Sorry for the lack of posting, I've worked six days straight to try and help with the staffing crisis an I am completely exhausted. I intend to stay in my pajamas and lay on the couch all day.

I am acutely aware that if we have a real pandemic WE. ARE. SCREWED.

This is why we do what we do

Ok guys, I am POOPED. We saw about twice or normal daily census today and they were all SICK. So no new post from me, sorry.

But over at Disappearing John I read a great post that explains why we do what we do. Go read it.

Nurse Over the Edge

Well.

Tomorrow is Monday.

Monday's are the worst days in the ER. I don't know why.

I'm sitting here with a large glass of something alcoholic dreaming up reasons to call in sick.

If I'm thinking of calling in sick, things have gotten really bad.

Really bad.

But I can't leave them shorter staffed than they would be anyway.

We've come to judge how bad the day will be by the number of hospital beds we walk by on our way to the break room. Today we counted fourteen.

Come on June, Come on June.

Nurses on the Edge

Come on June, come on June.

June is when we typically have a slow down in our ER and hospital census. Every year when this happens hospital administration 'freaks out' and starts calling off staff right and left. Soon the staff gets sick of not enough hours so they quit. Positions aren't filled.

Then winter comes and we get slammed with patients, there aren't enough nurses to take care of them. The nursing staff works a lot of overtime to try and cover until they start getting sick and injured. The staff illness and injuries further reduce the staff numbers until things reach critical proportions. Staff is hired but have to have orientation so they aren't really any help during the crisis.

Is it too much to ask for administration to look back over the years and see that the SAME THING HAPPENS EVERY STINKIN' YEAR? Are we really saving that much money calling everyone off when we balance it against all the overtime, sick calls and medical leave that follows? I truly doubt it.

Is it possible to be PROACTIVE instead of REACTIVE which never works? Could we really try to plan for surges in patient volume and to strive to provide the best possible care for our patients? Is it really wise to cut staff numbers just before the flu and pneumonia season?

We started the day two nurses short and with two ICU holds so that took one nurse for them, two nurses and the charge nurse to run the rest of the ER. It wasn't long until we all had 4 patients including the charge nurse and the nurse with the two ICU holds which put us way out of ratio. We told the nursing supervisor and her response was 'ok.' The other hospital went on diversion so we started getting all the ambulances plus the doctors were accepting patients from outlying facilities. Pretty soon we all had six patients including the two ICU holds, 3 step-down holds and 3 medical floor holds. there were 18 patients in the lobby with complaints of chest pain, weakness, pneumonia and there was nothing we could do about it. Fast track was doing work ups. The nursing supervisors response? "Do the best you can, we know it is bad down there."

WTF? You know it's bad down here? Get down here and help us for God's sake.

Our charge nurse blew her top. It was pretty impressive as she is the most even tempered, easy going person I have ever know. She never even raises her voice. She said to the supervisor "I am declaring an internal disaster" and hung up before there was any response. She overhead paged "Internal Disaster, ER now."

Surprisingly, when all the directors get called in there are bed assignments. Funny how that happens. The cath lab crew was called in to work in the ER, they threw a big hissy fit at that but were told they had to come in. The president of nursing told the nursing supervisor to put on scrubs and get down to help us, which she did - wonder how long it has been since she has done any real nursing?

I got out of work 9 hours after my shift was over, which means I worked 21 hours. I am whipped. Last I heard there was going to be a big pow wow this morning with all of admin to figure out a solution to the problem we've been having the last few months. Let me help you, get some nurse in here now!

Sheesh.

It's Change of Shift time so why don't you head on over and give it a read.

A New Way to Irritate Me

I was working away the other day and my boss came up to me and says: "we want you to stop charting that you tried to give report and the nurse was unavailable."

WTF? So I ask why and she tells me that the quality people don't like it as they feel it makes the floors look like they are delaying care.

Um. Isn't that what they are doing? If it takes me an hour and a half to give report and get the patient up to the room after I have received a room assignment then I for DAMN SURE am going to chart why unless you are asking me to falsify documentation.

"Well no, I'm not asking you to do that. Perhaps you could make it more generic then - for instance 'attempted to call report, nurse not available.' (I suspect this came from a chart where I tried to call report for close to two hours and got every excuse under the book: the nurse was at lunch and the break nurse was unavailable, the charge nurse was off the floor. Now the nurse is back and is in an isolation room. Now the nurse just got a post-op and the charge nurse is in an isolation room. Now I paged the nursing supervisor to clarify the issue with the floor and she didn't call back until after the fourth page. And so on.)

I told my boss that I take great pains with my documentation and I am not going to 'fluff' it. She was not happy. There are many days when I am sure she wonders why she took her position. Such as that one.

The Most Fabulous Day

I had the most fabulous day at work recently. I had a series of patients who were all legitimately sick and very thankful for the care I gave them. One lady had fallen and spent the night on the floor of her apartment and had been incontinent. I actually had the time and the supplies to give her a nice warm bath and then bundle her up with a pile of warm blankets. She had undergone a terrifying ordeal and told me how much it meant to have someone spend the time to clean her up and make her comfortable while she waited for a hospital bed. I also had a child who had a febrile seizure, his parents were understandably freaked out but I had the time to spend reassuring them and teaching them.

The number one dissatisfier of nurses is the feeling that were are giving inadequate care. I hate it when I feel like I have given the bare minimum. When I now a patient is wet and i am too busy to get right in an change their beds. When I know they are in pain and I can't get too them right away. When they have questions but I am too rushed to answer them. I hate it when I am too busy to chart adequately. I have nights when I barely get the minimum documented, I take a lot of pride in my charting and it frustrates me to be prevented from doing a good job because we are short staffed and trying to do too much with too little.

I really am angered when I am trying to do too much with too little, short staffed, no unit clerk, no nurses aides or techs, out of ratio and then the hospital nags us because we don't get clocked out on time. Give me a break, I've been busting my ass for 12 1/2 hours - do you really think I want to be here?

It's the little things that grind us down and burn us out.

Grand Rounds

Looking for some Grand Rounds? Head on over here.

Breaking News......Arnie is an IDIOT!!!

I see a news bullet in my paper today that Arnie has authorized two million dollars in budget cuts to help chip away at the 14.5 BILLION dollar deficit in California. Guess where most of those cuts will be? Schools and payments to doctors and other health care providers that treat Med-i-Cal patients.

Beautiful. Already reimbursements to providers and facilities from MediCal are ridiculous. Most communities have very few MediCal providers because of that which forces a lot of MediCal patients to come to the emergency room where they are assured of receiving care there.

Here is what is happening in our area.....One dentist in the whole county that will take MediCal patients. A couple of doctors and nurse practitioners that will. No orthopedic surgeons will so if you break something and we refer you to ortho, good luck. Two OB/Gyns only so prenatal care is hard to come by. Break your jaw and don't have private insurance? Hope you have a lot of cash. Have a back injury and need surgery, not happening here but you can always go to the ER for treatment of your chronic pain. Have a work comp condition? You won't find a doctor here that will take care of you.

So why can't the politicians, who are supposedly intelligent professionals go through the budget and slash the pork instead of the places that can least afford to lose funding? Because the pork programs are putting money in their pockets.

Arnie, don't ever look for my vote for anything.

Here we go again

I have a morbid fascination with plastic surgery disasters and I have found a whole blog about them.

Check this picture out, what a hot babe.

This Cartoon Says it All

h/t Nursey nurse

Well Duh.

I wonder how much of our tax dollars went into this study? Meanwhile, schools are laying off teachers, clinics are closing for lack of funding, state parks are being closed and so on and so on.

The Statement of the Day

23 year old female that has had chest pain with deep breath for FOUR months. She is pissed because she has been waiting for two hours while most of the ER staff dealt with a major trauma involving three victims. As I ran by her looking for more blood tubing she stopped me and asked how much longer it would be. When I told her probably awhile she says:




Wait for it:


"Well if I would have known I'd have to wait this long I just would have made an appointment with my doctor."

They Won't Stop Coming

The ER was full when we arrived. So was the waiting room. There were three ambulances off-loading patients in the ambulance bay and 4 police cars in the parking lot. We were two nurses short.

And they wouldn't stop coming.

Four more people signed in for triage. We were holding two ICU patients and three tele admits.

And they wouldn't stop coming.

The lady in room 21 respiratory arrested. She was successfully intubated and became our third ICU hold. Another 8 people signed into triage and two ambulances called in patient reports.

And they wouldn't stop coming.

The ER doc helpfully accepted two ER to ER transfers that should have been direct admits. We went on diversion, that stopped the ambulances for awhile but 6 more people signed into triage. The police brought in a raving psychotic in several pairs of handcuffs and hogtied.

The phones rang incessantly and the monitor alarms chimed in.

And they wouldn't stop coming.

The other three hospitals in town went on diversion which made us go on forced rotation. 10 people signed into be triaged and our first ambulance is coming in. All the hall beds are full, there is a chest pain workup in fast track and we declare an internal disaster.

And they wouldn't stop coming.

At 7:30 when I left there were the same three ICU admits holding along with 6 med-surg admits. All the hospitals in town were on diversion and there were 47 people waiting in the lobby - some for more than 6 hours.

And I have to go back tomorrow.

You Might Be Having a Bad Day If (Shamelessly copying 'You Might Be a Redneck'

When the patient in V-Tach on an amiodarone drip is your most stable patient, you might be having a bad day.

When the blood is pouring out of the patients rectum faster than you can infuse the units into the central line, you might be having a bad day (and the patient certainly is.)

When your first person of the day pukes right onto your socks, you might be having a bad day.

When you grab the choking little old man from behind and give him a heimlich maneuver and he has copious liquid stool right down your pants, you might be having a bad day (but he'll live to see a few more.)

When Doctor Huge Workup has every single one of your patients, you are definitely having a bad day and their orders all look like this: IV NS 1000cc bolus, 16 different lab tests, EKG, Chest Xray, CT scan of something, orthostatic VS, IV Pepcid, IV Compazine, Aspirin, IV Lopressor times 3, Nitro SL times 3, some sort of vascular study and an MRI. A list of nursing tasks that involves about 45 minutes and at least 9 sets of vital signs also guaranteeing that the bed will be occupied by that patient for at least 4 hours during which the offending MD will keep adding orders but neglecting to communicate with you so that you only find the orders by accident.

When every single one of your patients have vomiting and diarrhea but are over the age of 80 and demented and total care and unable to communicate, you might be having a bad day.

When all of your rooms are filled with psych holds, you might be having a bad day.

when your ER gets 8 16-year old OD patients from a pharm party that all need gastric lavage and charcoal, you are ALL having a bad day.

Hello JCAHO

Hello JCAHO? Are you listening? Pay attention. I have been a nurse for over twenty years and I can say with confidence that all your mandates have done ABSOLUTELY NOTHING to improve patient care. Yes, that is right, billions of dollars and countless hours of time and energy spent with NO RESULTS.

Except paperwork. Reams and reams and reams of paperwork. That is what they have done. Each mandate requires paperwork to prove that it is being carried out. And that is what they look for when they survey-paperwork. Oh yes and the top of the crash carts - God forbid they are dusty.

But seriously. I spend about half my day on documentation. Half. Those six hours could be way better spent on patient care. I have to fill out a medication reconciliation form on anyone. Then if we give insulin there is the insulin flow sheet. If we give heparin there is an anticoagulation flow sheet. If we admit the patient there is a patient belongings sheet and a sheet to document what you told the floor nurse in report. Yes, that is right, it is not good enough to give report and document 'report given' I have to fill out a one page form with all the same information I gave to the nurse, thereby doing the job twice. Then there is the PCA flow sheet, the critical care drip flow sheet, if we do a procedure we have another sheet that says that we did do a time out as required by JCAHO (how often do you think we stand over the patient and say OK, time out - before we stick in this central line do we have the right patient, the right site, the right procedure but we signed a paper that says we did and that is all JCAHO cares about - the paper) oh and don't for get the moderate sedation flow sheet - a six page masterpiece.

That is just the tip of the iceberg, they are out of control. It is time to get rid of JCAHO. Like any other bloated, self-procreating governmental agency they have no oversight and create mandates to guarantee their own continued existence. And they do nothing to improve patient care. Nothing. Wait you ask, haven't they eliminated wrong site surgery? Don't you think that probably would have happened without their input? After all, performing surgery on the wrong site creates huge national headlines as well as a multi-million dollar lawsuit for the offending hospital, other hospitals see that and thing "Good grief, we don't want that happening to us, we need to look at our processes to make sure it doesn't."

What we really need is a group of nurses who go from hospital to hospital and interview patients and examine the cleanliness of the facility. They could find out how often the rooms are actually cleaned, when the waxing is redone, how often the cubicle curtains are changed and when the beds and gurneys are steam cleaned. They could ask the patients how many times they were ambulated, how long it took for someone to answer they call light, when their bed was changed, did they get a bath each day, skin care, oral hygiene. Was their name bands checked. Did they see their doctor for longer than 2 minutes. Did their nurse have time to instruct them about the medications they were taking, their disease process. Did someone spend time making sure that they were really ready to go home and have the things they need to do ok at home, like a walker or a home care aid, so they don't decompensate and end up in the ER later the same day.

These are the things that really matter, a clean environment, good nursing care, good care from your doctor, tasty food, comfortable surroundings and discharge planning. All the paperwork in the world won't help you if your nurses don't turn you, check your skin, clean your teeth (prevents nosocomial pneumonia) and change your bed (dampness and wrinkles contribute to bed sores.) It doesn't do any good if you are rushed out of the hospital to home when you end up in the ER in a few hours.

But the truth is, JCAHO doesn't care about any of that. If the paperwork is there they are happy, they don't care if the hospital is filthy, they don't look behind beds and gurneys - all they see is the brightly waxed center hallway. They don't care if the patient hasn't been turned because all the nurses are busy fluffing their charts to pass inspection, they rarely talk to the patients anyway.

And now, the government in their infinite wisdom has decided to stop paying for all the things that good nursing care can prevent, nosocomial infections and bedsores. How ironic, they ensure that nurses have to spend half their time on useless, redundant paperwork taking them away from the bedside and now, that nosocomial infections and bedsores are increasing from that, decide not to reimburse for the care of those things.

Is it any wonder that nurses are leaving the bedside in droves?

Fast Track Woes

I had the grave misfortune to have to work in Fast Track today. Bleah. 6 people needing stiches, 3 sprained ankle, 1 fractured metacarpal from punching a wall (learn anything?) 4 back pains, 3 migraines, 2 young women with UTI's, 4 small children with fevers, 2 small children with snotty noses, 2 people with rashes, 1 suture removal, 1 rabies prophylaxis and a partridge in a pear tree. It was boring, boring, boring, boring and I felt like the Vicodin dispensing queen. Oh, I forgot....2 MRSA abscesses and 2 dental pains.

but by God, no one had to wait more than 27 minutes to get into a room. And....I passed out enough Dilaudid and Vicodin to guarantee my patient satisfaction scores should be stellar. My employee satisfaction, on the other hand, is in the toilet.

Friday Night in Triage

19 year old female with complaints of nausea and fatigue. Diagnosis? Wants pregnancy test.

23 yo female with low back pain after picking up a box. Diagnosis? Wants work excuse.

Stab wound to the upper arm. Diagnosis? Pissed off girlfriend.

Flu symptoms. Diagnosis? Wants work excuse.

Family of three with cold symptoms.

19 yo male with 'racing pulse.' Diagnosis? Lay off the Red Bull dude.

93 yo granny who is weak and dizzy all over. Diagnosis? Urinary tract infection.

17 yo male with excruciating back pain. Diagnosis? Wants Vicodin.

87 yo male with shortness of breath - straight back to a bed with him, he turned out to be in pulmonary edema.

2 year old male with shortness of breath. He looked even worse than the previous patient. Straight back to resus with him. Diagnosis? Epiglottits. Ended up getting tubed and going to PICU.

6 day old female with fever. Straight back with her, she was septic and also went to PICU

57 year old male with epigastric pain and heartburn. Seems straight foward right? Well he was also pale and sweaty and nauseated. Straight back to a room with him where he was found to be having an acute MI - off to the cath lab with him.

33 year old female with a sprained ankle.

43 year old woman with abdominal pain and vomiting who looked very uncomfortable. Diagnosis? Gallbladder attack.

38 year old male with testicular pain for several months that as become too much to take. Sadly, he turns out to have metastatic testicular cancer. Guys out there, if the boys are hurting something ain't right. Seek medical attention right away.

3 year old with fever. Diagnosis? Ear infection.

16 year old male with a broken nose from getting hit in the face with a basketball during a game.

78 year old female with abdominal pain and vomiting. Diagnosis? Bowel obstruction.

1 year old baby who is fussy. Diagnosis? Ear infection.

19 year old male with excruciating left side pain. Diagnosis? Kidney stone.

54 year old male with severe shortness of breath. Straight back to a room with him where agressive respiratory treatments and steroids save him from buying a tube.

41 year old male with depression and feeling suicidal. He is also three-sheets to the wind. Blood alcohol turns out to be .43.

7 year old female who fell skating. Diagnosis? Broken forearm.

13 month old male with fever. Diagnosis? Ear infection.

69 year old male with left sided facial droop and numbness. Diagnosis? Bell's Palsy.

64 year old female with abdominal pain. Diagnosis? Diverticulitis.

16 year old female with sudden onset RLQ pain. She is sheet white with a heart rate of 137. Straight to a room with her. She has a ruptured ectopic pregnancy and is trying to bleed to death.

13 year old female with RLQ pain (are we running a special?) Diagnosis? Pelvic inflammatory disease. At thirteen? Good grief

18 year old male who twisted his ankle playing basketball. Diagnosis? Fractured ankle.

43 year old female with vomiting.

22 year old male with vomiting.

87 year old female with vomiting.

1 year old with wheezing. Back to a room with that one too. I don't like little kids with airway problems.

41 year old female with bloody diarrhea for a week. Her heart rate is 159. I think she is a little dehydrated.

30 year old female with migraine. It is her 7th visit this month for the same.

24 year old female with painful urination.

47 year old male with chest pain. Back to the chest pain unit with him.

14 year old male accompanied by his mother who wants him to be drug tested.

The mother of the 14 year old who decided to be seen for back pain, since "She was here."

22 year old female with nausea and vomiting. Diagnosis? Pregnant. (haven't you people ever heard of Walgreens?)

69 year old male with back pain.

38 year old male from a group home for severely retarded people who was more combative than normal. It took me twenty minutes to get him triaged and he was almost successful in biting my arm. He came with two caregivers and the three of us were sweaty and disheveled when we were through.

a 27 year old male who "can't sleep." He was about as psychotic a person I have ever seen.

4 year old female with vomiting. she vomited on the triage room floor.

And so on, and so on and so on.

Can you believe there is a time when patient care was nurse driven and the patient's needs came before anyone else? A time when nurses were in charge of their units and they told administrators what they needed to do their jobs? What, you mean that isn't how it is now? (Heavy sarcasm)

Read the above linked post by Mother Jones and see how it really is now. A nurse decides to put a patient on 1:1 observation because she believes he represents a threat to other patients. When she tells her medical director what the situation is instead of support she is subjected to verbal abuse and being screamed at because she dared bring in extra staff.

It's a pretty sad state of affairs when the almighty dollar is more important than protecting the other patients and staff members, but it happens every day in every facility across the country.

Methadone

Why are we seeing 20 year old people with no history of trauma, cancer, congenital abnormalities or any significant medical findings on METHADONE for back pain?

Why are said people also unemployed and collecting welfare or disability?

WHAT IS WRONG HERE PEOPLE?

Another voice on the thirty minute guarantee. This is a fad that I hope will pass soon. On a day where you are short staffed, have dueling codes going on and patients parked all over the halls the last thing you need is some person with a cold screaming at you because they had to wait more than thirty minutes.

Let's put our priorities where they need to be....on the emergencies.