The local nursing home's Alzheimer's unit sent in a patient on a 5150 hold for "threatening to harm others." (A 5150 is a 72-hour psych hold.)
Ok, so first of all the patient has Alzheimer's and is on an Alzheimer's unit. And he s 94. And he weighs about 94 pounds. So, considering his advanced age and frail condition along with the fact that he is on an Alzheimer's unit where presumably there are not any unlocked, unloaded guns - how much of a threat can he be, really?
So I call them. Put on my professional demeanor and ask, "what's the story here?" Although not in those exact terms. It seems that he has been increasingly agitated and striking out at the staff and threatening to "kill" them.
Yeah? And? I'm confused, isn't this an Alzheimer's unit? Aren't you set up to take care of people with oh, say......Alzheimer's?
I'm told, get this, that they are not capable of taking care of someone that is threatening to harm them. And, they refuse to take him back.
So, now steam is coming out of my ears. Ok. The doctor and I confer and we decide to go ahead with the screening labs to make sure he doesn't have a reason for his agitation, for instance hypoxia or an UTI which in my experience, is the number one cause of altered mental status in elderly people. He is a little agitated but if we took our time and talked to him slowly, he did fine. If we got too pushy he'd get crotchety. Stands to reason, I would probably be the same way.
The labs were unremarkable so we called the psych resident who came and did his evaluation and lifted the 5150. He knew, as well as we did, that this wasn't an issue needing psychiatric hospitalization.
So I called the facility and told them that the patient had been taking off the psych hold and we would be sending him back. They again stated that they refused to take him back. I said "you can't" They said they were and hung up on me.
TaDa......ER social worker to the rescue. By this time it is the middle of the night. I explained the situation and he got right to work. Before long he had called the administrator at home and roused him out of their bed. He calmly, but firmly told them that they had to take the patient back, if they felt that he was not suitable for their facility then they would need to be responsible for seeking other placement for him and that they most certainly would not be shirking their duty by dumping the patient on the emergency room, and FURTHERMORE, he would be coming back in the morning on his day off to make calls to the various agencies in charge of licensing and regulating the facility to let them know of this occurrence to have them follow up and make sure they were operating properly.
I'll tell you, it was awesome to behold. And yes, the patient went back to the facility. He was in the department for 14 hours and 37 minutes. That is approximately 4 patients that weren't able to be seen in that bed not to mention the massive waste of medical staff resources for a NURSING HOME DUMP!!!
Sunday, September 30, 2007
Saturday, September 29, 2007
Overheard at the nurses station
From the IMCU float that had been sent down because we had three call ins "Jeez, it's awfully quiet, is it always like this?"
GROAN!!!
In the next hour we got a code, a minor gunshot wound, an acute MI, a patient with severe burns from a brush fire that had to be intubated and a psychotic, agitated jail clearance. Last I saw of the float she was running out of the room with the burn patient with her eyes bugging out.
Bet she won't come back.
I know it is superstitious, but we don't ever use the 'Q' word in the ER, woe be unto the person foolish enough to let it slip.
GROAN!!!
In the next hour we got a code, a minor gunshot wound, an acute MI, a patient with severe burns from a brush fire that had to be intubated and a psychotic, agitated jail clearance. Last I saw of the float she was running out of the room with the burn patient with her eyes bugging out.
Bet she won't come back.
I know it is superstitious, but we don't ever use the 'Q' word in the ER, woe be unto the person foolish enough to let it slip.
Thursday, September 27, 2007
Rude Obnoxious People
I'm pretty sure that these people have been in my ER once or twice.
When did we become a nation of rude obnoxious people? When did it become socially acceptable to use horribly foul language in public places, in front of children? And why do businesses allow people to come in and act like that? Is having another customer so important that they turn a blind eye? Thirty years ago anyone that acted like that would have been thrown out on their ear and told never to return. Now everyone feels free to act however they want with no fear of any consequences. And God forbid anyone try to tell them to knock it off, after all - they have all the rights, the rest of us have none.
ATTENTION: Business owners, if I come to your establishment and someone is allowed to act that way I will never return, furthermore I will tell all my friends and family not to go there. We have a lot more buying power than that one foul-mouthed person does.
When did we become a nation of rude obnoxious people? When did it become socially acceptable to use horribly foul language in public places, in front of children? And why do businesses allow people to come in and act like that? Is having another customer so important that they turn a blind eye? Thirty years ago anyone that acted like that would have been thrown out on their ear and told never to return. Now everyone feels free to act however they want with no fear of any consequences. And God forbid anyone try to tell them to knock it off, after all - they have all the rights, the rest of us have none.
ATTENTION: Business owners, if I come to your establishment and someone is allowed to act that way I will never return, furthermore I will tell all my friends and family not to go there. We have a lot more buying power than that one foul-mouthed person does.
Wednesday, September 26, 2007
FILTH
I've posted on this subject before, but Mousie got me thinking with his post on an encounter with a prune-faced bean counter named 'Olive.'
I have the bright-eyed, idealistic thought that hospitals should be clean. I know, I know, how naive right? I mean we are taught from day one during our training how important cleanliness is, how to put on sterile gloves and apply sterile dressings lest some stray microbe contaminate our patients surgical wound. Don't shake the linens as you will rustle microbes up into the air, brush your ventilated patients teeth every shift to prevent ventilator acquired pneumonia, wash your hands, wash your hands, wash your hands.
so with all the emphasis on cleanliness is next to Godliness, why is it that there is so little concern about the fact that our hospitals are FILTHY? Sure the halls are waxed and gleaming to trick the eye but when you pull out a gurney there is dirt and dust bunnies behind it, the ceiling vents are furry with dust, the windows are unwashed, the patient rooms are not wiped down and mopped daily and when is the last time you have seen a patient curtain changed?
What good does it do for me to wash my hands until they bleed when the patients room is a petri dish for every known organism? Think I'm over-exaggerating? Take the Wood's lamp into a room and turn off the light, it will light up like a crime scene.
Why aren't administrators more concerned with cleanliness? Saving money of course. After all, paying another cleaner or two minimum wage may mean the difference between bankruptcy and financial solvency. And the cleaners they do have don't all come equipped with a work ethic. After all, if you are cleaning up shit for minimum wage with no benefits, where is your incentive to bust your ass?
So when you and your loved one has to go to the hospital, ask them how many house cleaners there are per shift on the unit and how frequently the rooms are cleaned. Ask to have a new cubicle curtain hung. Watch them clean and make sure they wipe your over bed table, all the surfaces and around the light switch. It is just as important as making sure your caregivers wash their hands.
Tuesday, September 25, 2007
Grand Rounds
Grand Rounds is hosted at Kevin MD this week and he is a four time host! Congrats to Kevin MD for the honor of hosting four times and for kicking off the fourth year of Grand Rounds.
ERnurseys patented toxic foot odor containment technique
Well you asked and here it is. Have on hand foaming peri-wash spray or if you don't have that, spray betadine, 3 red biohazard bags (they are just thicker and sturdier than regular garbage bags) and 3 inch tape. Quickly strip off shoes and socks and secure in first biohazard bag. coat each foot in foaming cleanser, put each feet in a biohazard bag and secure by taping around the bag, taking care to not tape too tightly and not tape directly to skin (to make a biohazard bag sock.)
Now here is a little known fact about me that not even some of my closest friends would guess, I buy good condition used shoes at Salvation Army and stash them in the ER, I also buy white athletic socks there or at the dollar store. After the toxic feet have been percolating for a bit I give them a good soak in a couple of bath basins and wash and debride them and give the patient clean socks and shoes before they leave. I have never had anyone refuse to let me do this.
I had a patient one time that was homeless and came in with bilateral foot pain. He was relatively clean, dressed in jeans and cowboy boots and hat. It had been raining for days and he had walked for miles with wet feet. He had one of the worst cases of trench foot I have ever seen, both feet were covered by huge broken blisters. I got him cleaned, debrided and bandaged, three pairs of clean dry socks and slippers, dry clothes and we all chipped in and paid for a cab ride to the homeless shelter and sent him there with a note for them to please let him stay inside until his feet healed, otherwise they get sent out onto the street after breakfast. He was the most thankful patient I have ever had, called me ma'am and was unfailingly polite. I heard later that the mission got him a bus ticket to another state where he had a brother he could live with.
That was a day when it felt good to be a nurse.
Monday, September 24, 2007
Things that drive me nuts
Going out to the waiting room to bring back a patient with 'severe abdominal pain and vomiting' and finding them gulping down a big Burger King meal.
Having a patient with a chief complaint that mean they may need surgery that keeps asking for food despite repeatedly being told why they can't eat. And when I tell them no, asking the next person that walks by.
Toxic socks. Please Please Please don't help me by taking off my homeless persons shoes. I have a patented way of containing the smell, if I want those shoes off I will remove them myself.
Patients that come to the ER because they don't want to wait for 3 weeks to have their MRI that their doctor ordered, they want it today and someone orders one in the absence of any emergent need.
Trying to call back patients that have cleverly given us a bogus phone number so that we can't dun them for payment. Sometimes those cultures may be life threatening, I'm not calling you for my own enjoyment.
Nurses that start twirling when they have more than two routine patients. I'm sorry but the ER is a fast paced environment, if you can't hack it then go somewhere else. If you have been working in the ER for two years and still can't hack it then it is time for you to move on. The ER is not for everyone.
Filth. Mousethinks has an excellent post about this, I will rant more on this subject tomorrow, but suffice it to say that I think that hospitals should be clean and if you go into a dark exam room with a woods lamp it should not light up like the scene of a mass murder.
Drunks that pass out on the sidewalk. If you must drink yourself into a stupor please go somewhere private to do it so that you are not tying up an ambulance, ER room etc. because you have no self-control.
Having a patient with a chief complaint that mean they may need surgery that keeps asking for food despite repeatedly being told why they can't eat. And when I tell them no, asking the next person that walks by.
Toxic socks. Please Please Please don't help me by taking off my homeless persons shoes. I have a patented way of containing the smell, if I want those shoes off I will remove them myself.
Patients that come to the ER because they don't want to wait for 3 weeks to have their MRI that their doctor ordered, they want it today and someone orders one in the absence of any emergent need.
Trying to call back patients that have cleverly given us a bogus phone number so that we can't dun them for payment. Sometimes those cultures may be life threatening, I'm not calling you for my own enjoyment.
Nurses that start twirling when they have more than two routine patients. I'm sorry but the ER is a fast paced environment, if you can't hack it then go somewhere else. If you have been working in the ER for two years and still can't hack it then it is time for you to move on. The ER is not for everyone.
Filth. Mousethinks has an excellent post about this, I will rant more on this subject tomorrow, but suffice it to say that I think that hospitals should be clean and if you go into a dark exam room with a woods lamp it should not light up like the scene of a mass murder.
Drunks that pass out on the sidewalk. If you must drink yourself into a stupor please go somewhere private to do it so that you are not tying up an ambulance, ER room etc. because you have no self-control.
Sunday, September 23, 2007
Sometimes, even though the heart rate is strong and there is no problem with the breathing you have to drop everything and take care of the newcomer right now. One such patient came in by private car, he was laying in the back seat, pale, cool and diaphoretic. My first assumption is that he was having a heart attack but then I saw his boot. He and his friends had been out hunting and he had slipped on a wet rock while crossing water, the hunting boot he wore was soaked in blood, a hint of what was underneath. Obviously in severe pain, he didn't make a sound while we gently assisted him out of the car and onto a gurney, but his jaw was clenched so hard it was blanched.
We took him straight to a room, while one nurse obtained vital signs another started an IV while a third went for the doctor. Within five minutes he was being medicated with Dilaudid.
"We have to get his boot off and see what is underneath." The doctor said. He slipped his gloved hands down into the boot to stabilize the foot as I gently pulled on the thick, leather hunting boot. Despite being pretty sedated from the pain medicine the patient immediately stirred and screamed. "that's no good, I can't get a good enough grip on the foot, he has some massive open fractures under there. We'll have to use conscious sedation." The doctor went out and quickly explained to the mans brother what we intended to do.
We tried cutting the boot with trauma shears but they barely made a dent so one of the nurses got a scalpel and carefully cut the stitching apart. The doctor administered Brevital and when the man was almost fully unconscious, removed the remains of the boot. Underneath was one of the worst fractures I have ever seen, both bones broken and the foot dislocated, deep gaping laceration across the top of the foot which was floppy, having lost all of it's bony structure. The Xray was just as appalling, when we sent the man off to surgery we wondered if he'd ever have normal function in that foot.
Several months later we got our answer. One afternoon a man walked into the ER with a giant box of candy. He looked very different, upright, smiling with normal skin color and had to remind us who he was. And he was walking! Without a trace of a limp. Score one for us.
We took him straight to a room, while one nurse obtained vital signs another started an IV while a third went for the doctor. Within five minutes he was being medicated with Dilaudid.
"We have to get his boot off and see what is underneath." The doctor said. He slipped his gloved hands down into the boot to stabilize the foot as I gently pulled on the thick, leather hunting boot. Despite being pretty sedated from the pain medicine the patient immediately stirred and screamed. "that's no good, I can't get a good enough grip on the foot, he has some massive open fractures under there. We'll have to use conscious sedation." The doctor went out and quickly explained to the mans brother what we intended to do.
We tried cutting the boot with trauma shears but they barely made a dent so one of the nurses got a scalpel and carefully cut the stitching apart. The doctor administered Brevital and when the man was almost fully unconscious, removed the remains of the boot. Underneath was one of the worst fractures I have ever seen, both bones broken and the foot dislocated, deep gaping laceration across the top of the foot which was floppy, having lost all of it's bony structure. The Xray was just as appalling, when we sent the man off to surgery we wondered if he'd ever have normal function in that foot.
Several months later we got our answer. One afternoon a man walked into the ER with a giant box of candy. He looked very different, upright, smiling with normal skin color and had to remind us who he was. And he was walking! Without a trace of a limp. Score one for us.
Played out in ER's all over America
Doc to drug seeking patient: "I'm sorry but we don't prescribe narcotics for chronic conditions, you'll need to get those from your regular doctor."
Patient to Doctor: "motherf*&ker" storms out and calls admiminstration
Patient to Administration: "I went to the ER in severe pain and doctor wouldn't give me anything for pain."
Administration to Doc: "You have too many patient complaints, you aren't getting any bonus and if you don't clean up your act we're not going to renew your contract."
Doc to next drug seeking patient: "Here, have 4mg of Dilaudid and 30 Vicodin to go."
Patient to Doctor: "motherf*&ker" storms out and calls admiminstration
Patient to Administration: "I went to the ER in severe pain and doctor wouldn't give me anything for pain."
Administration to Doc: "You have too many patient complaints, you aren't getting any bonus and if you don't clean up your act we're not going to renew your contract."
Doc to next drug seeking patient: "Here, have 4mg of Dilaudid and 30 Vicodin to go."
OOPS!
Why don't you have a side of lead with your healthy eating? California learns why not to buy from China.
Saturday, September 22, 2007
Can you say "trailer trash"
This woman is truly a loser. Having millions of dollars does not mean you aren't trailer trash.
I found this link at EMS Haiku. It made me cry.
My son has been overseas for a month. It seems like a year. He called today for the second time and we talked for 15 minutes. He is OK, but homesick. They are pretty busy so he doesn't have much time to think about things. He tells me his is in a "relatively safe" place, as safe as one can be when you are in a part of the world that despises Americans.
I realized that this is the first year we will ever be apart at Christmas, and I haven't seen him since last Christmas.
My son is serving in the United States Air Force and I am very proud of him. but boy, I sure do miss him.
My son has been overseas for a month. It seems like a year. He called today for the second time and we talked for 15 minutes. He is OK, but homesick. They are pretty busy so he doesn't have much time to think about things. He tells me his is in a "relatively safe" place, as safe as one can be when you are in a part of the world that despises Americans.
I realized that this is the first year we will ever be apart at Christmas, and I haven't seen him since last Christmas.
My son is serving in the United States Air Force and I am very proud of him. but boy, I sure do miss him.
Friday, September 21, 2007
Change of Shift
Change of Shift can be found at Emergiblog this week. Sorry, Kim, that it has taken so long get this up, my laptop died earlier this week and I've been trying to use the kids computer which didn't really go all that great since every other minute some annoying IM thing would pop up with someone wanting to talk to my daughter and I couldn't find out how to shut the darn things off! But my faithful laptop has returned and I am back in business.
Another voice on Meningococcemia
Hey eveyone, this was a comment left on a previous post about meningococcus by Abby, I think you all need to read it.
Hello all, OK so I stumbled uopn this site and I suppose the timing was just right! NYC EMS... are you nuts? I had Meningococcal Disease when I was 22 (2003) and went into severe septic shock. My kidneys were already failing by the time I got to the ER. Blood pressure averaged 40/20 for too long and massive amounts of vasopressors caused necrosis of my limbs. My WBC count was over 80,000 and then fell to 100. I was on full life support for 2 weeks and had a bilateral hemorrhage from my adrenal glands. I also lost both of my legs below the knee. By the grace of God somehow I stayed sane but can you imagine what my family went through? My parents called my priest in to give me my last rites when the doctors told them I had a 20% chance to live. Can you fathom having to do that for your child?For 2 weeks I was in a coma, with multiple organ failure, bloated up, and dying. My entire body turned purple because I also had Disseminated Intravascular Coagulopathy. I have large scars and skin grafts all over my body. I had blood transfusions at least daily. So, yeah, obviously I woke up... but I woke up to months of surgery only to end in amputations that made even the surgeons cry. Then months of rehab and my adrenals never recovered so I have permanent adrenal insufficiency. I am sick all the time. Meningitis is not just a cold, or something that goes away once you survive the acute infection. It is sort of like a hurricane. Maybe we don't get hit by them often, and some places don't get hit at all. When, we do get hit, though, people run... they evacuate, and they board up their houses and once its all over, sometimes there is nothing left. If we had a way to prevent hurricanes and the state of Florida, or Texas, chose not to take the necessary steps to prevent them, wouldn't everyone think they were crazy? Kids are more important that houses, or belongings, or anything for that matter. No child should die from a vaccine preventable disease.Oh yeah, and the medical bills, and not being able to work for nearly a year. My parents were able to make things work but it wasn't easy. Some families can't make things work, though. I know a woman whose children were close in age like my brother and I. The daughter got sick, and then a year later the son committed suicide. Vaccines save more than just lives.The thought that a shot could have saved her or any other parent that kind of life, eats at me, and her, and many doctors. See, the funny thing about me is that I was educated about meningococcal disease. My mom is a nurse practitioner. I was not at home when I got sick. I had mere hours of symptoms, not really different than the flu. The only reason I knew to go to the hospital was the petechial rash. I knew it probably meant meningitis. The thing is, education is not enough. Kids die in hours, especially if they only have septic shock and no symptoms of meningitis. There is not a day that goes by that I am not reminded of how fortunate I am to be alive... Waterhouse-Friedrichsen syndrome (the adrenal hemorrhage) is almost exclusively diagnosed upon autopsy. The last thing I would like you to ponder is what about me, as the victim? I mean, obviously it affects everyone around me, but what does it do to me? What if I am a 17 year old cheerleader who desperately wants a normal social life, but since I am in renal failure, I spend my free time hooked up to a dialysis machine? What if I am an independent 20-something and suddenly have to rely on everyone else for even the most basic of functions. What if I have to try to comprehend why I was chosen to both of my legs have to be amputated from a preventable illness? I was in the best shape of my life when I got sick. I was 2 days away from leaving for ARMY basic training. The irony is that had I left, 2 days later, I would have had the vaccine!!!!!!!
www.meningitis-angels.org
Hello all, OK so I stumbled uopn this site and I suppose the timing was just right! NYC EMS... are you nuts? I had Meningococcal Disease when I was 22 (2003) and went into severe septic shock. My kidneys were already failing by the time I got to the ER. Blood pressure averaged 40/20 for too long and massive amounts of vasopressors caused necrosis of my limbs. My WBC count was over 80,000 and then fell to 100. I was on full life support for 2 weeks and had a bilateral hemorrhage from my adrenal glands. I also lost both of my legs below the knee. By the grace of God somehow I stayed sane but can you imagine what my family went through? My parents called my priest in to give me my last rites when the doctors told them I had a 20% chance to live. Can you fathom having to do that for your child?For 2 weeks I was in a coma, with multiple organ failure, bloated up, and dying. My entire body turned purple because I also had Disseminated Intravascular Coagulopathy. I have large scars and skin grafts all over my body. I had blood transfusions at least daily. So, yeah, obviously I woke up... but I woke up to months of surgery only to end in amputations that made even the surgeons cry. Then months of rehab and my adrenals never recovered so I have permanent adrenal insufficiency. I am sick all the time. Meningitis is not just a cold, or something that goes away once you survive the acute infection. It is sort of like a hurricane. Maybe we don't get hit by them often, and some places don't get hit at all. When, we do get hit, though, people run... they evacuate, and they board up their houses and once its all over, sometimes there is nothing left. If we had a way to prevent hurricanes and the state of Florida, or Texas, chose not to take the necessary steps to prevent them, wouldn't everyone think they were crazy? Kids are more important that houses, or belongings, or anything for that matter. No child should die from a vaccine preventable disease.Oh yeah, and the medical bills, and not being able to work for nearly a year. My parents were able to make things work but it wasn't easy. Some families can't make things work, though. I know a woman whose children were close in age like my brother and I. The daughter got sick, and then a year later the son committed suicide. Vaccines save more than just lives.The thought that a shot could have saved her or any other parent that kind of life, eats at me, and her, and many doctors. See, the funny thing about me is that I was educated about meningococcal disease. My mom is a nurse practitioner. I was not at home when I got sick. I had mere hours of symptoms, not really different than the flu. The only reason I knew to go to the hospital was the petechial rash. I knew it probably meant meningitis. The thing is, education is not enough. Kids die in hours, especially if they only have septic shock and no symptoms of meningitis. There is not a day that goes by that I am not reminded of how fortunate I am to be alive... Waterhouse-Friedrichsen syndrome (the adrenal hemorrhage) is almost exclusively diagnosed upon autopsy. The last thing I would like you to ponder is what about me, as the victim? I mean, obviously it affects everyone around me, but what does it do to me? What if I am a 17 year old cheerleader who desperately wants a normal social life, but since I am in renal failure, I spend my free time hooked up to a dialysis machine? What if I am an independent 20-something and suddenly have to rely on everyone else for even the most basic of functions. What if I have to try to comprehend why I was chosen to both of my legs have to be amputated from a preventable illness? I was in the best shape of my life when I got sick. I was 2 days away from leaving for ARMY basic training. The irony is that had I left, 2 days later, I would have had the vaccine!!!!!!!
www.meningitis-angels.org
Thursday, September 20, 2007
Something happened at work a while back that almost made my head explode. I was in charge and the ER was going berserk (I have heard whisperings of 'shit magnet' but I don't believe they were referring to me.) There was dueling codes going on in the trauma room and the gunshot wound to the leg that had previously occupied said trauma room had been unceremoniously shoved out into the hall. Keeping him company were three ambulance crews killing time waiting for someone to be discharged, and we WERE on diversion! Also in the hall were four gurneys and eight chairs filled with patients.
I was scribing for one of the codes when security asked if I could talk to someone in the waiting room causing a ruckus. I told them I'd be out when I could but not until things were squared away in the trauma room. When the officer opened the electric door to go out into the lobby an enraged woman towing along two little girls burst through the door before he could stop her.
"How much longer am I going to have to wait!" She demanded. Now mind you she was standing in the door of a big open room with two gurneys filled with patients getting CPR, right to the left of her was a gurney with a man dripping blood off his arm and onto the floor. Anyone with more than a grain of rice for a brain could see we were a little busy. The security guard had her by the arm but was trying not to use too much force because of the little girls but the woman was out of control. I have never heard so much profanity at one time. There was a police officer trying to interview the gunshot victim and he, his partner and the guard had to take her down after she took a swing at the guard while he was trying to get her out of the hall. She ended up getting arrested right there in front of the trauma room. It was surreal.
Oh, and why was she there? She had brought the little girls down because they had head lice and she wanted us to comb the nits out of their hair so they could go back to school.
I was scribing for one of the codes when security asked if I could talk to someone in the waiting room causing a ruckus. I told them I'd be out when I could but not until things were squared away in the trauma room. When the officer opened the electric door to go out into the lobby an enraged woman towing along two little girls burst through the door before he could stop her.
"How much longer am I going to have to wait!" She demanded. Now mind you she was standing in the door of a big open room with two gurneys filled with patients getting CPR, right to the left of her was a gurney with a man dripping blood off his arm and onto the floor. Anyone with more than a grain of rice for a brain could see we were a little busy. The security guard had her by the arm but was trying not to use too much force because of the little girls but the woman was out of control. I have never heard so much profanity at one time. There was a police officer trying to interview the gunshot victim and he, his partner and the guard had to take her down after she took a swing at the guard while he was trying to get her out of the hall. She ended up getting arrested right there in front of the trauma room. It was surreal.
Oh, and why was she there? She had brought the little girls down because they had head lice and she wanted us to comb the nits out of their hair so they could go back to school.
Tuesday, September 18, 2007
Nursing Satisfaction
Girlvet has written a post about nursing satisfaction with a tongue in cheek twist, but very real concerns. Here is my opinion on how to have satisfied nurses that want to work for your facility.
1. Don't f#$& with their schedule. Nurses work long grueling shifts, holidays, nights and weekends. Try to accommodate their needs when you do the schedule and they will be much happier than if you split their days, make them work extra holiday and weekends and deny their vacation requests.
2. Focus on Retention. Hospitals spend millions of dollars in recruitment with sign on bonuses, moving allowances and training costs. Here's a clue, why would I want to come to work everyday, do a good job and do extra shift when necessary if the new nurse gets all the recognition? Duh!
3. Insist that the medical staff treat nursing with professional respect. And, administration needs to treat nurses like the valued professionals that they are.
4. Stop trying to screw your employees to save a buck.
5. Spend money to send your nurses to seminars and conferences. Have a nursing education department that actually does some education other than BLS, ACLS etc.
6. Quit cutting, cutting, cutting bedside care and increasing, increasing, increasing clipboard nurses and administrators. Coincidentally, adequate bedside staff will increase the Holy Grail, the patient satisfaction score.
7. And I agree with Girlvet, a real live practicing nurse on the hospital board to represent nurses.
8. Free cafeteria food, free parking. You give it to the docs, why not the people actually providing patient care?
9. And one of my top concerns, adequate FUNCTIONING equipment to do my job.
Not so hard, really. If people don't quit because they are disgusted with how things are run and how they are treated they you won't constantly have to be recruiting, will you?
1. Don't f#$& with their schedule. Nurses work long grueling shifts, holidays, nights and weekends. Try to accommodate their needs when you do the schedule and they will be much happier than if you split their days, make them work extra holiday and weekends and deny their vacation requests.
2. Focus on Retention. Hospitals spend millions of dollars in recruitment with sign on bonuses, moving allowances and training costs. Here's a clue, why would I want to come to work everyday, do a good job and do extra shift when necessary if the new nurse gets all the recognition? Duh!
3. Insist that the medical staff treat nursing with professional respect. And, administration needs to treat nurses like the valued professionals that they are.
4. Stop trying to screw your employees to save a buck.
5. Spend money to send your nurses to seminars and conferences. Have a nursing education department that actually does some education other than BLS, ACLS etc.
6. Quit cutting, cutting, cutting bedside care and increasing, increasing, increasing clipboard nurses and administrators. Coincidentally, adequate bedside staff will increase the Holy Grail, the patient satisfaction score.
7. And I agree with Girlvet, a real live practicing nurse on the hospital board to represent nurses.
8. Free cafeteria food, free parking. You give it to the docs, why not the people actually providing patient care?
9. And one of my top concerns, adequate FUNCTIONING equipment to do my job.
Not so hard, really. If people don't quit because they are disgusted with how things are run and how they are treated they you won't constantly have to be recruiting, will you?
Grand Rounds
Grand Rounds is up at Six Until Me. It's a very tasty edition! Unfortunately I am in the middle of a 6 day stretch so I'll have to save it for one more day until I have the time to relax and really enjoy it, don't let that stop you though.
Monday, September 17, 2007
File this one under 'What will they think of next?'
Just when I thought hospitals couldn't get any stupider in their quest for excellent customer service I read about one that has come up with the idea of self-service check in kiosks because they were too busy in triage and it was taking too long for patients to see the triage nurse.
The triage nurse is one of the most important people in the ER. They get to spend a few minutes with people who often are very poor historians and have vague symptoms and they need to have the clinical experience and the 'gut' to know if a patient is OK to go back in the lobby or if they need to be seen right away. Twice in my career that I can remember, I have triaged people with silly complaints like 'constipation' or a 'reaction to my flu shot' that actually turned out to be a heart attack and a serious arrhythmia. No check in kiosk can replace that.
So hospital administration listen up and get a clue. NURSES CANNOT BE REPLACED BY MACHINES, NON-MEDICAL PERSONNEL, HOSPITAL VOLUNTEERS OR WHATEVER HAREBRAINED IDEA YOU HAVE COME UP WITH TO SAVE YOURSELF TRYING TO PAY A NURSING SALARY. If it is taking too long for patients to see the triage nurse you need to have more triage nurses. Duh.
How this hospital every got the nursing staff and the ER MD's to agree to this one is beyond my comprehension.
H/T Whitecoat Rants
The triage nurse is one of the most important people in the ER. They get to spend a few minutes with people who often are very poor historians and have vague symptoms and they need to have the clinical experience and the 'gut' to know if a patient is OK to go back in the lobby or if they need to be seen right away. Twice in my career that I can remember, I have triaged people with silly complaints like 'constipation' or a 'reaction to my flu shot' that actually turned out to be a heart attack and a serious arrhythmia. No check in kiosk can replace that.
So hospital administration listen up and get a clue. NURSES CANNOT BE REPLACED BY MACHINES, NON-MEDICAL PERSONNEL, HOSPITAL VOLUNTEERS OR WHATEVER HAREBRAINED IDEA YOU HAVE COME UP WITH TO SAVE YOURSELF TRYING TO PAY A NURSING SALARY. If it is taking too long for patients to see the triage nurse you need to have more triage nurses. Duh.
How this hospital every got the nursing staff and the ER MD's to agree to this one is beyond my comprehension.
H/T Whitecoat Rants
Sunday, September 16, 2007
Busted
so we get this patient in with kidney stones and the computer says he was here withing the last 48 hours so I pull up his visit history and it is his third visit in the last two weeks. Plus visits in the last year for back pain and dental pain. So, being of the suspicious nature that I am, I think something is going on here and voice my concerns to the doctor.
The doctor goes into see the patient and asks if he has followed up with the three urologist he has been referred to on his last visits and the answer is no. So the doc tells him he is going to send him over for an IVP and explains what the test is. The patient tells him he thinks he had one of those recently at hospital x across town. (Not too smart!)
The doctor tells him he needs to see his records from the test he had over there so he has us send for the results. The clerk in the medical records department calls back after getting the record release form and says she is having trouble finding it, do we know what month he had it. After checking with the patient we verify it was in the present month. There is a pause as she looks on her computer and then she says "Well he's been here 6 times this month, do you know which visit?"
Uh oh, busted! Not to smart to tell us you went to the other hospital dude. The doctor reviewed his previous record, no blood in the urine, no stone on CT (assumption was he passed it.) He went in and confronted the patient and told him no more narcotics from this ER, ever. The patient, who had been previously writhing around on the gurney leaped to his feet and leaves, yelling at us as he storms out of the department " I'm gonna sue your fucking asses, it's illegal to not treat my pain, I'll see you in court." Yeah, uh huh, like I haven't heard that one before.
I'd tell you I called the ER at hospital x and gave them a heads up that he was probably coming their way but that would be a HIPAA violation wouldn't it.
The doctor goes into see the patient and asks if he has followed up with the three urologist he has been referred to on his last visits and the answer is no. So the doc tells him he is going to send him over for an IVP and explains what the test is. The patient tells him he thinks he had one of those recently at hospital x across town. (Not too smart!)
The doctor tells him he needs to see his records from the test he had over there so he has us send for the results. The clerk in the medical records department calls back after getting the record release form and says she is having trouble finding it, do we know what month he had it. After checking with the patient we verify it was in the present month. There is a pause as she looks on her computer and then she says "Well he's been here 6 times this month, do you know which visit?"
Uh oh, busted! Not to smart to tell us you went to the other hospital dude. The doctor reviewed his previous record, no blood in the urine, no stone on CT (assumption was he passed it.) He went in and confronted the patient and told him no more narcotics from this ER, ever. The patient, who had been previously writhing around on the gurney leaped to his feet and leaves, yelling at us as he storms out of the department " I'm gonna sue your fucking asses, it's illegal to not treat my pain, I'll see you in court." Yeah, uh huh, like I haven't heard that one before.
I'd tell you I called the ER at hospital x and gave them a heads up that he was probably coming their way but that would be a HIPAA violation wouldn't it.
Saturday, September 15, 2007
Where canadians go for healthcare
Hey Micheal Moore, how come you don't talk about this? Canadians cross the border to get much needed healthcare. Yep, it's true. I used to live in upstate NY, right across the river from Canada and the hospital I worked at would routinely get people from Canada that came in with abdominal pain, neurological symptoms and chest pain. Why? To get their CT's and cardiac cath's without a six month wait. This was 15 years ago. Not only that, the nurses also came across the border to make a half way decent wage. People from Canada and the UK can tell you millions of stories of why universal healthcare ain't all it's cracked up to be.
American healthcare is broken and needs fixing but don't hold up these countries as the system we want to emulate.
Thanks, Kevin MD.
American healthcare is broken and needs fixing but don't hold up these countries as the system we want to emulate.
Thanks, Kevin MD.
Friday, September 14, 2007
A typical day
7am I pour a cup of coffee and take report, I have two patients in my four rooms, the first is on a mental health hold and expected to leave shortly to go to the MH unit. The second is a little old lady with new onset afib who has had labs and an EKG has gotten some IV Cardizem to slow down her heart rate which has worked well and she is currently resting comfortably.
0705 I go to assess my patients, the MH patient is drowsy from Haldol he was given when he came in but otherwise cooperative. The little old lady is fine, lungs clear still in afib but the rate is now 80's instead of 160's. She is a little short of breath and needs to go to the bathroom. We discuss putting in a catheter so she won't have to get in and out of bed or wrestle with the bedpan. She is agreeable. I tell her I will be right back.
0715 I talk to the doc about the LOL, I tell him she needs a catheter and is still SOB even though her rate is controlled now. He looks at her Xray and orders some IV lasix as he see's she has some pulmonary edema, fluid backed up into her lungs. When her heart was pumping so fast, it wasn't doing it's job of pumping blood strongly enough and it backed up into the vessels in the lungs, congesting them and causing fluid to leak out of the vessels and into the lung tissue and air sacs.
0725 supplies gathered I give the lasix, wash my hands and put in the Foley. I reposition her, get her another pillow and a fresh warm blanket. I turn down the light on my way out of the room so she can rest.
0737 I call report on the mental health patient and send him upstairs with the transporter. I strip the room and wipe down the bed, monitor and cables, the sink and the bedside cart. As a recent cost saving measure they have laid off all but one of our housekeepers and she can't keep up with the volume of the work so we have to pick up the slack. The triage nurse has put a patient who has flank pain into one of my empty rooms so I go in to assess him. I find a pale, sweaty middle aged man vomiting into an emesis bag. I suspect he has a kidney stone so I ask him to give me a urine sample and step out of the room.
0755 I talk to the doc about the new patient and he goes in to see him. I get an IV and blood draw set up and prime a liter of saline. Kidney stones are common and I know what the work up is.
0805 I start his IV, draw blood, hook up and start running in a liter of saline, label all the bloods and urine and send them to the lab. I give some pain and nausea medicine and when he is more comfortable hook him up to the monitor to keep an eye on his vital signs and oxygen levels as I am giving potent narcotics. I inform him and his worried wife that a transporter will be coming to take him to CT and that I will check back in about 15 minutes to see how he is doing but to come and get me sooner if there is a problem. I get the wife a cup of coffee. This all takes until..
0830I know have a third patient, she fell and may have a sprained ankle. I introduce myself, assess her injury checking to make sure that blood flow and nerve function past the injury is normal. She has moderate pain and swelling. i adjust the foot rest on the wheelchair so that the leg is elevated and get her an ice pack while she is waiting for Xray.
0845 I go check on my kidney stone patient to find him dozing, when roused he tells me his pain is now a '2'
0850 I take telephone admit orders from the LOL's doctor and give them to the clerk to arrange for a room.
0900 I think about having some toast but then we get a call that there is an ambulance coming in with a code blue so I go to help the nurse that is getting the patient. Sometimes really critical patients need two, three or even four nurses to do all that needs to be done to stabilize them.
0940 the patient is declared dead and after helping the other nurse clean up the room and body for family to view I go back to my assignment. My ankle injury patient has been xrayed and I give her a Motrin that has been ordered and put the chart up for recheck. The kidney stone guy is in CT. I have a bed assignment so I sit down to finish up the chart on the LOL so I can get her upstairs. The charge nurse has put a child with an ear ache in my fourth room but I decide to wait to see him until after I call report.
0950 The charge nurse upstairs tells me the nurse is on break and will call me back. That is par for the course but it is still annoying to hear when you have been busy and haven't had time for a break. I go see the kid with an ear ache, he is cute as a button, playing around and looking pretty perky. Mom is about 16 but very attentive to her kid and he looks well cared for. I ask her if she has help with him and she proudly tells me that she is finishing up high school but they live in a small apartment and he stays with grandma while she is in school.
1000 I get an ankle brace and fit crutches to the ankle injury, which is a sprain, and discharge that patient. I help another nurse accept an ambulance patient that is coming from a nursing home, the patient is febrile and has increased confusion. We get an IV, labs, hang fluid and insert a Foley to obtain a urine. The most common cause of these symptoms in the elderly is a urinary tract infection. We do all this before the doc ever gets to the room to improve efficiency.
1020 I call report on the LOL. She has to go up on a monitor so i hook her up and take her upstairs.
1035 I clean both my empty rooms and bring back a lady who cut her hand washing dishes and an elderly gentleman with cough and fever. I set the lady up to be sutured so the doc won't have to make two trips to the room. I place the gentleman on the monitor and order a chest xray to see if he has pneumonia, we have a 4 hour window to administer antibiotics if he does. I know he will need labs and blood cultures so I go ahead and put in an IV and get all that stuff along with an EKG. The EKG tech's are long gone as another cost-saving measure.
1100 now that I am done with the pneumonia guy I discharge little guy with a prescription for antibiotics and Motrin. I give him a little stuffed bear. Our ER doesn't have money for stuff like that so some of the nurses go to the dollar store and buy stuffed animals and play dough and crayons so we will have little prizes for our pediatric patient. The kidney stone patient is ready to be discharged home with a prescription for pain meds and instructions to drink lots of fluids and strain urine.
1115 the laceration lady's wound has been numbed so I irrigate it for the doc while he sees another patient.
1130 I get an ambulance patient with chest pain. EKG, monitor, IV. labs, aspirin and a first nitro. I tell that patient i will be back to assess him in a minute. I show the EKG to the doc and send the lab work off and ask the clerk to page for a chest xray.
1147 I am in the middle of cleaning my empty room when I suddenly realize I have to pee right NOW. I go to the bathroom and take two Tylenol for my aching back. Back pain is a work place hazard for nurses.
1203 pneumonia is confirmed so I hang an IV antibiotic and get him a cup of tea.
1208 Chest pain patient is pain free after nitro but has a pounding headache, I talk to the doc and get an order for Tylenol which I give.
1220 Laceration lady is sutured so I clean up her wound and apply a dressing and discharge her with directions to not do dishes until stitches are out!
1240 I bring back a lady with RUQ pain after eating, she looks very uncomfortable. I recognize the signs of a gall-bladder attack and start an IV and fluids before asking the doctor to take a look at her.
1300 The admitting doc is here for pneumonia guy, he asks me to give the patient a dose of IV steroids so I do. Chest pain patient is doing good, labs are pending so I update him on what is going on.
1310 The doc has seen gall-bladder lady and I administer pain and anti-emetic medicine, put her on the monitor and get an EKG.
1330 The charge nurse sends me to lunch. I have now worked 6 1/2 hours without a break or food. I am famished!
1400 Gall bladder ladies labs are back and she is resting comfortably. I put her chart up for recheck. Chest pain guy has an order for repeat EKG and cardiac enzymes so I do the EKG and redraw labs. The charge nurse had transferred pneumonia guy up to the floor.
1430 I have a patient with back pain in my fourth room, he is a frequent flier. I have a bed for pneumonia guy so I call report to the floor and send him up with a transporter. Gall bladder lady is going to get an Ultra sound of her gall-bladder
1445 I clean my empty room and get an ambulance with a lady who fell last night and couldn't get up so spent the night and most of the day on the floor. She is in her 80's and has obviously broken her hip. She has been incontinent of stool and urine. The ambulance crew already started her IV and given her morphine for her pain so I grab another nurse and we give her a bath and insert a Foley. She is hypothermic so we wrap her up in warm blankets after we are through.
1515 that took a half an hour. Chest pain guys labs are all back so I put his chart up for recheck, gall bladder lady needs more pain meds so I give her some. Her work up is completed, i look at her labs and US report and put the chart up for recheck.
1530 I tell back pain guy to find a ride and have it here before I will give him pain med. He has been here before and should know the drill but they always try.
1537 I give broken hip lady a little more pain med and send her to xray. The urine in her Foley looks like coke and I know she probably has rhabdomyolosis from laying on the floor all night.
1550 I take phone orders to admit chest pain guy and discharge gall bladder lady home with pain meds and instruction to follow up with a surgeon.
1600 I give back pain guy a shot since his ride is here. Broken hip lady is back from Xray, I hook her back up to the monitor and notice her BP is low so I give her a 500cc fluid bolus. I tell the doc about her BP and what I have done.
1630 Broken hip lady's pressure is still low so I repeat the fluid bolus and discharge back pain guy. There is a 2 month old with a fever in one of my rooms now and the doc is in seeing her.
1640I call report on chest pain guy and ask the charge nurse if the float can take him upstairs so I can get started on the baby. the police have brought in a patient for a jail clearance .and the other float is checking her into my fourth room.
1645 i get another nurse to help and we start an IV and get a straight cath UA on the baby. It takes 1/2 and hour, three IV sticks and two attempts at the cath before we are finished. The baby screams the whole time. The other nurse and I are frazzled by the time we are done. I hang fluids and leave mom and baby cuddling. Two month olds with fever are nothing to mess around with, she will also get a spinal tap to rule out meningitis before we are done.
1715 Jail clearance lady is getting sutured by the doc. The admitting physician is here for broken hip lady. She has better BP but is hurting so I give her a touch more pain med. I get a teenager with pelvic pain from the lobby and put her in the gyn room.
1745I put a dressing on jail clearance lady and discharge her with the police. Then I go into assist the doctor with the babies spinal tap. I have to hold the infant folded up into a comma, head touching knees. fortunately the doctor is very skilled and it only takes 15 minutes to get the crystal clear fluid which we send off to lab.
1630 I assist the doctor with a pelvic on the teenager, her labs are negative, she is not pregnant but we not a purulent discharge during the pelvic so he orders PID meds which I give.
1648 spinal fluid results are back on baby and are negative. The peds resident is going to come and admit her. I call report on broken hip lady who is going to intermediate care.
1700 I clean my empty rooms and fill them with a lady with asthma exacerbation and an elderly man with a possible fractured wrist from a fall. I call respiratory for a treatment for the wheezer and xray for the wrist.
1710 I hang antibiotics on the baby and discharge the pelvic pain.
1730 I start an IV on the wheezer and give IV steroids and send blood. I start an IV on the other guy who does have a broken wrist and give him some pain meds.
1740 I call report to the peds floor on the baby and take it up.
1755 I get back and find that the charge nurse has brought back another pelvic pain and chest pain. I do an EKG, IV and labs on the chest pain, which sounds more respiratory but he is the right age and has a history.
1820The ortho resident is reducing and splinting the wrist fracture, the wheezer is getting another breathing treatment. I set up the pelvic pain patient and assist the doctor with the pelvic exam. She is a possible miscarriage so she'll need an ultrasound and a UA so I put in a foley for the urine and leave it in so the ultrasound tech can fill her bladder during the test.
1840 I give the chest pain guy aspirin and a nitro patch. I help another nurse clean up her patient that had been incontinent.
1900 i give report to the oncoming shift. I've worked twelve hours with only one break. My lower back and feet are killing me. This is my first of four shifts in a row this week. I'm exhausted but I still have to go home and feed my kids before I fall into bed.
0705 I go to assess my patients, the MH patient is drowsy from Haldol he was given when he came in but otherwise cooperative. The little old lady is fine, lungs clear still in afib but the rate is now 80's instead of 160's. She is a little short of breath and needs to go to the bathroom. We discuss putting in a catheter so she won't have to get in and out of bed or wrestle with the bedpan. She is agreeable. I tell her I will be right back.
0715 I talk to the doc about the LOL, I tell him she needs a catheter and is still SOB even though her rate is controlled now. He looks at her Xray and orders some IV lasix as he see's she has some pulmonary edema, fluid backed up into her lungs. When her heart was pumping so fast, it wasn't doing it's job of pumping blood strongly enough and it backed up into the vessels in the lungs, congesting them and causing fluid to leak out of the vessels and into the lung tissue and air sacs.
0725 supplies gathered I give the lasix, wash my hands and put in the Foley. I reposition her, get her another pillow and a fresh warm blanket. I turn down the light on my way out of the room so she can rest.
0737 I call report on the mental health patient and send him upstairs with the transporter. I strip the room and wipe down the bed, monitor and cables, the sink and the bedside cart. As a recent cost saving measure they have laid off all but one of our housekeepers and she can't keep up with the volume of the work so we have to pick up the slack. The triage nurse has put a patient who has flank pain into one of my empty rooms so I go in to assess him. I find a pale, sweaty middle aged man vomiting into an emesis bag. I suspect he has a kidney stone so I ask him to give me a urine sample and step out of the room.
0755 I talk to the doc about the new patient and he goes in to see him. I get an IV and blood draw set up and prime a liter of saline. Kidney stones are common and I know what the work up is.
0805 I start his IV, draw blood, hook up and start running in a liter of saline, label all the bloods and urine and send them to the lab. I give some pain and nausea medicine and when he is more comfortable hook him up to the monitor to keep an eye on his vital signs and oxygen levels as I am giving potent narcotics. I inform him and his worried wife that a transporter will be coming to take him to CT and that I will check back in about 15 minutes to see how he is doing but to come and get me sooner if there is a problem. I get the wife a cup of coffee. This all takes until..
0830I know have a third patient, she fell and may have a sprained ankle. I introduce myself, assess her injury checking to make sure that blood flow and nerve function past the injury is normal. She has moderate pain and swelling. i adjust the foot rest on the wheelchair so that the leg is elevated and get her an ice pack while she is waiting for Xray.
0845 I go check on my kidney stone patient to find him dozing, when roused he tells me his pain is now a '2'
0850 I take telephone admit orders from the LOL's doctor and give them to the clerk to arrange for a room.
0900 I think about having some toast but then we get a call that there is an ambulance coming in with a code blue so I go to help the nurse that is getting the patient. Sometimes really critical patients need two, three or even four nurses to do all that needs to be done to stabilize them.
0940 the patient is declared dead and after helping the other nurse clean up the room and body for family to view I go back to my assignment. My ankle injury patient has been xrayed and I give her a Motrin that has been ordered and put the chart up for recheck. The kidney stone guy is in CT. I have a bed assignment so I sit down to finish up the chart on the LOL so I can get her upstairs. The charge nurse has put a child with an ear ache in my fourth room but I decide to wait to see him until after I call report.
0950 The charge nurse upstairs tells me the nurse is on break and will call me back. That is par for the course but it is still annoying to hear when you have been busy and haven't had time for a break. I go see the kid with an ear ache, he is cute as a button, playing around and looking pretty perky. Mom is about 16 but very attentive to her kid and he looks well cared for. I ask her if she has help with him and she proudly tells me that she is finishing up high school but they live in a small apartment and he stays with grandma while she is in school.
1000 I get an ankle brace and fit crutches to the ankle injury, which is a sprain, and discharge that patient. I help another nurse accept an ambulance patient that is coming from a nursing home, the patient is febrile and has increased confusion. We get an IV, labs, hang fluid and insert a Foley to obtain a urine. The most common cause of these symptoms in the elderly is a urinary tract infection. We do all this before the doc ever gets to the room to improve efficiency.
1020 I call report on the LOL. She has to go up on a monitor so i hook her up and take her upstairs.
1035 I clean both my empty rooms and bring back a lady who cut her hand washing dishes and an elderly gentleman with cough and fever. I set the lady up to be sutured so the doc won't have to make two trips to the room. I place the gentleman on the monitor and order a chest xray to see if he has pneumonia, we have a 4 hour window to administer antibiotics if he does. I know he will need labs and blood cultures so I go ahead and put in an IV and get all that stuff along with an EKG. The EKG tech's are long gone as another cost-saving measure.
1100 now that I am done with the pneumonia guy I discharge little guy with a prescription for antibiotics and Motrin. I give him a little stuffed bear. Our ER doesn't have money for stuff like that so some of the nurses go to the dollar store and buy stuffed animals and play dough and crayons so we will have little prizes for our pediatric patient. The kidney stone patient is ready to be discharged home with a prescription for pain meds and instructions to drink lots of fluids and strain urine.
1115 the laceration lady's wound has been numbed so I irrigate it for the doc while he sees another patient.
1130 I get an ambulance patient with chest pain. EKG, monitor, IV. labs, aspirin and a first nitro. I tell that patient i will be back to assess him in a minute. I show the EKG to the doc and send the lab work off and ask the clerk to page for a chest xray.
1147 I am in the middle of cleaning my empty room when I suddenly realize I have to pee right NOW. I go to the bathroom and take two Tylenol for my aching back. Back pain is a work place hazard for nurses.
1203 pneumonia is confirmed so I hang an IV antibiotic and get him a cup of tea.
1208 Chest pain patient is pain free after nitro but has a pounding headache, I talk to the doc and get an order for Tylenol which I give.
1220 Laceration lady is sutured so I clean up her wound and apply a dressing and discharge her with directions to not do dishes until stitches are out!
1240 I bring back a lady with RUQ pain after eating, she looks very uncomfortable. I recognize the signs of a gall-bladder attack and start an IV and fluids before asking the doctor to take a look at her.
1300 The admitting doc is here for pneumonia guy, he asks me to give the patient a dose of IV steroids so I do. Chest pain patient is doing good, labs are pending so I update him on what is going on.
1310 The doc has seen gall-bladder lady and I administer pain and anti-emetic medicine, put her on the monitor and get an EKG.
1330 The charge nurse sends me to lunch. I have now worked 6 1/2 hours without a break or food. I am famished!
1400 Gall bladder ladies labs are back and she is resting comfortably. I put her chart up for recheck. Chest pain guy has an order for repeat EKG and cardiac enzymes so I do the EKG and redraw labs. The charge nurse had transferred pneumonia guy up to the floor.
1430 I have a patient with back pain in my fourth room, he is a frequent flier. I have a bed for pneumonia guy so I call report to the floor and send him up with a transporter. Gall bladder lady is going to get an Ultra sound of her gall-bladder
1445 I clean my empty room and get an ambulance with a lady who fell last night and couldn't get up so spent the night and most of the day on the floor. She is in her 80's and has obviously broken her hip. She has been incontinent of stool and urine. The ambulance crew already started her IV and given her morphine for her pain so I grab another nurse and we give her a bath and insert a Foley. She is hypothermic so we wrap her up in warm blankets after we are through.
1515 that took a half an hour. Chest pain guys labs are all back so I put his chart up for recheck, gall bladder lady needs more pain meds so I give her some. Her work up is completed, i look at her labs and US report and put the chart up for recheck.
1530 I tell back pain guy to find a ride and have it here before I will give him pain med. He has been here before and should know the drill but they always try.
1537 I give broken hip lady a little more pain med and send her to xray. The urine in her Foley looks like coke and I know she probably has rhabdomyolosis from laying on the floor all night.
1550 I take phone orders to admit chest pain guy and discharge gall bladder lady home with pain meds and instruction to follow up with a surgeon.
1600 I give back pain guy a shot since his ride is here. Broken hip lady is back from Xray, I hook her back up to the monitor and notice her BP is low so I give her a 500cc fluid bolus. I tell the doc about her BP and what I have done.
1630 Broken hip lady's pressure is still low so I repeat the fluid bolus and discharge back pain guy. There is a 2 month old with a fever in one of my rooms now and the doc is in seeing her.
1640I call report on chest pain guy and ask the charge nurse if the float can take him upstairs so I can get started on the baby. the police have brought in a patient for a jail clearance .and the other float is checking her into my fourth room.
1645 i get another nurse to help and we start an IV and get a straight cath UA on the baby. It takes 1/2 and hour, three IV sticks and two attempts at the cath before we are finished. The baby screams the whole time. The other nurse and I are frazzled by the time we are done. I hang fluids and leave mom and baby cuddling. Two month olds with fever are nothing to mess around with, she will also get a spinal tap to rule out meningitis before we are done.
1715 Jail clearance lady is getting sutured by the doc. The admitting physician is here for broken hip lady. She has better BP but is hurting so I give her a touch more pain med. I get a teenager with pelvic pain from the lobby and put her in the gyn room.
1745I put a dressing on jail clearance lady and discharge her with the police. Then I go into assist the doctor with the babies spinal tap. I have to hold the infant folded up into a comma, head touching knees. fortunately the doctor is very skilled and it only takes 15 minutes to get the crystal clear fluid which we send off to lab.
1630 I assist the doctor with a pelvic on the teenager, her labs are negative, she is not pregnant but we not a purulent discharge during the pelvic so he orders PID meds which I give.
1648 spinal fluid results are back on baby and are negative. The peds resident is going to come and admit her. I call report on broken hip lady who is going to intermediate care.
1700 I clean my empty rooms and fill them with a lady with asthma exacerbation and an elderly man with a possible fractured wrist from a fall. I call respiratory for a treatment for the wheezer and xray for the wrist.
1710 I hang antibiotics on the baby and discharge the pelvic pain.
1730 I start an IV on the wheezer and give IV steroids and send blood. I start an IV on the other guy who does have a broken wrist and give him some pain meds.
1740 I call report to the peds floor on the baby and take it up.
1755 I get back and find that the charge nurse has brought back another pelvic pain and chest pain. I do an EKG, IV and labs on the chest pain, which sounds more respiratory but he is the right age and has a history.
1820The ortho resident is reducing and splinting the wrist fracture, the wheezer is getting another breathing treatment. I set up the pelvic pain patient and assist the doctor with the pelvic exam. She is a possible miscarriage so she'll need an ultrasound and a UA so I put in a foley for the urine and leave it in so the ultrasound tech can fill her bladder during the test.
1840 I give the chest pain guy aspirin and a nitro patch. I help another nurse clean up her patient that had been incontinent.
1900 i give report to the oncoming shift. I've worked twelve hours with only one break. My lower back and feet are killing me. This is my first of four shifts in a row this week. I'm exhausted but I still have to go home and feed my kids before I fall into bed.
Thursday, September 13, 2007
When did we stop offering Tylenol first and start giving everyone a Norco? And not just any old Norco, uh uh now we give a Norco 10mg all the time. For ankle sprain or lacerations. What about Motrin? It's my drug of choice.
When did we stop titrating Morphine? In our ER the standard used to be Morphine 2mg IV every 5 minutes up to ten milligrams. Now the order is Dilaudid 1 mg every 10 minutes up to 4 milligrams which is almost three times the strength of the 10mg of Morphine.
What about non-pain med interventions like heat, cold, positioning, massage etc? Now everyone is on a Dilaudid Cadd in the hospital and Norco, Oxycontin, Morphine, Fentanyl and Methadone all the time.
Why are we turning into a nation of drug addicts? It won't be to many more years and our country will be easy to be taken over, we'll all be too stoned to put up a fight.
When did we stop titrating Morphine? In our ER the standard used to be Morphine 2mg IV every 5 minutes up to ten milligrams. Now the order is Dilaudid 1 mg every 10 minutes up to 4 milligrams which is almost three times the strength of the 10mg of Morphine.
What about non-pain med interventions like heat, cold, positioning, massage etc? Now everyone is on a Dilaudid Cadd in the hospital and Norco, Oxycontin, Morphine, Fentanyl and Methadone all the time.
Why are we turning into a nation of drug addicts? It won't be to many more years and our country will be easy to be taken over, we'll all be too stoned to put up a fight.
Tuesday, September 11, 2007
I will not forget
ROLL CALL OF THE DEAD
I will never forget how I felt September 11, 2001 when I sat, transfixed with horror, in front of the television watching the first tower burn. The sick horror in the pit of my stomach as the cameras closed in on the smoke filled windows above the fire to show the people hanging out of them trying to breath and knowing they were doomed. That horror was eclipsed when a second plane appeared on the screen and plowed into the second tower. The sheer disbelief that a catastrophe of this magnitude could be happening here, on American soil.
My life was forever changed that day as I stood in the trauma center where I worked in central NY waiting for the possible casualties that never came. I will never be the same. Six years have passed and I think for a great many they have forgotten how truly awful that day was. I have not.
Please take a minute to think of the victims of 9/11, the injured and dead and all those they left behind. And no matter what you think of the war in Iraq, support our troops. Take the time to thank a service member for their sacrifice in serving our country that we may remain free, able to speak our minds, worship who and however we please. Take some time out of your busy day and assemble and send a care package to a service member serving overseas to let them know that we at home are supporting them.
Please don't forget the lessons learned that day.
I will never forget how I felt September 11, 2001 when I sat, transfixed with horror, in front of the television watching the first tower burn. The sick horror in the pit of my stomach as the cameras closed in on the smoke filled windows above the fire to show the people hanging out of them trying to breath and knowing they were doomed. That horror was eclipsed when a second plane appeared on the screen and plowed into the second tower. The sheer disbelief that a catastrophe of this magnitude could be happening here, on American soil.My life was forever changed that day as I stood in the trauma center where I worked in central NY waiting for the possible casualties that never came. I will never be the same. Six years have passed and I think for a great many they have forgotten how truly awful that day was. I have not.
Please take a minute to think of the victims of 9/11, the injured and dead and all those they left behind. And no matter what you think of the war in Iraq, support our troops. Take the time to thank a service member for their sacrifice in serving our country that we may remain free, able to speak our minds, worship who and however we please. Take some time out of your busy day and assemble and send a care package to a service member serving overseas to let them know that we at home are supporting them.
Please don't forget the lessons learned that day.
Monday, September 10, 2007
The NHS Song - Amateur Transplants
Thanks to Mashnut for pointing me in the direction of this video. Sadly, American hospitals have many of the same problems they have in the UK. This is the system people use as an example of 'Universal Healthcare.'
Migraine Wars Part 2
I get home from work today to find that my blog has been turned into a battle ground. Enough! I have disabled contents on that post. We will have to agree to disagree. Thank you all for stopping by.
Sunday, September 9, 2007
Migraine Wars
I've ignited a flame war with the migraine sufferers.
Let me repeat and expand on what I've said in the comments.
There is a difference between migraine and 'migraine'
People with migraines have a MD that they see regularly, they are often also followed by a neurologist and a pain specialist.
People with 'migraines' have no doctor, they may have been fired by several doctors including the 'doctor feelgood' that every area has. They may live 50 miles away and have passed up three other hospitals to come to yours.
People with migraines are on preventative, anti-nausea and abortive meds. They come to the ER as a last resort when their usual medications have been tried and failed.
People with 'migraines' are not on any migraine management meds and will often state allergies to them. In fact they are usually allergic to everything but Demerol or Dilaudid.
People with migraines come to the ER and wait patiently for their turn even though they are miserable.
People with 'migraines' come to the ER with their mom or significant other who comes to the desk every ten minutes or stands in the door of the room and glares at everyone that passes. They are abusive to the doctor and the nurses.
We get warning letters from the DEA about people with 'migraines.' Yes, they do track narcotic usage.
People with migraines, we recognize you. We will treat you, and with compassion and caring as soon as we have treated all the people with life threatening problems first. In the meantime we will give you a dark room as soon as one is free, an ice pack and a nice warm blanket.
people with 'migraines' you suck the life and spirit out of us. You waste our time in your endless search for your next high. You waste precious resources. And if you think we don't recognize the difference between someone with a valid medical complaint and someone that is drug seeking, think again.
Let me repeat and expand on what I've said in the comments.
There is a difference between migraine and 'migraine'
People with migraines have a MD that they see regularly, they are often also followed by a neurologist and a pain specialist.
People with 'migraines' have no doctor, they may have been fired by several doctors including the 'doctor feelgood' that every area has. They may live 50 miles away and have passed up three other hospitals to come to yours.
People with migraines are on preventative, anti-nausea and abortive meds. They come to the ER as a last resort when their usual medications have been tried and failed.
People with 'migraines' are not on any migraine management meds and will often state allergies to them. In fact they are usually allergic to everything but Demerol or Dilaudid.
People with migraines come to the ER and wait patiently for their turn even though they are miserable.
People with 'migraines' come to the ER with their mom or significant other who comes to the desk every ten minutes or stands in the door of the room and glares at everyone that passes. They are abusive to the doctor and the nurses.
We get warning letters from the DEA about people with 'migraines.' Yes, they do track narcotic usage.
People with migraines, we recognize you. We will treat you, and with compassion and caring as soon as we have treated all the people with life threatening problems first. In the meantime we will give you a dark room as soon as one is free, an ice pack and a nice warm blanket.
people with 'migraines' you suck the life and spirit out of us. You waste our time in your endless search for your next high. You waste precious resources. And if you think we don't recognize the difference between someone with a valid medical complaint and someone that is drug seeking, think again.
ERnurseys customer service model
If running the hospital was left up to me this is how it would go:
1. The hospital would be CLEAN. I would hire enough housekeepers and properly train/monitor them. I would also hire enough maintenance men to keep the walls patched and painted.
2. There would be enough nurses. If the unit was short then the director would be expected to work the unit, day or night. That is their responsibility.
3. There would be enough ancillary staff. It doesn't help to have a nurse to patient ratio if you then get rid of the ward clerk, PT aide, housekeepers and patient care techs so that the nurse has to do all that work also.
4. I would fire all the consultant/survey companies. I would then spend time every day talking to patients and family members to find out what they like/don't like.
5. Free phone/TV. It is asinine to charge people thousands of dollars for a room and expect them to cough up a daily fee for the TV and phone.
6. When they are in the ER and they get a room they go up to said room. Having to lay around a noisy, chaotic ER is very dissatisfying to the patients. ER gurneys are uncomfortable.
7. expect physicians to have discharges done by 11 like a hotel, discharges that aren't done hold up ER admits.
8. Edible food. Not prison slop. Enough said.
9. Enough staff to change the beds daily, bathe the patients, give back rubs like in the old days of nursing. Crisp clean bedding and feeling clean go a long way toward making someone feel better. As bare-bones as most hospitals staff, some of this just can't get done, especially with the ridiculous burden of paperwork the nurses are doing every day.
10. Expect all the staff, including the medical staff, to treat each other with respect and professionalism. Have a zero tolerance policy and adhere to it.
11. Have an admit/discharge nurse 24/7 to help with the admitting paperwork and getting discharges done.
12. FIRE JCAHO. Hospitals across America should do this and police each other. JCAHO only aim is to come up with more and more paperwork and foolish ideas to ensure their continued existence.
13. Streamline the paperwork, get rid of about 75% of the paperwork that has to be done now that exists only to prove compliance to JCAHO's regs. We spend less and less time with the patient but we sure can fill out forms. PAPERWORK DOES NOT = GOOD PATIENT CARE.
14. Have a massage therapist, music therapy, pet therapy. Have the auxiliary do patient visits. Patients love it when someone has time to just sit and listen to them. Have candy stripers to visit, bring magazines, fill water pitchers. All low cost ways to make the patients more comfortable and special. Hospitals tend to cut the lowest cost people like Techs, ward clerks etc. when they cut costs.
15. Get some decent pillows. Hospital pillows suck. I can go to Walmart and get decent pillows for around 5 dollars that are a thousand times better than hospital pillows. Send them home with the patients.
16. Put decent mattresses on the beds, when you are sick and spending days lying in bed, the mattress is a BIG DEAL.
17. Do NOT allow floor buffing, lab drawing etc. in the middle of the night. Allow people to sleep for the love of GOD.
LIfe in the NHS
I guess Michael Moore would be shocked to find that all is not peaches and cream with the British NHS.