8/18/07

Take a Guess: Which one do you think is telling the truth?

Patient number 1 is a early 40ish man with no medical history that comes in from his job at a construction site where he suffered a sudden onset of right flank pain. Driven in by a co-worker he is barely able to walk in, hunched over, pale, sweaty, diaphoretic, writhing on the gurney, tachycardic and hypertensive. Shortly after getting to triage he starts vomiting. During triage he seems apologetic when he rates his pain a "7 or 8."

Patient number 2 is a twenty something who is brought in from the parking lot in a wheelchair by a friend, they are laughing and talking on their cell-phones when you bring him in for triage. Chief complaint is a twisted ankle. Despite apparently being able to walk to the car at home he is now unable to walk and has to be brought into triage in a wheelchair. In triage his skin is pink, warm and dry and vitals are normal. He rates his pain a "12."

Patient number 1 is given Toradol and Compazine IV and has complete relief of his pain. He is diagnosed with a small, non-obstructing kidney stone. Discharged home with prescriptions for Motrin, Vicodin and Flomax as well as a urine strainer.

Patient number 2 is diagnosed with muscle strain. He is offered an stirrup splint and a prescription for Motrin. He is unhappy and demands a pain shot, crutches, work note and a prescription for Vicodin. He is told no at which point he jumps off the gurney and stomps out of the ER in a huff, screaming "I'm never coming back to this motherfucking place." Another miracle cure, courtesy of emergency medicine.

This is the kind of thing that clogs up ER's all over our country. America is filled with people that contribute nothing to society but come equipped with a massive sense of entitlement, they want what they want, when they want it, when they want it. Told no, they became belligerent and assualtive, spewing threats toward they staff. Fearing patient complaints or confrontation, more than one practitioner has taken the path of least resistance. Hospital administration, driven by their wish for high patient satisfaction scores, fails to allow MD's to practice medicine and join JCAHO in forcing us to be legalized drug pushers rather than medical practitioners.

Someday, when there is an epidemic or surge of casualties from a natural disaster or terrorist attack the ER won't be able to care for those victims because we will be full of patients with 'chronic pain' who are seeking drugs.

8/8/07

R Privacy Issues

Let's face it, ER's are crowded and noisy. Despite our best attempts to maintain a patients privacy, when the next patient is six feet away with only a thin curtain between them, it is hard not to over hear what is going on next to you.

One night we had an elderly gentleman in curtain area 1 and next to him a prim, middle aged lady. The PA was trying to explain to the man what his diagnosis was but his efforts were being hampered by the fact that the man was very hard of hearing. The problem was something of a personal nature so the PA was trying to be discreet.

PA: Sir, you have pubic lice
PT: What's that you say?

PA: I said you have pubic lice.
PT: What?

PA: You've got lice down there
PT: Can't hear you son, you have to speak up


PA: I SAID YOU HAVE BUGS DOWN THERE
PT: Oh.


Of course we all overheard the conversation, including the prim lady in the next cubicle, who was red as a beet by now. The ER staff, dignified until the end, were draped across the counters shaking with silent laughter until tears ran down our faces.

Most of the time privacy in the ER is an illusion maintained by patients pretending they don't see or hear what is going on around them. Sometimes it is impossible to pretend.

6/27/07

Medication reconciliation

Do you think medication reconciliation works in the ER?

Giggles comes in from home. She lives alone with a caregiver that comes three times a week but didn't accompany her to the hospital. She is a very vague historian, has no clue what med's she takes or what pharmacy she gets them from. She gives me her physicians name so I put in a call to his office. Three calls and much time on hold later I finally get in touch with the medical assistant who is finally able to tell me that the patient is not theirs. Close to 45 minutes wasted and still no clue what medications she is on. He last hospital record is from three years ago and she was admitted by the hospitalist then. I could start randomly calling pharmacies but there are 39 of them in the area and that would take hours.

Nice mid sixties gentleman comes in with Chest Pain. He knows he takes a blood pressure pill, a water pill and something for his sugar, not the names or the dosages. He gets his med's through the mail from the VA. I don't know about where you work, but I could part the Red Sea easier than I could get that information from the VA.

A 77 year old lady comes in with all her pills (14 different kinds) helpfully arranged in a pill box. It is midnight and her pharmacy and doctors office is closed. It takes over an hour with the identidex system and help from the pharmacist to identify 13 of them. The last one is an alien pill that denies definition and she has no idea what it is for.

Who has time to spend doing this nonsense. Tracking down the elusive med list, the ambulances keep coming, starting IV's, titrate pain meds, do EKG's, start foleys, gastric lavage, restrain and monitor psychotic patients, talk to familys, take admit orders over the phone, arrange to get my patients upstairs and so on and so on. Spending hours trying to track down a med list that is one or two or three people that are sitting in the lobby waiting for a bed or a sick patient who's not being taken care of isn't going to work.


Nurses need to be at the bedside. Period.

6/24/07

Rules for non-bedside nurses

We are very concerned about the nursing shortage in
America, if the paperwork nurses actually did some nursing, no shortage would exist.

1. Nurses that do not provide direct patient care on a daily basis should not develop policies for nurses that do. (Have you ever noticed how the policies for your nursing practice are written without any input from the people who have to carry out the policies?)

2. Nurses that do not provide direct patient care on a daily basis should not develop forms for nurses that do. (that way a nurse won't have to waste her time putting the VS on the flow sheet and the graphics form and a report sheet etc. etc. etc.)

3. Nurses that do not provide direct patient care on a daily basis should not represent nurses that do in any advertising portraying them as bedside nurses. If you don't do the job, you don't get to claim the glory. ( I don't know about you but I've never seen any of the people who are portrayed as nurses at my hospital or they are all directors and QRM people.)

4. Nurses that do not provide direct patient care on a daily basis should not ever speak for those that do. (It is not OK for QRM to tell admin that the ER nurses should do audits on every patient to see if they meet admission criteria.)

5. Nurses that do not provide direct patient care on a daily basis should not develop staffing guidelines since they have no clue how much work is involved in caring for patients in today's world, including filling out the myriad redundant forms developed by the nurses that do not provide direct patient care on a daily basis. (don't tell us we don't need tech's when you haven't worked at the bedside in 20 years.)

6. Nurses that do not provide direct patient care on a daily basis should not ever have a place on any committee or governmental agency that develop policy or have oversight over nurses that do. (JCAHO etc. needs to have practicing nurses so that someone can tell them how idiotic their policies are and help them actually do some good.)

7. All nursing staff should be required to perform clinical shifts on a regular basis so that they don't lose their skills which may be needed in times of surge capacity and so that they don't forget how hard nurses have to work.

If this sounds a bit bitter, it probably is. Thanks to the non-practicing nurses I now spend more than half my time filling out redundant forms rather than be at the bedside with my patient.

6/22/07

Filth

A pet peeve for many is the fact many hospitals are filthy. Housekeepers often come from contracted services that provide the lowest amount they can get away with and pay them minimum wage with no benefits. The turnover is stupendous and they have no incentive at all to do a good job.

Sure, the center hall is buffed to a glossy finish but the patient rooms aren't wiped down every day, curtains aren't changed, walls not wiped and high dusting not done. All those areas are teaming with bacteria.

ER's are the worst. The gurney and surfaces wiped quickly by the RN in between patients but the rooms are cleaned well only once daily, if that. Pull our the gurney and look at what is under it. No wonder hospital acquired infections are rampant. That should be the first thing looked at when a hospitals infection rates go up, how many housekeepers are there....is one person responsible for covering three units?

I think housekeeping services need to be hospital based, not contracted. Pay them a decent living wage and give them benefits. That way you can attract and retain people that want to work and not the bottom of the barrel. Fire them if they don't want to do the job because there will be people wanting to work for you. Give them proper training on why it is so important to do their jobs well and hold them to a high standard.

It doesn't do the staff any good to wash their hands until they bleed if the hospital itself is filthy.