. Z claims he was trying to go to the bathroom to pee. I patient inform the patient that he has a Foley catheter and as such, he's already peeing and doesn't need to go to the bathroom. I emphasize the importance of calling us for any needs that he may have. He doesn't appear confused; he's still alert and oriented.

I check his Foley bag - there a little more urine in there than the last time I checked it. Not a whole lot more, but an increase no less. Just as a precaution, I do a bladder scan on him. The bladder scan is a nifty little ultra sound machine that lets us estimate how much urine is in the bladder. I repeat the scan thrice - each time, the machine bleats "000 ml". His bladder is essentially empty. Satisfied, I inform Mr. Z that because of the position of his urinary catheter and where it rests in his bladder (against his sphincter - the "valve" that controls voluntary urine flow) - he's going to have this "sensation" of being "full" and "needing to void". I tell him that this is normal and that he doesn't have to go to the bathroom - the catheter takes care of it for him. I once again, stress the need/importance of calling us for any needs he may have, make him comfortable and walk out. As a precaution, I douse the lights but leave the door open - just so I can hear better from his room.

I resume my rounds on my patients. I medicate as needed for pain, continue my assessments on my recent post-op patients (increase the O2 flow rate on one patient, irrigate an NG tube on another, do a wet-to-dry dressing change on a third patient), and get back to the nurses station to begin the arduous task of "chart checks" (night shift is assigned the duty of "chart checks" - essentially we go over a patient's chart and make sure everything is in order... that physician orders have been implemented/carried out, labs and other diagnostics have been ordered, check the ordered medications with the current one present on the Medication Administration Record {MAR} on the computer, note any changes in treatment plan for the oncoming shift etc.)

At Zero Dark Thirty [that's "Half past midnight" for you non-Army folks ;-)], the Tech (nursing assistant) comes and tells me that the patient is "quaking". She'd just done his vitals (vital signs) so I ask the obvious question:
"Well, is he co..."
But before I can finish she answers:
"No, he's not cold. His temp is 36.8. But Spook, his HR is 156. BP 156/80. Resp 34. Pulse ox was difficult to get since he was shaking and shivering like crazy but the probe told me 96% on room air. I put two extra blankets on him to warm him up before I came to see ya".

So I goes to see my patient. Mr. Z is in there quaking like a leaf in the wind. Despite my many attempts to gauge his pain, he constantly denies pain. And then I notice something queer - his arms are bent at the elbow and his hands are scrunched up to his chest. The hands are shaking violently, but his arms more or less lie in the same position. I ask Mr. Z to "extend" his arms at the elbow (i.e. straighten 'em out). He says "I can't"

You can't? Or you won't?

So I try to straighten 'em out. I have to apply a good bit of effort to do so! His arms seem to be "locked" in position - I am able to straighten 'em out, but boy, I really had to TRY! That concerns me - if I was less informed, I would jump and say "Tetany!" but I notice that his other muscles don't seem to be affected. His legs are mostly fine, his breathing... while fast, doesn't seem to be impaired. His heart sounds fast as well... but I can't detect an anomaly right away. To be on the safe side, I do a quick Neuro assessment (fearing a stroke - his BP and age certainly put him at risk for it) - but the neuro assessment check out ok too.

Now I'm puzzled - but at the same time, more "worried". My "gut" tells me "something's up buddy".

I look down at his Foley drainage bag - hmmmm, no real change in urine output. Actually, come to think of it, the output looks no different at all! I walk over to the store room; pick up a bottle of sterile saline, a piston pump and a drainage tray. Donning gloves, I proceed to "irrigate" the patient's Foley (disconnect drainage bag from catheter. Instill 30 cc of saline into bladder. Allow to drain. Repeat as desired). I notice that my irrigation brings about bloody urine with LOTS of clots. That is unexpected. I irrigate as much as I can (for over 20 minutes) and dislodge plenty of clots in the process. Finally, the urine starts clearing up. I stop irrigating and reattach the drainage bag.

Now what smartass?

And then, it hits me - patient is allergic to latex. Evening shift has somehow overlooked this fact and has installed a Foley which has Latex in it (as opposed to the silicone we use in such cases) - could this be the cause of bloody urine? Possibly, but if patient was allergic to latex - shouldn't I be seeing an anaphylactic/systemic reaction? What I'm seeing is not an anaphylactic reaction - but I'm hesitant to rule out a systemic reaction.

So, trusting my "gut" and for no real justifiable reason, I rouse the tech and tell her to get me a Data scope and monitor leads. I proceed to place Mr. Z on a limited, 3-lead ECG set up.

Time: 0137

Right away, I notice something "awkward". The monitor doesn't reveal anything earth-shattering or "critical" - but all the same, it looks "different". I'm uneasy - I know the patient has some cardiac history - but nothing significant. And yet, if I filter out his obvious tachycardia - his EKG still doesn't "look right" to me. Acting on my own initiative, I page RT (Respiratory Therapy) and have 'em come up and do a 12 lead EKG for me (on night shift, RT does all the 12 leads in the hospital). While RT is doing this, I double check the chart and make sure pt. has blood transfusion consent form signed and call Lab to verify is Mr. Z has been "Typed and Screened" (a procedure that tests a patient's blood and matches to his/her exact blood type). I tell lab I might need at least 2 units of PRBC (Packed Red Blood Cells).

Then, I page the Hospitalist (Hospitalists are Internal Medicine specialists who are assigned to patients who don't have a Primary Physician or have Primary Physician who is out of town or have no privileges at the hospital). I give her the full report and state my concerns. She says she'll be up soon.

10 minutes later, Hospitalist is on floor. By this time, RT has completed the 12 lead EKG and has printed a detailed strip. We go over patient's chart together, and I outline in detail my concerns as well as recent vital signs and patient behavior. Hospitalist goes in to observe patient.

10 minutes later, she returns. Orders are written:
Stat (meaning "immediate") Cardiac Enzymes (typically Troponin and CKMBs). Repeat in 6 hours. Call results of lab tests to Hospitalist.

"You think Mr. Z has had a heart attack?"
"Most likely, Spook. I'm not sure yet. He doesn't seem to be a typical heart attack patient; even his EKG seems to be non-critical. But I agree with your assessment - I'm also 'uneasy' over the way the patient is presenting. Gimme a call as soon as the lab values are back. And makes sure he is Typed and Screened."
"Already done Doc! I'll call you with the results"

I call Lab and tell them to send someone up pronto to draw the requested labs. I go in to check my patient - and while I'm assessing him, he utters the cardinal words - "Nurse. I don't know... but I just don't feel good.

"I just hurt all over! I feel like I'm going to die".

Hellloooo! "Mayday" call here!

I've learned to recognize and respect the "feeling of Doom" my patients sometimes tell me about. While my patient isn't exhibiting any of the "classical" heart trouble/attack "symptoms" of chest pain (often radiating), shortness of breath (while he is breathing fast, he doesn't complain of feeling out of breath) and an altered EKG - I'm still worried. His last comment of "I feel like I'm going to die" coupled with the Hospitalist's 'fear' just makes the case.

I look down to peek at the Foley drainage bag - no real out put since the last time I checked it. As I walk back to the nurse's station to check on the stat labs as ordered before, I tell the Tech to do a bladder scan on Mr. Z. The labs aren't awful but they don't look good either.. Both his Troponin and CKMB reveal a possible muscle injury. At about the same time, the Tech comes back to me and reports with wide eyes and the patient has over 900 cc in his bladder. I page the Hospitalist and tell her that lab results are back. She thanks me for the information and advises me to keep monitoring the patient.

I have 6 other patient's to attend to. Some have been calling out for over 20 minutes. It's 6 of one or half a dozen of the other. I request a peer, a nurse who works the float pool now... but who used to work ICU and actually used to be the Director of the ICU 6 years ago to go assess Mr. Z and the lack/low urine output. She declares that she is going to pull out the current catheter and try replacing it with a latex free silicone one.

I get busy attending to the needs of my other 6 patients. Some need pain medication. Some need anti-nausea medication. Some need to be repositioned in bed. I help the Tech with the ones who need help getting to the bathroom.

Time: 0330

My peer (the former ICU director) informs me of her inability to get a catheter into Mr. Z. She tried the three smallest catheters we have on the floor and she couldn't get in. Now, she's been an ICU nurse for over 15 years and has years of nursing experience before that. She looked me straight in the eye and said:

"Spook. You need to get him transferred off the floor, NOW. He needs critical care - and we can't give it to him on this floor." She'd checked his bladder residual via Bladder Scan after her last failed attempt to insert a catheter in him and it'd come back as over 1100 cc.

I swore under my breath and literally assaulted the phone. I called the Cardiologist on call and advised her of the situation. She asked me a dozen questions to which I responded the best I could with the information I had. She said she'd be on site within the hour.

Next, I called the Urologist on call. He rattled off a list of items he wanted readied and said he'd be on site within the hour as well.

Next, I called the Hospitalist. Informed her of the lab results.

"Oh wow! Mr. Z is having a heart attack. Please STAT page Cardiology. I'll come up soon to assess patient. Also start patient on prophylactic antibiotics - Zosyn prophylactic dosage IV every 6 hours and Vancomycin daily standard dosage IV every day per Hospitalist standing orders. Inform Cardio...."
(Cutting her off) "I've already talked to Dr. DO for Cardiology and Dr. NS for Urology and advised them both of the urgency of the situation. They will both be here within the hour."
"Oh good! Please monitor patient carefully. I'll be up in a few minutes.
"Will do, Doc!"

Next, I call the House Supe (House Supervisor) TA (a Registered Nurse) and let her know of the meltdown on the floor. She lets out a silent groan and asks me "what's the plan?"
"DO and NS are coming over to work on the patient. I suspect he will soon be moved to the Cath Lab. TA, I could really use some help. I'm juggling 7 patients here."
"Ok, I'll be up soon and I'll bring along EM from ICU"

EM is an ICU nurse. ICU nurses, along with RT respond to a "rapid response" on the floors. Though I have not "called" a Rapid Response on the patient - given the situation, it's understood that this is warranted. RT is already on the floor.
I've worked with EM and TA before - they're swell. As soon as I'm done talking to them, I call the Cardiologist again and request that the patient be transferred down to the ICU or the Cath Lab - reason being that folks down there are more attuned to crises of these sort, have more training and also more "leeway" in terms of physician orders to deal with it. Cardiologist refused - stating that she needs to assess patient before allowing transfer because she didn't know if patient needed to go to Cath Lab right away or if transfer to ICU would be appropriate for the moment. I could understand her PoV... but at the same time, I cursed it. Because I knew that the minute she would walk onto the floor, she'd ask me a million and half questions - and a lot of them I would not be answer because I simply didn't have the authority to order those tests or carry out those interventions. A nurse in the ICU or Cath Lab could have - but I couldn't. I lacked the "standing orders" protocol and authority.

With the calls done, I decide to prep the patient's chart - transfer to a "different unit" requires some amount of paperwork - thanks to "The Joint Commission" (cue reverential music). Mostly unnecessary BS that actually eats up my (and more importantly the patient's) vital time... but who am I, a lowly staff nurse on the floor to argue with the rules laid down by the demi-gods in JCAHO?

While I'm prepping the chart, I tell the Tech to get me a fresh set of vital signs on the patient. She responds and promptly reports the news: HR: 110, BP: 150/100, resp rate: 28, Pulse ox: 90%

Not good. I grit my teeth...

Time: 0415

... and as I'm doing do, the Urologist walks onto the floor. I ask my fellow nurse on the floor (and the tech) to cover my side of the floor while I assisted the Urologist.

Then, I gather the equipment and walk into the patient's room to assist. Urologist administers local anesthesia and proceeds to brutally ream out the man's urethra (penis). But he does get a good sized latex free, silicone catheter into him and immediately drains over 1100 cc of urine from Mr. Z's bladder. Near the end of this procedure, the House Supe and the ICU nurse arrive on the floor.

I feel a degree of relief - I have back up now. The ICU nurse immediately proceeds to take a quick report on the patient from me, and then says "Spook, I know you have 6 other patients to look after. Take care of them; I've got Mr. Z under control here". She proceeds to diligently monitor the patient with help from the House Supe. I place a call to the patient's wife and inform her of the events. She is distraught, as expected, but informs me that she'll be over as soon as she can wake up her son to take her to the Hospital (she's disabled).

Time 0445:

The Cardiologist walks onto the floor. Converses briefly with the Urology. Then turns to me and begins a barrage of questions - many of which I am unable to answer. EM, the ICU nurse steps up and says "Well, it's hard for staff nurses on a regular floor to do these things. They usually have more than 6 patients to worry about and their freedom of action is restricted by the lack of standing orders in case of emergencies. Do you still want to move the patient off the floor?"

Cardiologist softens her stance a bit. "No, I still have to see the patient. Let's go".
I turn to EM and she winks at me with a smile before accompanying Cardiologist to see the patient. I'm grateful - while I do feel like a blubbering idiot for not knowing everything the Cardiologist asked of me, EM showed that it wasn't entirely my fault. That helps... a little.

Meanwhile, it's almost 0515. Time for I/O, morning meds, blood glucose checks and insulin administration, changing IV bags and PCA pumps, helping patients to the bathroom.

While all that is going on, I'm frequently interrupted by the nurses/doctors hovering over Mr. Z. Pharmacy has sent up the Abx ordered by the Hospitalist for Mr. Z. I hand them over to EM.
Then it occurs to me that I have not charted on Mr. Z for a while now and that in all possibility, he is going to be transferred off the floor! I hurriedly jot down the Physician orders I've recd. over night for Mr. Z and then sign them off. Also, as a courtesy, I print of a Med Reconciliation List and other needed documents [a "The Joint Commission" (cue reverential music) requirement] and hurriedly place them in the chart.

By the time AM shift arrives on the floor - Mr. Z has mostly been stabilized and is just awaiting swift transfer to the Cath Lab. I'm tying up loose ends and paperwork... while simultaneously trying to deal with my 6 other patients - who are all due morning antibiotics, I/O, pain medication and toileting. Cath Lab folks are now in Mr. Z's room - TA and EM will handle transport for me (standard protocol)... and I'm grateful for that. The Cardiologist has managed to obtain consent for possible procedures. Lab has blood work confirmed.

Charge nurse walks onto floor and observes flurry of activity and just shakes her head.
I am unable to tape report for the next shift and thus must give verbal. Some of the nurses on AM shift roll their eyes, as if stating "He hasn't taped report yet! That is so inconvenient!!" Some nurses on AM shift instantly piss me off by asking inane, dumbass questions they don't need to ask (because they can look it up for themselves). One of the nurses on AM shift grouses over the fact that I haven't discontinued a Foley catheter on a patient - I thought it was incredibly rude, condescending and short sighted on her behalf and I'm tempted to tell her that I had "7 patients all to myself with one of them having an active heart attack" but I bite my tongue and say nothing. It's pointless - day shift has never had to deal with short staffing.

I finish report just as they are wheeling Mr. Z off the floor. I thank TA and EM again for their help and assistance - truly, I wouldn't have been able to do 1/10th of what I did without their help.

I haven't eaten in over 14 hours. I haven't even taken a bathroom break to piss in my entire shift. I quietly go and relieve myself, then sit down to chart.
After 3 hours of charting at the end of my shift, I tiredly walk to the elevators, punch out and leave for home.
Fighting sleep the entire way, I drive home in one piece and collapse in bed.

Only for 3 hours though. For I'm scheduled back for that night.

Mr. Z ended up getting a quadruple bypass surgery. He's still in the Cardio Vascular Care Unit as I type this....

JCAHO and "safety"

2007-09-18T10:17:00.000-05:00

My hospital is still waiting for "The Joint Commission" (cue reverential music) demi-gods to make their ~~interrogation~~ inspection and ~~pronounce summary judgment~~ announce the results of the survey.

This isn't the first time I've voiced disdain and ire about "The Joint Commission" (cue reverential music).

But while I rant in my crude, unsophisticated fashion; Dr. Whitecoat does the same... only with panache. Head on over to Dr. Whitecoat and read this little gem.

Just be sure you're not eating/drinking anything lest you do a spit-take...

I firmly believe ERnursey is right when she says this about JCAHO:

They are like any governmental entity, they make stuff up that makes no sense in the quest to ensure their own continued existence.

Couldn't agree more.

Proverbial "Week from Hell"

2007-09-15T09:48:00.000-05:00

Holy crud!

I haven't felt this tired since they made us do forced marches in the Army with a full pack and ammo load over beach sand. My legs feel like they've been hammered with a baseball bat. My brain is quite literally numb. More like mush.

Blech!

The entire freaking hospital has been packed to the gills all week. I think we had ONE bed (each) free in the Cath Lab and the ICU. That's it. Every other unit was packed. I was seeing 10 patients a night - 2 admits, 2 discharges, 2 routines and usually 4 post-ops. I think we had a code almost every night on the floor. Every body is in a foul, evil mood.

I just want to crawl into bed and sleep for a week. But I'd already volunteered for an extra shift tonight.

Which will be my 5th 12 hour shift in a row. *groan*

Note to self: Next time charge nurse drips sugar and honey when asking you to volunteer for an extra shift - don't be an idiot and say "Yes!" without checking your schedule first!

I feel like a world class moron. At that time, a part of my brain was probably telling me "I smells a rat here" but I was probably too dumb (or too tired. Lack of sleep has wondrous effects on your judgement) to notice.

Meh! So that's where I've been all friggin' week. The only good thing was that I finally got my tickets confirmed for my vacation and sent the dates to my boss. Charge nurses aren't happy (though I'm scheduled for only 3 12s a week... I work an extra shift or two almost on a routine basis), because now they're gonna have to scramble like mad to fill my slots.

I don't care. I haven't had a vacation in over 4 years now. I haven't been home in over 3 years. I need a break or I'm going to burn out...

Today is the day...

2007-09-11T11:56:00.000-05:00

"A day which will live in infamy" for my generation.

I often refrain from making comments about today... as a reflection upon "the day".
Because "The Day" in question holds a mixed bag for me.

I remember coming home in time to see my parents watching TV. The scene seemed right out of a Hollywood disaster flick. Smoke billowing out of a skyscraper. Excited voices on TV. My first thought was "Huh. Wonder what the new movie is going to be about..."

... and then I watched in fascination... as a plane (the second airliner) slammed into the Second Tower.

And then I realised, to my utter horror, that I wasn't watching 'E! Entertainment' but 'CNN'.

This was no disaster flick. This was "real life".
I wish I could erase from my mind and memory those innocents jumping from the burning towers to their sure deaths....

I was traumatised. I was shocked. I was numb. I was angry. I was upset. I was belligerent. I was enraged. I was weeping with hurt and sorrow.

All and once.

I called one of my best friends. I just couldn't bring myself to wish her a Happy Birthday... all I said, with anguish was : "Turn on your TV. CNN. " Then I put the receiver down. I could barely speak.

I've lost close friends to terrorism. I've lost a "brother" fighting that idea and the folks who preach that ideology.

Though I knew no one who lost their lives that tragic day, I was deeply wounded.
The murder of innocents rarely ever makes sense to me.

But, the aftermath of "The Day" has and still affects me today - as I said, "The Day" is a mixed bag to me.

For the first two years following that tragedy, I was careful when I ventured outside. On the way to campus. On the way to the gas station. On the way to the grocery store.

Folks were quick to judge me. Hurl epithets. Rain abuses. Step in my way and threaten bodily harm and worse. "Don't bomb my country!" was a common abuse hurled my way. As were "Sand nigger", "Camel jockey", "Towel head", "Fucking Ayrab", "I'm going to fucking kill you and your Momma you rag head mother fucker"... among others.

I'm not Muslim, heck I don't subscribe to any particular religious denomination (my thoughts and concerns about a god are my private business. As I think is the case with every one else). I'm not of Middle Eastern descent. I don't and have never condoned the killing of innocents - no matter what the cause.

But my 'tanned appearance' was enough to provoke some folks.

I was distraught. I hurt. I was bewildered and at a loss as to what to make of it all.

I was in Oklahoma City when McVeigh hit Alfred P Murrah and slaughtered those hundreds. I was barely in 7th grade... and I went with a friend, to pay my respects to those who lost their lives in that tragedy. No one said a word to me then... rather some folks welcomed me.

That was then. This is now.

This doesn't detract from the horrific tragedy that was September 11, 2001. Just as it doesn't distract from April 19th, 1995.

I mourn the loss of 9/11.
I mourn the loss of 4/19.
Just as I mourn the loss of my "brother".

Rest in peace, all ye who lost your lives as consequence of senseless violence.
May we yet learn to grow out of it all.

- Spook

Why I do what I do...

2007-09-05T16:49:00.000-05:00

A very thought provoking entry on Float Pool RN's blog prompted me to post the following.

It isn't exactly something new.... but it does give a glimpse into my past.... and possibly my future.

A glimpse of why I do what I do...

I was a student nurse.

Working our first peds rotation at Children's Hospital. This rotation was always high in demand - I picked it for no other reason because I wanted to figure what peds would be like [and definitely for the instructor. I loved her to pieces - she was just completely awesome! :-)]

Up until that time - I really didn't have an idea of what I wanted to do once I got done with school, yeah? I had some vague ideas of getting into some kind of critical care at some point in time.

Anyways, this was my last week of clinicals. Up until that point, the whole experience had been a roller coaster. We had some really sick kids who coded and didn't make it and also some sick kids who got well and went home. Peds was starting to "affect me".

But my last patient was the cake.

She was in for a double ureter re-implant. I was assigned to her the day after she'd had the surgery. She was this really sweet 6 year old girl.

Absolutely the bravest person I've met in ages.

Ne'er a cry or whimper. She was absolutely delightful - never asked for pain meds unless it really really really hurt. Despite my assurances that it was ok to ask for something to make the pain go away - she never did.

We were assigned 8 hour shifts and I went about it my own way - general checks/assessments q2h, checking her tubes (2 JPs and 1 SP) and drains Qh. Meds as ordered. Gave her baths. Linen change. Played "chance" and some other games - heck, even played with her stuffed toys! LOL

The only thing she wanted to know was when could she get outta bed - because she wanted to go for a ride in the toy cart :-)! She asked me all kinds of questions, from her body, her condition, to me, my background etc.

So anyways, I go back the next day. And I'm assigned to her again (mildly surprising. I'm the only guy in our batch on the floor who has constantly been reassigned to the same patients. I didn't find out till the end of our rotation that this was done at patients request - they'd liked me and the job I did so they wanted me again!)

So I walk into the room to do morning assessments and while checking her BP I could see she was trying hard not to giggle. So I turn my back to get her meds - and I can see her squirming in her bed. So I ask her what's up.

She asks me to close my eyes, she has a surprise for me.

I close my eyes and in my hands, she places this little card. Made in green paper.

It said "To Spook

Thank you for taking good care of me

from,
XXXX"

Her Mom explained that she'd spent 4 hours, painstakingly drawing with her right hand (she's a southpaw but her left hand was boarded with an IV board).

My vision was blurry. I don't cry easy but I did feel that one tear drop down my cheek. I gave the kid a warm, heartfelt hug.

I'd been having a horrible week to the point that I even came to doubt myself. I was wondering if I'd bitten off more than I could chew. Debt was killing me. Working two jobs just to barely keep my head above the water, sleeping about 4 hours a night at best etc. etc.

That card and her smile when she gave it to me changed all that.

That was when I decided - right then and there - that it was all worth it. That's when I decided that when I graduated, I was going to do peds. Life or death, sickness, suffering or recovery; I just knew right then that I'd be doing it with kids.

I'm still workin' on that goal...

Someone please tell me how this makes any sense...

2007-09-05T10:25:00.000-05:00

Example 1 -

Unit census: 30 patients.
Staffing grid allocation: 5 nurses, 2 nursing techs (assistants).

Ergo: 6 patients to each nurse. 1 tech assisting.

Example 2 -
Unit census: 12 patients.
Staffing grid allocation: 2 nurses. Zero techs.

Ergo: 6 patients to each nurse. No techs assisting.

Why the drop in staffing? The patient:nurse ratio hasn't changed.
Do you think it makes any difference to me if there are 30 patients on the floor or 12 - I'm still juggling 6 patients!! If it doesn't make a whit of a difference to me, then why am I expected to "make do" with no assistants when there are only 12 patients? Does having "12 patients" somehow = "less work than" having 30 patients?

They are called "Nursing assistants" - not "floor assistants" - for a reason.

Don't get me wrong - I'm not trying to "avoid" work here. Merely wanting to point out that all management can speak about is "patient satisfaction" and "customer service". Does their rhetoric match the implemented plan?

I don't think so.

I've asked this question at work - mostly my peers/colleagues. 98% of them pretty much shrugged their shoulders, implying that it was a rule set in stone.

I don't think it is. All I need to do, is compile evidence.
I'm working on some of my own (the simplest being 'average response time to call lights').

I invite suggestions and ideas from y'all...

Staffing again...

2007-09-03T00:22:00.000-05:00

ER Tech Dude makes a critical point about staffing in hospitals.

So I say let's spread out the overcrowding with each unit absorbing a portion of the ED overcrowding. Nurse patient ratios aren't a valid excuse when it comes to refusing a patient admit to the floor, the ED nurse patient ratios are out of proportion daily. What's acceptable for one department should be acceptable to all departments.

Hospital administration has to stop sending nurses home mid-shift because the patient population has fallen 1 patient under the arbitrary ratio number. They also have to be willing to call in additional staff or use a staffing agency when capacity is reached.

Other departments don't care about ED overcrowding not because they're uncaring, it's because as long as the patients can be housed in the ED, it's not their problem.

The solution to ED overcrowding is to get rid of the crowd. Admit and move the patient to the medical floor and watch how fast beds are found.

One flaw with the proposition is that regular floors aren't equipped the way EDs are. Try running a code on a crashing patient on a medical floor and you'll know what I'm talking about. Nurses and equipments on medical floors simply aren't equipped to deal with potential problems the way the ED is.

I'm not saying what's happening is right - having a "stuffed to the gills" ED doesn't sound safe to me either. I'm just trying to provide a different perspective.

At my hospital, my unit typically takes all overflows - even though we are the Surgical/Ortho floor. I've seen everybody up here - Medical, Tele, Gyne, Pulmonary, Oncology, Uro, Neuro ... hell, even the occasional peds patient (even though none of us up here are PALS certified).

The problem, I submit, is the recent shift in hospital admin views about unit census. The current theory is that to stay out of the red, units should be staffed as close to being "full" as possible. They figure this to be efficient - hence why they closed the Medical/Oncology unit in my hospital. Now not only do we see their medical patients, we see their oncology patients too. And on top of that, we take their overflow as well.

We nurses, of course, think this is stupid. "A nurse is a nurse is a nurse" is a fallacy - when you cram different patient populations in the same unit without adequate staff training to take care of them, patient outcome is going to suffer. A medical nurse cannot take care of my post-op knee any better than I can take care of her pneumonia patient.

Besides it being unsafe and all...

I do concede the point that unit managers need to stop judging scenarios based on some arbitrary "Staffing ratio" number. But this again, is a two sided story - those "numbers" are set by admin. Once again, admin wants to eat it's cake and have it too - they want to increase efficiency but look with evil eyes everytime staffing goes "over the limit".

Then again, this isn't exactly something new....

All patients don't come to the hospital through the ER. Many are electives. Some are direct admits. Floor nurses see patient dumping too.

ER Tech Dude, you have my sympathy and support. Let us see if we can change the numbers game...

Cool new widget

2007-08-30T11:54:00.000-05:00

Just added the "MyTube" widget - now allows me to share YouTube videos. Scroll down and give it a whirl (like the Stairway to Heaven cover).

Need to work on customizing it (the white area makes the blessed thing look "patchy", no?)

"Ooohs" and "Aaahs" welcome ;-)

Truth is often stranger than fiction

2007-08-25T15:01:00.000-05:00

A 27-year-old lady presented with persistent cough, sputum and fever for the preceding six months. Inspite of trials with antibiotics and anti-tuberculosis treatment for the preceeding four months, her symptoms did not improve. A subsequent chest radiograph showed non-homogeneous collapse-consolidation of right upper lobe. Videobronchoscopy revealed an inverted bag like structure in right upper lobe bronchus and rigid bronchoscopic removal with biopsy forceps confirmed the presence of a condom. Detailed retrospective history also confirmed accidental inhalation of the condom during fellatio.

I ain't makin' it up...

I don't think I'll be able to keep a straight face the next time someone says "suction"...

"Vick's" Chew Toy

2007-08-25T14:22:00.000-05:00

"Vick's" chew toy for your doggie dearest.

Get 'em while supplies last?

Natch...

Wonder how long it'll take before the lawsuits start flying...

Professional Nurse? Or "trained monkey" ?

2007-08-22T13:17:00.000-05:00

My appy-pologies to MonkeyGirl. I simply use her moniker because it is an apt 'term' pertaining to the situation.

New rules at my hospital following JCAHO recommendations: If a PRN medication is ordered in a specified range (dosage or strength), it is not ok to administer a dosage less than what has been ordered.

For example: I have an order for: Morphine 3-5 mg IV every 2-3 hours for pain.

Now not only am I not allowed to exercise critical thinking and nursing judgment by figuring out how much medication my patient needs, I am also supposed to automatically interpret that medication order to read: "Morphine 3-5 mg IV every 2 hours for pain".

"So what, Spook?" you say. "It follows The Joint Commission (cue reverential music) recommendations on the very subject. In fact that med order that you gave as an example is cited by The Joint Commission (cue reverential music) as something to be avoided - you can see their recommendations here. Your organization is just following recommended policy".

So, if someone is ordered 6 mg Morphine IM for pain, I can't exercise my critical thinking skills and administer 4 mg because the patient may not need 6 mg (or maybe because 6 mg would be an unsafe dose. More on this later). Instead, I'm supposed to call the physician and request s/he lower the dose.

All medications carry side effects - why administer more than that which is required? Don't get me wrong, I don't think patients should sit around suffering in pain (not only is it inhumane, but constant pain slows down the recovery process). But to dose them 6 mg when 4 mg work just fine is just plain stupid.

"But Spook, you can always call the physician and have the dose lowered. Aren't you bothered with medication safety?"

Well, yes, I could call the physician. And it works fine for a couple hours. What if the patient starts reporting increased pain? Now I have to call again to get the dose increased! This seems fine and dandy on paper - but it's a fools errand in real life. I am yet to find a nurse in the trenches who agrees with this approach and implementation.

"But Spook, that's why they have dosing ranges".

Right and wrong. Dosing ranges exist - but no longer do we have (say for example) 'Morphine 4-8 mg IV'. Ranges are now supposed to be much narrower along the lines of 'Morphine 4-5 mg' or some such. I welcome folks to handle a single post-op patient on my floor with such narrow dosage strengths...

Remember earlier on in this post where I mentioned the fact that a patient may not need the dosage ordered? I once had an anesthesiologist order "6 mg Dilaudid IV push now and repeat in 10 minutes" .... for an 86 year old female with a hip replacement with a respiratory rate of 16. I repeated the order four times to clarify - and each time he was adamant it was right.

Needless to say, I didn't carry out the order. I exercised clinical judgment and gave the patient a bolus of Dilaudid 0.5 mg and it helped her immensely. Patient reported good pain relief and was resting comfortably within 30 minutes. I documented the hell out of that incident and also placed and incident report - and made sure the floor Director knew what happened.

Now technically, according to JCAHO - I'm not supposed to do that. I'm not supposed to administer less than the dosage ordered. While it's easily obvious in this situation as to why I shouldn't have followed recommendations; I use this example just to point out that a lot of times, it is not as clear cut in black or white. Precisely why Nurses are taught critical thinking and are allowed to exercise clinical judgment.

Ladies and Gents, unless I'm missing the big picture somewhere - all this new intrusion by The Joint Commission (cue reverential music) is simply eroding my authority as a trained medical professional. If I can't be trusted to exercise my judgment in determining the appropriate intervention and medication dosage for my patient - what the hell am I there for?

Might as well replace us with trained monkeys and be done with the whole deal.

And speaking of JCAHO, I have another post/rant lined up about it...

The LawDog Files: This is exactly what I'm talking about ...

2007-08-17T12:26:00.000-05:00

Stopped by the The LawDog Files and picked up that little beaut of a story.

I'll file that under my ever thickening folder titled "Federal Gummint cockups!"

Hat tip to Lawdog.

Pass the word around boys and girls. I hear them critters in D.C. braying for "Universal Healthcare" again...

Nurse. Lye attack victim. Clinging onto life

2007-08-16T13:04:00.001-05:00

THETFORD, Vt. (AP) -- Two months after she was maimed in a lye attack, Carmen Tarleton continues her fight for life.

Family members and friends, meanwhile, pray for her recovery from what one doctor called "the most horrific injury a human being could suffer."

Burned over 80 percent of her body when her estranged husband allegedly doused her with the chemical, she has undergone more than 16 skin graft operations and has more to come.

Now blind, with one ear burned off and another damaged, the 39-year-old nurse and mother of two remains in the intensive care unit of the burn center at Brigham and Women's Hospital in Boston, heavily sedated and unable to speak.

Hospital officials won't release her condition, but family members say it is critical, although her vital signs are stable. Doctors are optimistic about Tarleton's chances for an eventual cornea transplant that could restore her sight, but that's months away.

"It's pretty gruesome," said her father, Joe Blandin, 64, of Fairlee. "The best case scenario is Carmen's never going to be the same again. But we're hoping that there'll be enough quality of life."

Link to Ms. Tarleton's website.

How horrible! Words cannot express my anger and anguish!
Please support her in any way you can!

Thank You!

- Spook

Quick thinking nurse saves baby's life

2007-08-16T06:27:00.000-05:00

Quick action by a Cardinal Glennon Children’s Medical Center nurse on board a plane may have helped save the life of a very sick baby.

It happened Sunday night as 27 year old Ashley Dollarhide was flying back home to St. Louis after a week of volunteer medical work overseas in Cambodia. Ashley told us about ten hours into the 14 hour flight from Taiwan to Los Angeles, the captain came on asking for medical help for a passenger. Ashley rushed to assist and found a 10 month old baby boy named Kyle very pale and having trouble breathing.

Full story

Learn more about Intra Osseous access

Refreshing to hear something positive about nurses in the news! :-)

Kudos to Ashley. Hope baby Kyle makes it out ok...

Of Pain Control, Teaching and Intimidation

2007-08-14T12:06:00.000-05:00

For some strange, inexplicable reason, my internet access just died.

Just up and died.

And in just as strange fashion, it came back from the dead.

Totally bizarre.

Speaking of bizarre, ever have patients who complain about their pain being a "12/10", grimacing and carrying on, demand pain medication that-I-wanted-yesterday ?

Same patient who, upon bringing said pain medication, is found snoring away in bed with drool dribbling from mouth?

The very same patient, who, the next day insists to the physician that s/he has had a "horrible night in pain", was "ignored by the nurse. He never gave me a damned thing for my pain!", and claims that the "Darvocet did nothing for my pain!" - despite having being found as above... snoring in bed with drool dribbling from the mouth?

Well, I'm sure some of you somewhere have met this patient.

I'm just talkin' because it seems that off late, 5 out of my load of 7 patients per night seem to be of this kind. The gorked-out-of-their-minds type who demand more and more meds and then wonder why the hell do they feel constipated, bloated, nauseated and "funny".

Speaking of constipated and funny - how about the ones who demand opiates because their "stomach hurts". Yeah, it hurts. It hurts because you've been doping yourself on so much pain meds that you've got "gas pains". Taking more morphine and lying in bed ain't gonna help - it's only gonna make it worse.

It is, of course, at this very point then that you are accused of being a "mean nurse". I think people in general don't like being told "No."

Don't get me wrong. I acknowledge that a hernia repair can be painful. Hell, someone just cut you up and sewed you back on. I know it hurts. And for some of you, it's probably the worst pain in your life. Alls I want folks to think about is that every med and every intervention carries consequences and risks. I find it distressing that so many think their post-op recovery is going to be "pain free" - even the ones who end up getting say fusion surgery from T1 to L4 vertebrae because of scoliosis.

Dude, you just had a 14 hour surgery where they ripped your back and built you a new one. Do you honestly think you are going to be pain free?

And of course, you have the concerned, worried family.

Concerned Girlfriend: "Can't you see he is in pain? Why don't you give him his Xanax?"
Spook: ('Ummm, yeah. Xanax for pain control on a post-op ACF guy. That'll work!') "Ummm. I'm sorry but I haven't assessed the patient yet. I need to see him and assess him before I can intervene".
Concerned Girlfriend: (annoyed) "But he's hurting real bad! How can you just sit around and do nothing?"
[I was faxing med orders to pharmacy. Unless pharmacy has med orders, I can't even pull out a Tylenol, much less the PCA and Dilaudid bolus per orders]
Spook: "Ma'm, I'm sorry but unless I assess his condition, I cannot and I will not intervene. He can end up having complications that could be potentially fatal. I'm not going to risk his life for wont of patience and time. I understand you are concerned about his pain, but you have to let me do my job."
Concerned Girlfriend: "That's so easy for you to say! I don't think you understand at all!" (Twirls on heel and walks away in a huff).

Barely 5 minutes after this conversation, patient has had a 1 mg bolus (instead of the 2 mg ordered) of Dilaudid, a PCA set up and explained and pain down to a 4 (and falling). All it took was 5 minutes - yes, I realise, 5 minutes of pain... but it was 5 minutes that potentially prevented a serious complication.

I actually like assisting family members in dealing with their loved ones illness - teaching is a secret passion of mine. Symptoms (such as pain, fever etc.) often tell a wide and varied story. Rather than jumping at the first sign of a symptom and attempting to "cure it", it's better to assess and think for a while. This is why, for example, I prefer to give Toradol to my hysterectomy patients rather than the Morphine ordered for their abdominal pain because it has been my experience that the anti-inflammatory action of Toradol kills their pain better than the masking-opiate effect of morphine. Also, if the Toradol doesn't work, I at least have the stronger dose of Morphine to fall back on.

Now if Concerned Girlfriend had given me 30 seconds of her time, I could have patiently explained me reasons to her. But she didn't and all it made for was an unpleasant experience necessitating a rant on my blog now.

Family members who follow you around with a notepad and pencil, jotting down everything and anything you do, waiting for you to make a "mistake" really get on my nerves. It destroys the atmosphere of mutual assistance and trust. Not helping anyone and least of all the patient. If you have an issue with the way I work, please pull me aside and bring it up to me. If we can't resolve it, I'll direct you to my boss.

But please. Please. Please, don't try to "intimidate me". It doesn't work. I don't get "intimidated into doing my best" - I just get royally pissed off.

Diagnosis: Benign Sinus Tachycadria

2007-08-06T01:49:00.001-05:00

Scared the pee out of me!

I showed up at work 1845 sharp. Collected my things and started getting ready for report. I'd woken up just an hour or two earlier (my usual routine) and was feeling a little "queer" - which I attributed to my having to grab some food via drive through while having just a "Vault" energy drink and thus miss usual food intake. I fully intended to eat something during report.

So, I get to work and I notice that for some reason, my mouth/oral mucosa was feeling super dry. It irritates me when my throat is parched so I drank a full glass of water. Still felt queasy.

Then noticed that my heart was thumping.
Made me feel worse. You know that kind of uneasy, queasy feeling you get when your heart is pounding but won't stop? Like you just ran 2 miles and stopped all of a sudden and felt your heart hammering away? That's what I was feeling.

All the way walking from kitchenette to report room, it seemed like I was struggling for air.

I went in and sat down but my discomfort didn't go away. I was sitting there fidgeting and a co-worker asked if I was ok. "You fine? You're flushed red".

No chest pain. But noticeable SOB now. Thumping chest still there. I keep telling myself "anytime now. It's gonna stop anytime now. Just give yourself a minute and relax..."

I walked outside and took a vital sign cart and hit the BP button while I slapped on the pulse ox probe to finger....

Heart Rate: 157/min
Blood Pressure: 161/102

Holy Toledo! My baseline is HR 58-62. BP 130/70

I took a few deep breaths, pursed my lips and tried a Valsalva or two.

No good... HR still 158 and climbing.

Began my massage my carotids to stimulate baro receptor response while slow breathing.

HR still 160! Feeling all queasy and crummy. Definitely panting for breath by now (breathing 44 times a minute).

Co-worker dragged me to an empty patient room and slapped a 3 lead monitor on my chest. Strip seemed fine. Definitely sinus tachycardia.

For the next half hour or so, I tried everything I could remember and everything the charge nurse suggested. No help. HR still up and so is the BP. She kept insisting that I needed to go to the ER NOW... but I kept demurring and deferring.

My mind kept saying "This is nuts. This shouldn't be happening!" over and over again.

Finally, grudgingly, 60 minutes post onset of symptoms; I let charge nurse wheelchair me down to ER. 12 lead EKG comes out ok. Kept me under observation for 90 mins then turned me lose. Told me to stay off stimulants and to follow up with my primary doctor.

Slowly drove home.

Very bothered by the whole episode.

I know I can stand to lose about 5 lbs. I drink that "Vault" and "Mountain Dew" and tons of good "coffee" on a regular basis without any trouble so far. I've also been cutting back on my meat intake and don't eat candy, pies, chocolate or ice cream.

There was no expectation for prolonged, unabatted, tachycardia! I don't take any meds, eat a pretty decent diet (better than when I was in college anyway) and don't have any medical history or allergies.

Like I said: Scared the pee outta me!

Guess I can add "benign tachycardia" to my medical history now!

Perspectives

2007-08-04T01:13:00.000-05:00

Y'all need to read this.
Now!

Start off here with Matt @ Better and Better

Touch base with AD @ A Day in the Life of an Ambulance Driver

Round off with Babs @ Just Peachy!

Read 'em all... in that order.

And grab a box of tissues on the way...

"Hey Spook? I can't get a BP ..."

2007-08-01T05:23:00.000-05:00

Assignment board for the noc:
RNs - Mar, Spook, Jane
Tech - Linda
Census - 21

Given our "staffing ratios grid" ... we didn't rate an extra nurse. We were expected to start off with 7 patients per nurse. "OK", I asks the charge nurse (who of course, isn't available on nights) "Do we have anyone for call in case we get admits?"

Guess what the charge nurse said? Yep! She said: "You have no one on call".

I log on to a computer and run up a quick list for hospital wide census - Medical has 1 bed free. CVCU and step down are full. ICU has 4 beds free. Neuro has 1.

That means, our floor would be getting all the admits for the night. This (Medical and general overflow admits) has been happening ever since they closed down the MOU (Medical Oncology Unit) and it has been a source of great frustration and resentment amongst staff on our (Surgical) floor. TPTB figure "A nurse is a nurse is a nurse is a nurse. Specialties be damned!"

And naturally, since we don't rate a charge nurse position for nights, I assume 'Charge' as well.

And I have one tech for the whole floor who is too new to the game. Great! Gonna be one long night...

Take quick report and start my rounds.

Amongst the chores of assessment, I also hang TPN (bag #19) on one of our "residents" (i.e. Patient who has been admitted to the floor for a long time with no general progress or change in condition). Start PM antibiotics for my post-op patients. Do a dressing change on a massive mastectomy patient awaiting a wound-vac (Negative Pressure Wound Therapy) consult in the morning - which I thought was pretty 'cool' (I needed one nurse to lift open her chest wall flap while I packed wet kerlix into the wound. Patient's wound was so extensive and deep, I could shove both hands all the way into the cavity! Used up at least 2 fat rolls of Kerlix, a pack of 4x4s and 2 ABD pads minimum per dressing change. If you are wondering what it all means - for a sub-acute surgical floor... that's a lot! Spending 20+ minutes doing a single dressing change on one patient is high intensity/acuity for a sub-acute General Surgical floor).

Medicate for pain as needed. Switch empty PCA cartridges and clear PCA and IV pumps for I/O.

Before you know it, you look at the clock and it's 2300 hrs. The 3-11 shift staff start winding up and leaving the floor. A couple of the nurses are still around - they need to finish charting. Taking their cue, I settle down and begin charting my own assessments.

"Hey Spook, gotta minute?"
I look up. It's Mar.
"Yeah, whatcha need?"
"Can you start an IV on Mr. Link in room 71? He's a post-op bowel resection and has IV Flagyl and Kefzol. I tried twice but his veins keep blowing".
"Sure, I'll give it a shot".

Apparently, I am the "go to" guy for IV starts. I don't have a ton of experience myself and working a surgical floor doesn't help much - but I did 2 months in the ER when I got out of nursing school and was taught the finer points of IV starts by a kick-ass ER nurse with over 20 years of experience.

Mr. Link is a pleasant gentleman in his 30s and quick inspection reveals tree-trunk veins .

This shouldn't take too long...

Or so I thought. But upon my first attempt, I found out that Mar was right. For some inexplicable reason, you'd insert the needle, get a good "flash" of blood in the chamber, and then advance the plastic catheter ... only to have the vein "blow". That was the fate of my first and second attempts. I sat and thought for a minute and then recalled a similar experience during my ER rotation. I took off the tourniquet and tried again...

Bingo! A #20 inserted on his left wrist. Feeling pretty pleased with myself, I decide to go the extra mile and do a good "tape job" on the IV site. I was just hooking the IV tubing back onto the new IV site when the Tech, Linda, pokes her head into the room and says "Hey Spook, I can't get a BP on Room 97".

"Do a manual", I said, without even turning my head.
"I tried. But I still can't get one".

Something made the back of my neck tingle.
"Ok thank you. I'll check it out".

After making sure Mr. Link was comfortable, I headed over to room 97.

A brief history.
Ms. Smith is 78 years old. A nursing home resident, she had been admitted by her primary care Dr. Guy for rule/out Bowel Obstruction Vs Ileus. I had assesed the patient at the start of my shift. Good vital signs (BP 128/90, HR 80, Resp 16, afebrile with SpO2 of 100% on 2L O2 via NC). Had a small chat with pt. while assessing - hypo active BS, no flatus but presenting with diarrhea (which seems "strange" given that the patient's admitting diagnosis is impaired bowel function... but it has been known to happen). X-Rays in ER showed no obstruction of bowels (essentially normal bowels) while ER labs were inconclusive. Patient denies pain, but is very pleasant, alert and oriented x3... just complains of being "tired". Last pain killer was 2mg MSO4 IV at 1500 hrs. NG tube to medium intermittent suction inserted at 1600. Drainage was brown colored then.

Reassessed pt. at "I/O time" (2200hrs). Patient essentially same as before. Slightly drowsy - but good U/O (over 400cc from foley). Follows commands and is co-operative. NG drainage still brown colored.

Cue to the present (about 0100 am). I walk into the room and quietly try a manual. Can't get it either. So I try palpating pulses - on radial, brachial, carotid, dorsalis pedis, posterior tibialis, Popliteal and finally femoral.

I could only palpate a femoral pulse! Pulse rate told me "56 bpm"!

Damn...

Instantly whipped stethoscope of my neck to listen to apical - I got a reassuring (if somewhat borderline tachycardic) rate of 96 bpm ("lubb-dupp"). I trust the apical auscultation over the femoral palpation.

I stepped back and looked at patient and saw patient was "sound asleep". That's when it hit me - despite my poking and prodding her, she hadn't responded much.

Shit! You idiot! Don't just assume a patient is sleeping!

I called out patient's name. Elicited a slight response. Called out name while proceeding to shake arm a little bit. Patient opened eyes to look at me... appeared v.drowsy and barely able to hold conversation. While this was going on, I tried to raise patient's arm one more time to check pulses and noticed that patient couldn't keep arms extended in air - dropped to bed the minute I released them. I snapped my flashlight out and did a quick pupillary check - PERRL with brisk accommodation.

Problem still persists - I still don't know patient's BP and now she seems to have altered mentation/status. I calmly told the tech: "Get me the Doppler and the jelly!" Then, knowing my unit and our 'restocking procedure' (or it's lack there off), I told the tech "if you can't find the Doppler gel, get me some KY jelly from the store room".
"Shall I get the crash cart?"
"No, not yet anyway. Thanks for asking but you wouldn't be able to get it out without my keys. Get the Doppler please".

While the tech flees to find the Doppler, my heart is pounding! I grab the accucheck machine and do a stat BG check. Machine bleats "80".

"Damn! Normal BG".

I take a look at her NG tube output - still brown colored but it is showing signs of red flecks/clots/discharge. Not much to be concerned - but a change nevertheless.

By this time, the tech has returned with the Doppler. I proceed immediately to try and get a Doppler pulse. Vessel occludes at 40 systolic!

Damn! Double damn!

I punch in the desk number on my "charge nurse" phone and ask them to page Dr.Guy STAT! Doc calls back and conversation goes something like this:

"Dr. Guy? Hi, this is Spook, RN here at Tiny City Medical. I have Ms. Smith here with no palpable pulse and cannot get a BP. Patient is very lethargic and responds only to pain or vigorous physical stimulus".
"Yeah. She's a little hard to measure up. What's her vitals?"

Didn't I just tell you I can't get a BP on her?

"Uhhh Doc. Last vitals were over 2 hours ago and she was 128/80 with HR: 72. I have an apical pulse right now which is 96. No BP - vessel occludes at 40 with Doppler. Urine output for the past 4 hours is exactly zero cc. Resps 22. I don't think she is perfusing well - I can't get a pulse ox reading and her extremities are cold. She looks pale but not cyanotic. Blood glucose 80. Fluids running at 125/hr. Last medication given was Morphine 2 megs IVP at 1600 (over 8 hours ago)."

"Ok. Bolus patient 500 cc over 15 minutes. I'll call you right back".

"Uhhh, that's it? Nothing else? Her NG output has changed - it was brown but now it is more reddish with specs and clots".

"No. Just push the fluids. I'll call back".

Seeing all the commotion, George calmly walks in. George is a nurse working the 3-11 shift. He was all set to go home at the end of his shift, but I asked if he'd stay and work double because we were insanely busy that night. George had agreed (of course, he would also get paid time-and-half for his troubles).

I feel much better knowing he is on the floor - George is a buddy and has been a paramedic and nurse for decades. In the midst of all this confusion, I give myself a little pat on the back for having the huevos to defy "The Almighty Staffing Ratio Grid" and keeping him around rather than send him home at the end of his shift.

My iMED pumps won't let me program a bolus of 500 cc in 15 minutes. George simply winks and unclamps the line from the pump, reattaches the line direct to the hub of the catheter sans Clave port and begins squeezing the bag with his hands. By this time, Doc calls back.

Still no appreciable BP. Patient mentation is still same. Order: Repeat bolus and admin 0.5 Narcan and repeat in 10 minutes if no change.

George walks over to get me the Narcan. With one hand still dumping in the fluids, I use the other hand to call the House Supe.

"Dude, you better get up here. I got a LOL (Little Ol' Lady) with no BP and barely any pulse".
"What the hell happened?!"
"I can't talk right now. Just get up here!"

My buddy saunters in with the Narcan.

I hand him the bag while I push the med in. Almost instantly her eyes snap open and starts darting around. I instruct my buddy to try and get a BP on her.

Apparently the 1000 cc fluid bolus did something for we managed to get a BP reading of 50/20.

*whistling sound behind my head* "Whoa! That's not a good sign"...

I turn around and see the House Supe walking in. "Call the code, Spook", he says to me.

I yank my phone out and call ICU and have them prep a room for an insta-transfer. One of their nurses hurries over to the floor. While the three nurses are in the room getting the patient ready to transfer, I run over to the desk and pack up patient's paperwork, hurriedly scribbling down the telephone orders on an order sheet.

I reach the elevator the same time they do, with the patient on the bed. I leaf through the chart and pick out the face sheet. I call patient's daughter in town and tell a sleepy voice that patient is being shifted to ICU and it would probably be a good idea to come in.

"What the hell happened?"
"Well, her BP dropped and she's very lethargic and unresponsive."
"Oh my God! I'm coming right over".

I glanced over at the foley bag - still no urine output.
Dang!

Auscultated her while we reached the floor - HR still running in the 90s. Resps 20. Failed to get a palpable BP....

Well, we got her to ICU and got her hooked up and set up. Gave report to ICU nurse.

Walked back to the floor and was instantly met with a pile of messages from my patients... each one of them asking "What took so long? I've been on the call light for hours".

*sigh* "Here's your iced tea and your Tylenol PM. Have a good night. Anything else I can do for you?"

Morning rolls around and charge nurse walks in. If I thought my night was bad, it wasn't about to get any better.

Points to my buddy and asks me indignantly: "What's he still doing on the floor?! Wasn't he supposed to have gone home last night?!"

(A very weary, tired, Spook): "No. I kept him around because it was insane up here. We have 4 post op knees - two of them sun downers who insist on climbing out of bed every 10 minutes sitting on beds whose bed alarms don't work because the beds are 30 years old. Four patients in isolation. One with aspiration pneumonia because medical is full and have no beds. I had 7 patients in gen surg all to myself spread all over the floor. Oh and did I tell you about my ICU transfer yet?"

"You could have kept the second tech!"

"But what could the tech have done? Passed meds? Done chart checks? Push fluids or get me some Narcan? Co-ordinate a transfer to the ICU? Look after my patients while I was downstairs giving report? Nah... sorry. There were 4 patients in the ER - two of them possible surgicals at shift change time and I thought it best to keep him rather than send him home and then call him back. Don't worry, I'll do the paperwork".

Charge Nurse saw that I was tired, hungry and just wanted to get the hell outta there. Wisely chose to drop issue and let me get back to charting.

Didn't get home till late in the day.

The numbers game

2007-07-20T11:18:00.000-05:00

"Almighty Staffing Grid"

We've all heard of that one before. That hallowed piece of paper that quotes "If there be X number of patients on the floor, there shall be Y number of nurses and Z number of techs. No more... but certainly less".

Yep. I walked onto the floor yesterday, took one look at the census and instantly lost half my energy and strength.

You see, we were at "cusp" - A special combination of 'numbers' which guarantees 'absurd staffing'. Last night was 22 patients - which means 3 nurses. No doubt some of you realize this means, two nurses with 7 patients a piece while one poor slob gets saddled with 8.

Guess who was the gopher last night? Yep, yours truly.

We don't "technically qualify" for an additional nurse until census hits 24. Anyone want to think about the absurdity of that equation? At 23 - two nurses would be juggling 8 while the third would be hacking through 7. For a surgical floor - 6 patients a nurse is the safe max limit. 7 is asking for trouble. 8 is just irresponsible.

Keep in mind, two of the 'new' patients would be admits - which means admit paperwork and assessments and chasing down primary docs and putting together charts (naturally, we don't rate a secretary for nights. I mean 'admits on nights? Whoever heard of such a thing!') and the other myriad bullshit that comes with the territory of "admit" (and while all this is happening, all the other patients and their needs are magically taken care of by the ghost of Ol' Flo').

Now if this wasn't numbing enough - add another admit before we are allowed to call in the on call nurse. Where are we now? At 24 with 4 nurses, which equals? 6 patients a piece --- full ****ing load again!!

Every night is just a race - running from one crisis to the next. Putting out one fire after another. You manage to do your job - barely - and the price you pay is immense personal dissatisfaction. Some days, I run my tail off yet I feel like I accomplished nothing - the entire shift turning into one big, blur of crises merging into each other.

Last night was no different. I started with 6 when I got out of report at 1930. By the time I got done with my assessments, hanging meds, antibiotics, pain interventions , I/O for the shift - it was shift change time. Which means staffing ratios were about to increase - I would have to pick up an extra 1 - 2 patients at this point.

I haven't charted or documented at any point in my shift now. And if I thought I could get away with picking up one, I was sorely mistaken. The other nurse working the 12-hr with me was assigned patients all over creation. No possible way she could take 8 patients. The new nurse coming on to cover the 8 hrs till morning could not possibly start off with 8 - she is yet to see a single patient and if she started with 8, she'd never get done and we'd never leave the floor till noon!

So I was stuck with 8 - three of them being TPNs (which meant lab draws in the morning besides additional interventions), two of them confused/combative post-surgicals (which meant a bitch of a chart-check for each one), one with wildly fluctuating blood sugars and one in isolation for antibiotic resistant illness.

Oh and did I mention that I had only one nursing assistant all night? Who was new and not yet certified to pull foley's or do blood glucose testing? Not only did the poor dear have the whole floor to herself, we nurses had to pitch in and pull her slack (she has but two arms and two legs. There is only so much she can do).

Forget the fact that I was also "Charge" for the night. Which means I was the "go to" guy for the floor - any idiot anywhere in the hospital had a question, a comment or an itch - I was obligated to answer 'em.

Joey from 5th Floor: "Hey Spook! Are you guys busy tonight?"
Spook: "Heck no! We're never busy here. I only have 8 patients to sweat out. How may I serve you?"
Joey from 5th Floor: "Well, we're at 11 patients and have three nurses, but no assistants! Can you imagine that?! We're short staffed! Can you send us one of yours?"
Spook: "Sorry Joey! I only got one for tonight and it's a zoo up here. I can't spare a warm body."
Joey from 5th Floor: (hurt showing through her voice) "Oh! But we're really short, can't you send her down for a half shift?"
Spook: "Joey, I'm sorry but I absolutely can't. Take it up with the House Supe(rvisor)".

A little while later:
Spook: "This is surgical. Spook, RN. How may I help you?"
ICU Sandy: "Heeeeey! Spook! What's up?
Spook: "Uhh, can't talk now Sandy. Sorry. Really busy."
ICU Sandy: "Uh huh. Hey, is Tasha (float pool nurse) working up there?"
Spook: "Nope."
ICU Sandy: "Really? But I was sure she was. See I talked to her last week at the gym and we were going over her schedule. I mean, you know what she's like right? Working all those crazy hours. So any way, we were talking and ..."
Spook: "Uhhh, Sandy, I'm not kidding. I gotta go. I'm super busy here".
ICU Sandy: "Oh ok. If you see Tasha, be sure to tell her to call me, yeah?"

Momentarily -
Spook: "This is Surgical. Spook, RN. How may I help you?"
CVCU Kelly: "Uhhh, this is Kelly in CVCU. Can I speak to the charge nurse?"
Spook: "I'm it. Surgical doesn't rate a charge for nights..."
CVCU Kelly: (astonishment plainly apparent in her voice) "What?!! Really? Wow! I've never heard of that. How do you guys pull it off? It must be..."
Spook: "Was there some thing you needed, Kelly?"
CVCU Kelly: "Oh yeah. Do you guys know how to hook up a CBI to irrigate a Foley?"
Spook: "Didn't you call the House Supe?"
CVCU Kelly: "Yeah, but she doesn't know. She told me to call you guys up in Surgical"
Spook: (Unbelievable!) "Find the Bard access package from CS. If you can't find one, you can always steal one from OR 10. Insert like you would a regular Foley. Remove stopper from third port and connect CBI tubing. Run CBI at rate sufficient to keep Foley output tubing free of clots.
CVCU Kelly: "Thanks!"
Spook: "Yep".

So on and so forth. All freaking night long. And I get to field them calls... "Burden of responsibility" and all that...

To say this was a tough assignment would be an understatement.
And some of the day shift folks couldn't understand why I was 'moody' in the morning...

It took me two and half hours after the end of my shift to finish charting for the night.

It's good I have two nights off. I need the break - unfortunately, I have a 200 mile round trip drive to look forward to tomorrow - need to see my car dealer and finish installing parts on my new car.

No rest for the weary.

Until later...

Conquering Mt. Hampermore and the Insinkerator

2007-07-16T05:11:00.002-05:00

I've come to the following conclusions:
1. I do not like to do laundry (especially ironing freshly, laundered clothes).
2. I do no like doing dishes.

I don't mind doing any other freaking chore around the house: scrubbing toilets, mopping floors, general clean-up-and-put-things-away etc.

But hot damn! I really dislike doing them two chores!
I think it stems from the two part time jobs I held when I was going through college.

Naturally, this aversion manifests itself in procrastination - I put these two chores off until health concerns (like starting to run short of underwear for example) light that big ol' fire under my ass and I hop to it. Of course, since I've ignored the problem for a while, there is that much more to be cleaned, scrubbed, washed and ironed.

Now, every time this happens, I promise myself that the next time I'll be more prudent and attend to things right away.

Of course, me being me, conveniently develop amnesia the minute the chores are done... until next time....

Repeat. Ad infinitum.

Of course, to make matters worse, a cleaning agency left it's calling card on the door knob of my apartment - tempting me with their "low rates". Are they psychic or something?

The sad state of healthcare staffing

2007-07-15T04:38:00.000-05:00

This is an old, old, article (published some time in February 2001) I believe. I don't have a link to the original publication and I'd appreciate it if someone could let me know if they do.

Not only is the article bang-on-target, it's ominous that in the 6 years since it's publication, the conditions haven't changed for the better.

In fact, they've gotten worse.

The Sad State of Healthcare Staffing

Night after night, registered nurse Julie Ginther finds herself at ground zero in the national nursing shortage. One recent evening, Ginther was responsible for six patients recovering on the postoperative floor at Menorah Medical Center in Overland Park, Kan. The patient load was two more than Ginther deemed safe, and she was worried she wouldn't be able to keep up.

Her concerns proved justified. A few minutes into the shift-as Ginther helped an 80-year-old man to a bedside commode-she was informed that a patient in her 70s, confused by anesthesia, had climbed out of bed. Ginther rushed to help the woman but was unable to respond to a concurrent call from another elderly man recovering from abdominal surgery. Meanwhile, the patient she'd helped to the commode was dutifully waiting for assistance in getting back into his bed, a task Ginther couldn't accomplish without help.

Finding her co-workers equally stressed, Ginther raced off the floor to get a supervisor to help her lift the man up. Only then was she able to respond to the third patient who'd rung for help some 15 minutes earlier. By that time, the man had relieved himself in bed.

"How would you like it if that was your father, or husband or grandpa, sitting in his own urine and waste?" Ginther says. "Because he had an abdominal incision, it was a major infection concern. But if I hadn't gotten to the woman who climbed out of bed in time, she could have fallen and broken a hip or opened her incision. You run from fire to fire all night long."

By all accounts, Ginther's precarious work environment is increasingly the rule nationwide, as nursing's thin white line buckles under the combined weight of long hours, low pay and little respect. Yet as serious as the problem is, experts warn that the nursing shortage is only the most visible piece in a broader healthcare staffing crisis that, if left unchecked, threatens to implode the country's delivery system in the coming years.

Hospital and health plan executives say worsening shortages are being felt at nearly all points along the continuum of care. Nurse's aides, nurse anesthetists, radiology and nuclear medicine technologists, lab techs and respiratory therapists-not to mention food service and maintenance help-are all in short supply. So too are pharmacists, who are abandoning careers in acute care for other opportunities, as well as anesthesiologists and other specialists, whose importance was mistakenly de-emphasized during the healthcare reform upheaval of the mid-1990s.

In a recent survey of nearly 500 acute-care hospitals conducted on behalf of the American Hospital Association, 62 percent of respondents said that personnel shortages had increased either somewhat or dramatically from a year earlier. Another AHA study showed 126,000 nursing vacancies at hospitals nationwide. The problem is being similarly felt in home health and nursing home care. But while the industry as a whole is mobilizing in search of solutions, few observers expect the overall employment crisis to pass anytime soon in a sector that employs nearly 14.6 million people, or slightly more than 10 percent of the U.S. workforce.

Grim Outlook

His is going to get worse," predicts Greta Sherman, senior partner with the Healthcare Group of Louisville, Ky.-based JWP Specialized Communications, an employment consulting firm. "I've been doing this for 25 years, I went through the nursing shortages of the '70s and '80s, and I've never seen anything even come close to what we're facing now. I'm 49 years old and I don't want to get sick. It scares me to death."

In the broadest sense, the staffing shortage is the latest side effect of healthcare's awkward transformation from a somewhat insular cottage industry into one that's increasingly susceptible to the market forces that impact nearly every other business sector. But now the competition is not only among providers themselves but with other industries as well, and the prize is not new business but employees. After profiting for generations from a steady supply of female employees with few other avenues of employment, hospitals and other healthcare organizations now find themselves unable to compete with a wide-open universe of work opportunities for women.

The situation is worsened by a complex web of cultural, economic and demographic factors. Relentless financial pressure at the provider level is not only containing salaries but increasing the workload for a broad range of clinicians. The resulting turmoil has made it harder to recruit new workers and has triggered an exodus of the veteran staffers who've carried the industry for years, a situation that further increases the burden on those who remain.

"It's a pretty pathetic situation," says Michael Morrissey, a veteran respiratory therapist at St. Francis Memorial Hospital in San Francisco. "We're very short-staffed. Nobody wants to become a respiratory therapist anymore, basically, because you can make more money going into computers or some other line of work where you don't get coughed on or spat on. It's just a dirty job and nobody wants to do it."

Making matters worse is the steady shift from inpatient to outpatient treatment, which means that only the sickest of the sick are now cared for in the hospital setting. This, too, increases the responsibilities and stress on a clinician pool that is already approaching its limits.

Finally, the worker shortfall comes as upwards of 80 million baby boomers inch toward old age, ill health and infirmity. And because the shortages stretch far backward into the educational pipeline-and thus will take years to rectify-the problem extends over the horizon and beyond.

"The demands for higher acuity healthcare will intensify significantly over the next decade," says John Leifer, CEO of the Leifer Group, an Overland Park, Kan.-based healthcare consulting firm. "At the same time, we're at a point of unparalleled cost restraint within healthcare, and a resulting decline in the economic health of the nation's provider organizations.

"Add to that an increased demand for quality healthcare by payors, businesses and consumers, along with the recognition that medical error is an enormous problem that needs to be rapidly mitigated," Leifer declares, "and all in all, I'd say you've got a pretty ugly situation."

Delays, diversions, low pay

Just how ugly can be seen in New York, one of the states hardest hit by the worker shortage. Daniel Sisto, president of the Healthcare Association of New York State, says he's increasingly hearing of surgeries postponed or delayed and hospitals sending ambulances away due to the worker shortage (see sidebar).

"Between 80 and 90 percent of our members are reporting significant vacancies, whether it's RNs, LPNs, nurse's aides or technicians," Sisto says. "The fact is, I don't believe any hospital CEO in New York state can assure the public that optimum quality of care is being delivered now. And that's not something I'm proud to say."

Staffing vacancy rates-particularly for nursing positions-are exceeding 20 percent in some areas, up from traditional levels of less than 10 percent, notes Peter W. Butler, CEO of Methodist Health Care System in Houston and chairman of an American Hospital Association initiative charged with addressing the problem.

"Unlike previous shortages, where you could anticipate a recession and those that were on the sidelines would come back, there really aren't any on the sidelines now," Butler says, noting that a wide range of alternative employment opportunities exists not just in healthcare, but in any number of more lucrative and less-stressful fields. As for money, most providers don't have enough to compete effectively in the still-powerful economy. In 2000, nurse salaries averaged $46,782, up from $42,071 in 1996. When measured against inflation, however, salaries for nurses have remained nearly flat for 20 years, according to the U.S. Department of Health and Human Services' Bureau of Health Professionals.

Yet for the 60 percent of the nation's 2.6 million RNs who work in acute-care settings, the money is apparently less important than the arduous conditions of the job itself.

"I've left work sometimes and my feet hurt so bad they don't stop hurting for two days," says Leslie Remington, a Kansas City, Mo., nurse. "Twenty-year-old nurses are getting back injuries, and people are going for 12 hours without even being able to go to the bathroom. It's the slave labor conditions that are the real problem."

According to a recent survey of 700 current and former nurses conducted by the Federation of Nurses and Health Professionals, an AFL-CIO-affiliated union, 84 percent of those surveyed said they believe there is a moderate or severe nursing shortage. Half of the currently employed nurses said they've considered leaving the patient-care field, and 20 percent said they plan to quit soon. The primary reason cited for leaving, or contemplating it, is the desire for a lower pressure and less physically demanding job. Of the respondents, 56 percent gave job conditions as the biggest problem, versus 18 percent who cited compensation.

Education catch-22

The current reality is that there are not enough newly trained nurses waiting to take the places of all of those running for the exits. The American Association of Colleges of Nursing reports that enrollment in nursing programs has fallen by a cumulative total of 25 percent over the past six years, with no reversal of the trend in sight.

The growing reluctance to pursue a patient-care career is reflected in the advancing average age of nurses nationwide. According to the Bureau of Health Professionals, the average nurse was 45.2 years old last year, nearly a year older than in 1996. Significantly, only 31 percent of nurses today are under the age of 40, down from 53 percent in 1980.

"Potential students don't see nursing as the most attractive career," says Polly Bednash, Ph.D., R.N., executive director of the American Association of Colleges of Nursing. "At the same time, we're having difficulty getting enough faculty in the schools. It's quite a complex problem."

Given the current educational and demographic trends, government experts warn that by 2020, there will be a shortage of 400,000 nurses nationwide.

Bednash acknowledges that part of the problem is the competing tracks that nurses can pursue to earn a nursing degree. Currently, nurses receive comparable R.N. licensure through either a two-year associate degree or a four-year baccalaureate degree. Yet typically, getting a four-year R.N. degree doesn't translate into much higher pay. Hence, students who are committed to a full four-year college education are less inclined to enter a profession where an additional two years of training doesn't mean greater earning power.

"If you look at medicine, dentistry and veterinary medicine, the number of women entering those fields has gone up tremendously," Bednash points out. "The people who used to come into nursing are choosing other fields that more clearly reward a better education."

Grueling, stressful work

The same core issues that are undermining the nursing workforce also are affecting a range of other clinical occupations. Hard, stressful work and a multitude of employment alternatives are taking a toll on therapist, aide and technician positions. In fact, in AHA's recent survey of member hospitals, 71 percent of respondents reported that their greatest workforce shortage was in radiology and nuclear imaging.

Mark Bakken, chief operating officer of U.S. Radiology Partners Inc., an Irving, Texas-based radiology management and services firm, says the imaging technician shortage is being fueled in part by the surging growth in the volume of clinical imaging, which is increasing at about a 13 percent clip annually nationwide.

In a recent study of Colorado's impending worker shortage by the U.S. Department of Health and Human Services, the agency predicts that by 2006, Colorado will need 80 percent more physical therapists, 73 percent more emergency medical technicians, 62 percent more occupational therapists, and 56 percent more home-health aides.

At the same time, a shortage of pharmacists continues to plague acute-care providers across the country. HHS's Health Resources and Services Administration says the number of unfilled pharmacist positions nationally rose from approximately 2,700 in February 1998 to nearly 7,000 by February 2000.

Mary Anne Koda-Kimble, dean of the School of Pharmacy at the University of California at San Francisco, attributes the shortfall to the exploding array of expanded, high-paying pharmacy opportunities in both retail and managed care, as well as a dramatic increase in the overall volume of prescriptions. And as in nursing, there has also been a sharp decline in the number of pharmacy school applicants, with the numbers in 1999 down 33 percent from 1994, according to the Health Resources and Services Administration.

Moreover, she says, the job has become considerably more complex and demanding than it used to be.

"There are more new drugs, more complex drugs, and the way they must be administered is much more complex," she says. "There is a growing trend toward combined drug therapy, which requires multiple medications working in unison and means a greater likelihood of drug interactions and side effects."

Even as many patients are taking greater responsibility for their healthcare, the need for pharmacists to provide them with consultative services is more critical than ever. Yet most pharmacists have far less time to play that traditional role, Koda-Kimble says.

On the physician front, an anesthesiologist shortage is forcing some operating rooms to shut down and some surgeries to be postponed, observers say, although no statistics are yet available.

According to Armin Schubert, M.D., chairman of the Department of General Anesthesiology at the Cleveland Clinic Foundation, only 390 anesthesiology residents who graduated from U.S. medical schools finished their training last year, compared with 1,500 in 1995.

"I hear reports from virtually all over the nation that operating rooms remain closed that would otherwise be open, and that pain management practices are being closed or limited," Schubert says.

Gregory Unruh, M.D., an academic anesthesiologist at the University of Kansas Medical Center and chairman of the American Society of Anesthesiologists' Physician Resources Committee, attributes the shortage to a sharp decline in the number of students who pursued the specialty in the mid-1990s.

"There was the perception that with the shift toward managed care, we wouldn't need nearly as many [anesthesiologists]," Unruh says. "Of course, that's proven not to be true."

Schubert adds that with salaries climbing, he's confident market forces will eventually rectify the shortage as more students select the specialty. It's the next five to 10 years that has him worried.

"My concern is that with a limited labor supply, there will be limited growth in surgical medicine and that means access to care will be limited," he says. "We're already seeing this in terms of waiting periods for some elective surgeries. It's kind of frightening, but I don't see any immediate solution because people still aren't coming into the specialty at a very high rate."

Even graver concerns surround radiology, which, like anesthesiology, saw a sharp decrease in residents during the healthcare reform tumult of the mid-1990s. Though residency programs are beginning to fill back up, the problem will be made much worse in the near term due to a 1997 decision by the American Board of Radiology to require that diagnostic radiologists complete a one-year internship in addition to their four-year residency.

"That means that next spring, there will literally be no new residents coming out," says Lori Boyd, director of administration for the American Board of Radiology. Bakken of U.S. Radiology Partners assesses the situation this way: "The impact will be massive, but most people I talk to-administrators and heads of radiology and imaging groups-have no idea this is going to happen. I feel like Noah before the flood."

Bakken predicts that the shortage will quickly become acute, and that over the next seven to 10 years it will probably lead to the closing of many small, rural hospitals that are simply unable to attract radiologists.

"A hospital can function without an extra surgeon, but without a radiologist or access to interpretation of images, it cannot exist," he warns.

Beyond anesthesiologists and radiologists, other physicians predicted to be in short supply as baby boomers enter their twilight years are a variety of intensive-care physicians. These specialties include pulmonologists, cardiologists, gerontologists, urologists, obstetricians and cardiologists.

Mark Kelley, M.D., CEO of Detroit-based Henry Ford Medical Group and executive vice president and chief medical officer at the Henry Ford Health System, recently co-authored a study concluding that a shortage of pulmonary critical-care specialists will get progressively and substantially worse across the first three decades of the century.

"By 2010, we won't have enough people to provide even the critical-care levels that we have now," Kelley says.

According to the study, published in the Journal of the American Medical Association in December 2000, the overall shortage of ICU specialists will mean a shortfall of 22 percent of demand by 2020 and 35 percent of demand by 2030.

"I think our paper should be a wake-up call to the public-policy makers," Kelley says. "They had better start paying attention to this, because you don't just throw a switch to get these kids trained to be critical-care specialists."

Seeking relief

Butler, the CEO of Houston's Methodist Health Care System who is heading up the AHA's workforce commission, says efforts to address the overall problem are proceeding on two tracks: An external advocacy effort is aimed at alerting political leaders to the implications of the current trends and developing legislative initiatives to address them. At the same time, an internally focused effort is concentrating on pushing the structural and cultural changes necessary to improve the work environment in healthcare.

Butler believes there is growing recognition of the problem in Washington, and several bills have recently sought to address elements of it. In early April, two bipartisan bills aimed at reversing the nursing shortage were introduced in the Senate and a companion bill introduced in the House. The Nurse Employment and Education Development Act, sponsored by Sen. Tim Hutchinson, R-Ark., would authorize $105 million in fiscal 2002 to fund a variety of nurse-training, education and scholarship programs.

"The educational system has to have the capacity and attractiveness to bring people into the field, and that will require support from elsewhere," Butler says. A number of bills pending both at the federal and state levels, he notes, would attempt to increase the size of the labor pool. On the internal front, Butler says it's going to require bold, creative thinking and real action to reverse the growing perception that healthcare is a less-than-desirable career path. "Some of these ideas may not be all that attractive to our members," he acknowledges.

Sisto, president of the Healthcare Association of New York State, agrees that fundamental cultural changes, many of which may be unsettling to providers, need to occur within hospital organizations in order to turn the tide.

"Something we've tried to pound into our administrators is the fact that the view patients have of their hospitals is going to be based on how they felt nurses responded to them," says Sisto, who's been instrumental in assembling the broad-based Workforce Investment Now Coalition in New York to address the state's staffing shortages.

"If the nurses are feeling good and they're energetic and delivering attentive care, then you've got a great hospital. If the nurse comes in and says, 'You won't believe the terrible conditions in this place,' then the person is going to believe their stay was poor, regardless of the outcome.

"So we have to give nurses a decent environment to work in, we have to retain the staff we have, and we have to attract older workers, retirees-not only nurses, but firemen and policemen or others who are considering a second career in their 40s or 50s," Sisto says.

Bednash, of the American Association of Colleges of Nursing, agrees that nurses are at the core of the acute-care experience and should be treated as such.

"If you go into a hospital and stay overnight, it's for one reason only," she says. "It's because you need sophisticated skilled nursing care to support you in your recovery process. That's the only reason people get admitted to hospitals. And until hospitals understand this, nurses will not be valued, and they'll continue to be treated as though they were janitorial staff."

Bednash adds that history has made her skeptical about how much real change will occur as a result of the current crisis.

"It's déjà vu all over again," she says, noting that in the last major nursing shortage in the '80s, hospitals did make changes that included more money and more autonomy or authority for nurses. But hospitals soon grew complacent, she claims, and began worrying more about the bottom line and less about maintaining morale. The result was layoffs, along with reductions in the governance role of nurses.

"In many cases, senior expert-care nurses have been laid off, and the organization culture that kept nurses happy has been destroyed," she says. "And now the hospitals are crying that they're having problems."

James Barba, chairman and CEO of Albany Medical Center, acknowledges that providers must take some of the blame for the current situation.

"Certainly, healthcare has not been as efficient, generally, in terms of business practices and the delivery of care and the bottom line as other industries," Barba says. "And now it's our turn. The problem is that we find ourselves at an enormous disadvantage, since 60 percent of the revenue stream of this particular institution comes from government, and we have no way to negotiate or bargain with the government on those rates."

Barba believes that ultimately, reversing the current situation will require increases in Medicare and Medicaid reimbursements, as well as a massive effort to warn the public of the looming train wreck up ahead.

"It is inconceivable to me, quite frankly, that the American public will put up with this very long, once they understand that if one of their loved ones needs to go into a hospital, they may not be able to."

Bonar Menninger is a freelance writer based in Kansas City.

"It's Getting Worse, Not Better" One hospital's daily struggles with staffing shortages To understand the impact of the healthcare worker shortage, look no further than the emergency department at 500-bed Albany Medical Center in upstate New York.

On any given day, up to a dozen patients in the department can typically be found parked in hallways on gurneys, waiting for hospital beds. The problem isn't the availability of beds, but the inadequate number of nurses and other clinicians to provide the care. Albany Medical Center serves 3 million people across eastern upstate New York and western New England. "It's getting worse, not better," says Lynne Longtin, R.N., the medical center's patient care services director. "Closing beds is not part of our plan right now, but that's a realistic possibility if we're unable to staff them."

Vacancy rates are the highest-upwards of 20 percent-in the departments with the sickest patients, according to Albany Medical Center chairman and CEO James Barba. When the ER is full and patients need immediate treatment, Barba adds, Albany uses its helicopter to transfer the patients to other regional tertiary-care centers that are less understaffed.

Beyond the backlog in the emergency department, the difficulty of maintaining a full staff throughout the hospital has forced Albany to postpone elective surgeries. Although the postponements so far have been relatively infrequent-perhaps one or two per month-it's nonetheless a growing problem, Longtin says.

The arduous working conditions nurses face at the hospital have also sparked labor organizing efforts. Last year, a proposal to unionize the facility's nurses was defeated by only one vote. "I think it's discouraging that the nurses are choosing to partner with the union to remedy the situation, rather than to work more actively with both the government and with us," Longtin says. While the shortages are most serious in clinical areas, even janitorial and food-service workers are hard to find.

"In this region of New York state, we have virtually full employment," Barba points out. "And the starting wage at fast-food restaurants around here is $8 to $9 per hour, with full benefits. We just can't compete with that, so we're losing out on entry-level workers."

Barba says a solution to the growing staffing crisis must begin with further restoration of the 1997 Balance Budget Act's Medicare cuts, along with increases in state Medicaid reimbursements. In addition, he says, a comprehensive national plan must be developed to address the expense of caring for the uninsured. Last year, Albany Medical Center spent more than $20 million on uncompensated care.

"The responsibility for providing that uncompensated care belongs to the government, or to society as represented by government," he says. "But it does not belong to Albany Medical Center."

Ultimately, Barba believes, solving the worker shortage will require the equivalent of a "Marshall Plan" for healthcare.

"It amazes me that we could develop a tax cut program of more than $1 trillion in only a few weeks in this country, or that we could suddenly make education our number one priority, basically in the space of a single presidential campaign," Barba laments, "yet no one is paying attention to the enormous problems in the healthcare industry."

-Bonar Menninger

Nursing Home Needs

The recruitment of nursing personnel could become increasingly problematic for nursing homes unless there are substantial changes that address the systemic problems in long-term care. As the need for long-term care services increases over the years-due in part to the aging baby boomer population-the proportion of available nursing personnel needed in nursing-home settings increases.

The need for RNs in nursing homes is expected to increase 66.1% between 1991 and 2020. The need for LPNs in nursing homes is expected to grow by 71.5% from 1991 to 2020.

The need for nursing aides in nursing homes is expected to grow by 69.1% during the same period.

At the same time, the government's calculation of nurse staffing availability is not encouraging, and questions remain as to whether the supply of nurses will meet the demand. The U.S. Department of Health and Human Services projects a 14% shortage of nurses nationwide by the year 2020. Other research has projected a shortage as great as 20% by the year 2020.

SOURCE: American Health Care Association, February 2001

So, the next time you hear some politician flap his lips about "Health care reform", see if he addresses this issue.

Bwahahaha!

2007-07-14T06:05:00.000-05:00

What's the difference between an oral thermometer and a rectal thermometer?

The taste.

Not in charge!

2007-07-10T14:11:00.000-05:00

For the first time in friggin' days, I was not left in charge of night shift!

We don't have a dedicated charge nurse position for our floor (Medical rates one, though. Funny, that!) so every shift I do work, I volunteer to 'act' as charge. I work 12s, so I handle staffing for noc shift and for days. Also keep track of beds on the floor and do patient (assign patients on the floor to staff) and room assignments (assign admits to rooms/beds on the floor).

Help out with admits (put together the chart, fax orders, task supplies) - since we don't rate a secretary for nights and our techs are too green (not to mention the fact that they are not trained for this. Then again, neither am I but what the hell - when the chips are down, the nurse is expected to pick up the slack).

And of course, I handle a full load of patients as well!

I don't necessarily have to do it and some of my peers on the floor tell me I'm foolish for doing it without being compensated - but I figure that when I can afford to, why the hell not? My Father always taught me that "when you begin your career, what you learn is more important than what you earn". And I do learn, a lot. Much of it is problem solving on your feet. And I make mistakes along the way - some of them pretty stupid. But as I said, I'm learning tons.

There is a valid counter-argument that I am perpetuating the status quo. That management sees that the floor is managing without a "charge nurse" for nights and thus sees no need to make it a permanent position (it actually was a permanent position but management took it away a few years ago). I have a hard time coming up with a counter argument to that position. Maybe they are right - heck, I don't know.

But last noc, I was not charge. It wasn't a bad night, but it was a welcome break in any case. "Only" five patients but of course, no tech. So the nurses were the "be all and end all" on the floor. Was pissed off with yet another Medical admit being sent up to our floor - but I think I've come to the conclusion that this isn't going to change in the foreseeable future and whining about it only makes my shift suck more. Let it go, champ.

Only got two admits and between the charge nurse and I, we wrapped them up lickety-split. Jess, the gal in charge was/is one of my most favourite people on the floor and she had just come back from vacation. Love working with her - total team player all the way.

Interestingly, at the end of the shift, day shift charge (we have charge nurse from 7a-7p) came up to me and wanted to talk about the possibility of me coming in early for a few days two weeks from now to take over from her early - as charge! Certainly an interesting proposal and I accepted it ("glutton for punishment", I hear some of you snicker. Or maybe just "you idiot!"?)

Ain't due for my evals yet - but I'm thinking all this extra efforts gotta count somewhere.
Besides, extra hours equals extra pay - and with college loans plus a new car.... I need all the dough I can get my 'ands on!

I'm off for two nocs - gotta take 'em as they come!

Wow! I have my own blog!

2007-07-09T10:47:00.000-05:00

Folks like me are entrusted with the apparatus (or should that be apparatuses?) that enables me to spew my thoughts free flung into cyberspace to be instantly swallowed up by the thronging masses!

Ha!

On the other hand, what's my blog like - 1 amongst a gazillion? (I'm sure someone will come up with the correct comparison soon enough).

Welcome to the world of "Notamalenurse" - or for those of you with challenged eyesight, that's : "not a male nurse".

That's right. I'm not a "male nurse". I'm a nurse.
When there is no "female nurse", why should there be a "male nurse"? (I frequently answer the question "What made you decide to be a male nurse?" with the response "When I found out the prohibitive medical costs required through surgery to transform myself into a female nurse.").

Yep. Welcome to a pet peeve of mine (amongst others as you shall soon discover).

I'm sure I could post dozens and dozens of supportive data about the long, extensive history of men in nursing. About how it was not a "female profession" until very recently.

But I'll laze and let Wikipedia do some of the talking for me.
Tidbit from Wikipedia article:

Contrary to the perceptions of some, nursing has been a male dominated field for most of human history.

Click the link above to read the rest, boys and gals.

Now, truth be told - I don't really give a damn if a profession is "male" or "female". I think it's dumb, stupid, ignorant and asinie to assign "gender labels" to 'professions' and 'careers'. If an individual is up to the mark, s/he should be allowed to do the job. Be it female fire fighters or male nurses. Be it female soldiers or male "single" parents. Et Cetera. Ad infinitum.

You get the drift.

Now I can see some hands at the back of the class: "Well, if you don't give a damn about gender in the work place, why does 'not a male nurse' feature predominantly as the address to your blog?"

Smart question, don't you think?

Simple answer? If I had a dime for every instance where I heard someone remark "Oh, you're a MALE nurse", I could have closed shop years ago, set up a fund and lived the rest of my life in disgusting opulence and wealth.

This isn't to diss my female colleagues in this great, honoured, respected profession. On the contrary, 99% of my female colleagues accept me as I am - my hairy face and gruff voice not withstanding. (What of the other 1% you ask? Well, you are bound to meet shallow idiots any and every where ... profession notwithstanding).

And of course, how could I leave out the whole "male nurses are men who couldn't cut med school" stereotype... followed with a snickering comment about Gaylord Focker?
What can I say, except the fact that people aren't paying attention. Gaylord Focker (of "Meet the Parents" fame) did qualify for Med school - but chose not to pursue the option.

Food for thought folks.

(Again, this isn't to piss on physicians or their profession. I work with some wonderful Docs on a daily basis and the vast, overwhelming majority respect me and my profession - just as we nurses respect physicians and their profession).

Stereotypes make for some hillarious instances (I personally did enjoy the "Meet the Parents" movie. I do however, think that "Meet the Fockers" was a let down).

But "stereotypes" are just that - "stereotypes".
'Unrealistic' portrayal of ordinary humans.

We need something better....