In our ER we love the hospitalists.
Here is how getting a patient admitted used to go.
ER doc talking to patients primary care: "I have your patient Debra Peel here, she has fallen and needs to be admitted for ORIF of her right hip.
PCP: Well.....thanks for calling me but I don't really admit any more, why don't you get her admitted by Ortho.
ER doc talking to Ortho on call: I have a patient here who is 67 and fell today in her driveway. She has a femoral neck fracture that will need repaired.
Ortho Doc: Why don't you have her primary admit and we'll consult for the fracture.
ER Doc: She doesn't really have any medical problems, only takes one pill for her BP which seems to be well controlled. And besides, her doc is Dr. X, he doesn't admit.
Ortho Doc: Well we prefer to just consult, why don't you call the on call?
ER Doc talking to medicine on-call Doc: I have a patient who needs to be admitted for a hip fracture. I've talked to ortho and they requested we call you and they will consult. Her primary is Dr. X and he doesn't admit.
Medicine doc: Why can't ortho admit?
Anyway, you get the idea, multiple phone calls to multiple doctors to get someone to finally cave and admit - an ordeal that could sometimes take hours.
NOW IT GOES LIKE THIS.......
ER Doc to the Hospitalist: I have an admit for you.
Hospitalist: OK, I'll be right there.
LOVE THEM!
Sunday, March 30, 2008
Saturday, March 29, 2008
How about just telling people no?
30 PEOPLE ARE RESPONSIBLE FOR 2400 AMBULANCE CALLS.
Why is this allowed to continue? In the article it goes on to say that they are going to go out and visit the top offenders and 'work with them gently to curb the inappropriate calls.'
C'mon. If someone calls an ambulance over 100 times in one year, do you really think they are going to listen? When did we become the nation that can't say no. I'm sorry but unless you are paying the bill and you don't have an emergency then the EMS crew should be able to tell you no. And if you persist then the legal system should become involved.
A lot of the chronic ambulance abuses are the habitual drunks that pass out in public. They cost you BILLIONS of dollars every year. If you can't control yourself to this degree then you should be institutionalized until you can.
We need to get back the ability to say no.
h/t Kevin
Why is this allowed to continue? In the article it goes on to say that they are going to go out and visit the top offenders and 'work with them gently to curb the inappropriate calls.'
C'mon. If someone calls an ambulance over 100 times in one year, do you really think they are going to listen? When did we become the nation that can't say no. I'm sorry but unless you are paying the bill and you don't have an emergency then the EMS crew should be able to tell you no. And if you persist then the legal system should become involved.
A lot of the chronic ambulance abuses are the habitual drunks that pass out in public. They cost you BILLIONS of dollars every year. If you can't control yourself to this degree then you should be institutionalized until you can.
We need to get back the ability to say no.
h/t Kevin
Friday, March 28, 2008
Triage
How many times today did someone tell me they were having back pain, dental pain, extremity pain, head ache and so on? Lots.
How many of them took some sort of pain killer to see if it made the pain better? None.
Apparently I am not the only one this bothers.
I'm not suggesting Tylenol for obvious deformity of a limb, thunderclap headache or the like but if I have some sort of musculo-skeletal pain or headache I try something OTC and see if it goes away. My initial thought is not "must go to the ER for this headache I've had for an hour."
c'mon people.
How many of them took some sort of pain killer to see if it made the pain better? None.
Apparently I am not the only one this bothers.
I'm not suggesting Tylenol for obvious deformity of a limb, thunderclap headache or the like but if I have some sort of musculo-skeletal pain or headache I try something OTC and see if it goes away. My initial thought is not "must go to the ER for this headache I've had for an hour."
c'mon people.
Think my job is all sweetness and light? Via Crzegrl.
Violence is a serious concern for ER staff, read about it here
I've been assaulted on the job. And discouraged from pressing charges, not an uncommon occurrence.
Hospital administration tends to take an ostrich with it's head in the sand approach. My own hospital cut security guards in the last round of budget cuts. I've worked in several places where the security they had were paid minimum wage, had almost no training and were mostly comprised of retired men with an average age of 70.
THINGS THAT NEED TO BE DONE NOW!!!!
-metal detectors and xray devices at all entrances, especially the emergency room
-the ability to lock down every unit
-armed police officers in the ER 24/7
-properly trained security in sufficient numbers
-secured, patrolled staff parking and security escorts to make sure staff get to their cars safely
-ZERO tolerance for patients who are threatening or assaultive to staff. Hospitals that condone that type of behavior MAKE ME SICK!
-ALL STATES must make it a felony to assault a health care worker.
-properly train ER staff to protect themselves and in how to safely de-escalate and take down patients. We are expected to deal with psych patients in crisis but not giving any training in how to do so.
Violence is a serious concern for ER staff, read about it here
I've been assaulted on the job. And discouraged from pressing charges, not an uncommon occurrence.
Hospital administration tends to take an ostrich with it's head in the sand approach. My own hospital cut security guards in the last round of budget cuts. I've worked in several places where the security they had were paid minimum wage, had almost no training and were mostly comprised of retired men with an average age of 70.
THINGS THAT NEED TO BE DONE NOW!!!!
-metal detectors and xray devices at all entrances, especially the emergency room
-the ability to lock down every unit
-armed police officers in the ER 24/7
-properly trained security in sufficient numbers
-secured, patrolled staff parking and security escorts to make sure staff get to their cars safely
-ZERO tolerance for patients who are threatening or assaultive to staff. Hospitals that condone that type of behavior MAKE ME SICK!
-ALL STATES must make it a felony to assault a health care worker.
-properly train ER staff to protect themselves and in how to safely de-escalate and take down patients. We are expected to deal with psych patients in crisis but not giving any training in how to do so.
Thursday, March 27, 2008
My How the Times Have Changed
When I was a child Lucy and Desi, a married couple, weren't allowed by TV censors to sleep in the same bed so they had twin beds.
Tonight on TV I have been subjected to several erectile dysfunction, tampon, condom and how to talk about sex with your teen commercials. And it is 6pm, not midnight.
Oh God, how I wished I lived back in the 1950's sometimes.
Tonight on TV I have been subjected to several erectile dysfunction, tampon, condom and how to talk about sex with your teen commercials. And it is 6pm, not midnight.
Oh God, how I wished I lived back in the 1950's sometimes.
Hello JCAHO?
Ahem. JCAHO, if you are really serious about making medication reconciliation work here is what you need to do - pay attention now, here is something you could do that REALLY WOULD IMPROVE PATIENT CARE.
Create a national data bank that is immediately accessible by any health care provider that has all of a patients prescription information readily available. When a patient takes a prescription to a pharmacy it goes into the database, the pharmacist would also benefit by seeing what the patient is getting filled at other places, like the 120 Vicodin he filled across town yesterday. When a patient is given a sample his practitioner would have to hand enter the info into the data base.
Until something like this is created, medication reconciliation will never work. So many patients either a)Have no clue what they take or b)lie about what they are taking or c)get meds from many different doctors filled at many different pharmacies. We simply do not have infinite time to call around to all the pharmacies in town to try to figure out what they are actually on. I feel it is much more dangerous to send out an incomplete or inaccurate list than to not do one at all.
So JCAHO, here's your chance to walk the walk, show us that you really do mean to improve patient care.
Create a national data bank that is immediately accessible by any health care provider that has all of a patients prescription information readily available. When a patient takes a prescription to a pharmacy it goes into the database, the pharmacist would also benefit by seeing what the patient is getting filled at other places, like the 120 Vicodin he filled across town yesterday. When a patient is given a sample his practitioner would have to hand enter the info into the data base.
Until something like this is created, medication reconciliation will never work. So many patients either a)Have no clue what they take or b)lie about what they are taking or c)get meds from many different doctors filled at many different pharmacies. We simply do not have infinite time to call around to all the pharmacies in town to try to figure out what they are actually on. I feel it is much more dangerous to send out an incomplete or inaccurate list than to not do one at all.
So JCAHO, here's your chance to walk the walk, show us that you really do mean to improve patient care.
Wednesday, March 26, 2008
This is just appalling!
"According to one Institute of Medicine study, nurses on medical and surgical units spend just 1.7 hours in a 12-hour shift on direct patient care. The rest of it? Filling out forms, chasing down supplies, collecting information — much of it redundant."
Read the full article here.
Read the full article here.
Of course, what was I thinking?
These are the real things we can do to improve patient care:
Have no drinks at the nurses station, after all - we never have time for a break so if we can't keep drinks handy we will become dehydrated and eliminate the need for those pesky trips to the bathroom that take the nurse away from her JCAHO mandated paperwork.
Don't allow us to keep things we use frequently in patient rooms, like straight cath kits, because they have betadine in them - goodness knows there are scads of patients out there who will think nothing of opening those kits and sucking the betadine out of the swabs to either attempt to get high or kill themselves. It is so much better to make the nurses have to spend untold minutes running around the department looking for the needed supplies to do their jobs.
Make our paperwork so cumbersome that nurses have to be hired away from the bedside to do nothing but review charts to ensure it is done correctly.
Bolt closed all the cupboards under the sinks.
Dust the top of the crash cart daily - that certainly ensures that I know what to do in case of a code.
Have no drinks at the nurses station, after all - we never have time for a break so if we can't keep drinks handy we will become dehydrated and eliminate the need for those pesky trips to the bathroom that take the nurse away from her JCAHO mandated paperwork.
Don't allow us to keep things we use frequently in patient rooms, like straight cath kits, because they have betadine in them - goodness knows there are scads of patients out there who will think nothing of opening those kits and sucking the betadine out of the swabs to either attempt to get high or kill themselves. It is so much better to make the nurses have to spend untold minutes running around the department looking for the needed supplies to do their jobs.
Make our paperwork so cumbersome that nurses have to be hired away from the bedside to do nothing but review charts to ensure it is done correctly.
Bolt closed all the cupboards under the sinks.
Dust the top of the crash cart daily - that certainly ensures that I know what to do in case of a code.
Tuesday, March 25, 2008
musings on illegal abbreviations
JCAHO (I refuse to refer to them as THE JOINT COMMISSION as they now wish to be called) has spent God only knows how much time and how many millions of dollars developing a list of abbreviations which must never be used.
Never mind that the whole point would be moot if doctors all had to use computerized order entry so you took their crappy hand writing out of the equation. How many times have you seen a group of nurses clustered around a chart asking each other "what do you think that says" and hazarding guesses? Multiple times every day.
Some do make sense for instance trailing zero's. why write 1.0 mg? the zero is completely unnecessary and if the period is overlooked a ten time over dose will occur. Why would anyone write a number like that? It happens all the time. Or .5 instead of 0.5 - a hastily written decimal could be mistaken for a one. Those make sense.
For eons medical personnel have used the abbreviation MS for morphine sulfate. JCAHO has determined we must never do so. Foolish staff may mistake it for Magnesium Sulfate. Never-mind that we abbreviate that MgSO4. Never mind that the dosing is different - if a doctor was to write MS 1 gram (meaning Magnesium Sulfate 1 gm) I would certainly question the order. But JCAHO fears some one would administer 1 gram of morphine. In my ER that would require I pull out 100 vials!
Now doesn't that make sense? Now we have a whole contingent of people who used to do bedside nursing who's job is to look through all the charts for the unapproved abbreviations and chase down and chastise the offender. And every shift for the last 3 months we have been short at least one nurse. Perfect.
Never mind that the whole point would be moot if doctors all had to use computerized order entry so you took their crappy hand writing out of the equation. How many times have you seen a group of nurses clustered around a chart asking each other "what do you think that says" and hazarding guesses? Multiple times every day.
Some do make sense for instance trailing zero's. why write 1.0 mg? the zero is completely unnecessary and if the period is overlooked a ten time over dose will occur. Why would anyone write a number like that? It happens all the time. Or .5 instead of 0.5 - a hastily written decimal could be mistaken for a one. Those make sense.
For eons medical personnel have used the abbreviation MS for morphine sulfate. JCAHO has determined we must never do so. Foolish staff may mistake it for Magnesium Sulfate. Never-mind that we abbreviate that MgSO4. Never mind that the dosing is different - if a doctor was to write MS 1 gram (meaning Magnesium Sulfate 1 gm) I would certainly question the order. But JCAHO fears some one would administer 1 gram of morphine. In my ER that would require I pull out 100 vials!
Now doesn't that make sense? Now we have a whole contingent of people who used to do bedside nursing who's job is to look through all the charts for the unapproved abbreviations and chase down and chastise the offender. And every shift for the last 3 months we have been short at least one nurse. Perfect.
Monday, March 24, 2008
Thank God I work in the ER where I can intervene swiftly and save lives - here is a sampling of what I saw in triage recently
A 19 year-old mother brought in her 1 year-old for a check up. She had an appointment at he pediatrician later in the same day but didn't want to have to take the bus across town - apparently we were within walking distance.
a 22 year-old male who had headache, nausea and vomiting. Come to find out he had too much to drink the night before and wanted us to fix his hangover.
a 32 year-old male who vomited once. That's right one time and he rushed on in.
a 2 year-old with the chicken pox. She had no fever and about 20 pox but was 'itchy.'
a 44 year-old female with constipation. (they have a whole aisle devoted to this at the grocery store.)
Someone with a sore throat, someone who wanted a pregnancy test for welfare and three people with dental pain.
disclaimer: as previously stated all patients represented on this blog are composites, not specific patients.
A 19 year-old mother brought in her 1 year-old for a check up. She had an appointment at he pediatrician later in the same day but didn't want to have to take the bus across town - apparently we were within walking distance.
a 22 year-old male who had headache, nausea and vomiting. Come to find out he had too much to drink the night before and wanted us to fix his hangover.
a 32 year-old male who vomited once. That's right one time and he rushed on in.
a 2 year-old with the chicken pox. She had no fever and about 20 pox but was 'itchy.'
a 44 year-old female with constipation. (they have a whole aisle devoted to this at the grocery store.)
Someone with a sore throat, someone who wanted a pregnancy test for welfare and three people with dental pain.
disclaimer: as previously stated all patients represented on this blog are composites, not specific patients.
Sunday, March 23, 2008
Gotta Have it NOW medicine
I had a patient that came in today because they had been scheduled for a MRI which required insurance pre-authorization which typically takes a week or so.
Instead of waiting a week they came to the ER so they could get an MRI, in fact, their complaint was "Need MRI."
So, did the doctor tell them they didn't have an emergency and could wait for the outpatient MRI? Of course not.
Is it any wonder that ER's are over-crowded?
When did we become so afraid to say no?
Instead of waiting a week they came to the ER so they could get an MRI, in fact, their complaint was "Need MRI."
So, did the doctor tell them they didn't have an emergency and could wait for the outpatient MRI? Of course not.
Is it any wonder that ER's are over-crowded?
When did we become so afraid to say no?
Saturday, March 22, 2008
Rectal Temps in Pediatrics
A previous commenter suggested we stop doing rectal temps on infants and use tympanic temps.
If you google this you will find myriad articles available on comparisons of different methods of obtaining a temperature on kids- Here is one of them. Temporal artery scanning is the worst then comes tympanic. I worked in a pediatric ER where we did our own study and typanic temps correlated to rectal temps in less than 66% of the cases, temporal artery scanning correlated less than 42% of the time.
Rectal temps are the GOLD STANDARD of obtaining a temperature in neonates and infants. I would never take the chance of missing a temp in a septic kid even if it means the chance of getting splattered with baby poop. A little baby poop never hurt any one.
If you google this you will find myriad articles available on comparisons of different methods of obtaining a temperature on kids- Here is one of them. Temporal artery scanning is the worst then comes tympanic. I worked in a pediatric ER where we did our own study and typanic temps correlated to rectal temps in less than 66% of the cases, temporal artery scanning correlated less than 42% of the time.
Rectal temps are the GOLD STANDARD of obtaining a temperature in neonates and infants. I would never take the chance of missing a temp in a septic kid even if it means the chance of getting splattered with baby poop. A little baby poop never hurt any one.
Friday, March 21, 2008
ERnursey is suffering from spring fever. Spring leads to peace and contentment which has unfortunately caused bloggers block. I have no discontent right now so I have nothing to write about. Sorry.
I'm off to kayak. See ya.
I'm off to kayak. See ya.
Thursday, March 20, 2008
Shit. Shit. Shit. Shit. I just got a letter that my doctor is closing her practice. Bloody hell. Do you know how hard it is for me to find a doctor that I trust? That will put up with my not so compliant nature with a smile? That can always give me a same day appointment when I need it and never once say go to the ER when I have called on a Friday morning? Plus she's a woman. No offense to all the wonderful male doctors out there but I just feel more comfortable with someone who has the same anatomy and hormonal issues that I do.
I'm more upset about this than I was over my divorce. Finding a good doctor is harder than finding a spouse sometimes. I feel like I am entering the dating pool again. Heck. This sucks.
Wednesday, March 19, 2008
Rivers of Baby Poop
As we finish up the RSV season, we are no longer going through gallons of Albuterol - now we head into the spring season of Rotavirus. Little kids with rivers of liquid yellow poop. Poop that runs down their legs, poop that shoots out of diapers and poop that splatters the unaware nurse attempting to obtain a rectal temp. And they are all dehydrated and need IV's . Kids getting poked scream, poor things. Usually they are screaming more from being held down that the actual needle stick. It's not easy to put an IV into a screaming, wiggling, dehydrated kid. That means time bent over them with them screaming at full volume into your face. It also means wrestling with hot, sweaty angry kids until you are also hot and sweaty. I left yesterday with my head pounding from the continual onslaught of noise and my back aching from the constant bending.
I'm very good at peds IV's so I do them a lot. I don't enjoy it, kids don't understand that you are doing the things you are doing to help them and their abject fear breaks my heart. Sometimes I don't think parents understand you are helping their child either, I have had more than one get very angry when we have to stick the kid more than once - I understand, you don't want to see your child hurt but we wouldn't do this unless they were pretty sick and sick little kids don't have the greatest veins.
Anyway, as much as I love spring I never care for the rotavirus that comes along with it.
WASH YOUR HANDS, WASH YOUR HANDS, WASH YOUR HANDS!
I'm very good at peds IV's so I do them a lot. I don't enjoy it, kids don't understand that you are doing the things you are doing to help them and their abject fear breaks my heart. Sometimes I don't think parents understand you are helping their child either, I have had more than one get very angry when we have to stick the kid more than once - I understand, you don't want to see your child hurt but we wouldn't do this unless they were pretty sick and sick little kids don't have the greatest veins.
Anyway, as much as I love spring I never care for the rotavirus that comes along with it.
WASH YOUR HANDS, WASH YOUR HANDS, WASH YOUR HANDS!
Monday, March 17, 2008
Taxes
Please excuse me for a couple of days while I do my taxes which involves a lot of pain and suffering and Merlot. Be back soon.
Sunday, March 16, 2008
The End of the Code
The patient arrested at home, family started CPR and EMS were on scene quickly, transport time was minutes but despite all efforts she did not survive. She was an elderly woman but had no real medical history to speak of and had always been in good health.
I went with the doctor to the family room to deliver the bad news. The family was devastated, especially since they had lost their father, her husband of 63 years, just a month ago. Ever since he died, they told us, she had been despondent and withdrawn-barely eating.
Diagnosis? death from a broken heart.
It is not as uncommon as you think.
I went with the doctor to the family room to deliver the bad news. The family was devastated, especially since they had lost their father, her husband of 63 years, just a month ago. Ever since he died, they told us, she had been despondent and withdrawn-barely eating.
Diagnosis? death from a broken heart.
It is not as uncommon as you think.
Friday, March 14, 2008
I've won a scrubby! How nice to know that someone found what I had to say interesting. Go check out the site, Red Scrubs, there is some interesting reading there.
And thanks for the award.
dear man on Cell Phone at Chili's. I was trying to have a nice lunch with a dear friend that I had not seen in awhile but the incessant ringing of your cell phone and being forced to listen to your conversations (since you put your phone on speaker so as not to interrupt your eating) ruined it. After the fifth call in fifteen minutes my dear friend had enough and offered to assist you with your cell phone problem by shoving it up your ass. (This is an Xray of how it would have looked had I let her do so.) My friend is 5 feet tall and weighs about 95 pounds. She is always coiffed, manicured and dressed to the nines, however you would completely believe she is capable of such an act if you knew her.
I just wanted to thank you for the priceless look on your face, I haven't laughed that much in a long, long time. The laugh was greatly needed especially on this day because my dear, dear friend was telling me she had been diagnosed with metastatic breast cancer and was looking at a long hard road with a very uncertain prognosis.
So normally I hate people like you that are so self important that they can't miss one call, I hate the incessant noise of ring tones that one is forced to listen to in public and I hate having to listen to the details of every one's boring conversations that frequently interrupt my peace, today though you gave us just what we needed.
Next time, I'll shove the phone up your ass.
Thanks, a very sad ERnursey
Talk talk talk talk talk. All you hear and read about is that Emergency rooms are at the breaking point. But what is anyone doing about it?
Hospitals are vigorously advertising to attract non-urgent customers, how is that helping?
Hospitals are closing, further increasing the burden on other facilities in the area. How is that helping.
Medicare and medicaid are cutting, cutting, cutting reimbursements. How is that helping?
JCAHO continues to come up with newer and more ridiculous mandates causing an ever increasing burden of paperwork. How is that helping.
Primary care providers are refusing to take medicare and medicaid due to the ridiculousness of what they have to do to get reimbursed which further increases the number of patients who are forced to use the ER for primary care. How is that helping.
Nurses are aging and leaving the profession faster than new nurses are entering. Who will take care of us when we are old?
Are we going to start trying to do something now or wait until it is too late?
Hospitals are vigorously advertising to attract non-urgent customers, how is that helping?
Hospitals are closing, further increasing the burden on other facilities in the area. How is that helping.
Medicare and medicaid are cutting, cutting, cutting reimbursements. How is that helping?
JCAHO continues to come up with newer and more ridiculous mandates causing an ever increasing burden of paperwork. How is that helping.
Primary care providers are refusing to take medicare and medicaid due to the ridiculousness of what they have to do to get reimbursed which further increases the number of patients who are forced to use the ER for primary care. How is that helping.
Nurses are aging and leaving the profession faster than new nurses are entering. Who will take care of us when we are old?
Are we going to start trying to do something now or wait until it is too late?
Wednesday, March 12, 2008
Great Moments in ER Nursing
A post at Ten out of Ten reminded me of my own experience of accidentally administering a drug to myself.
Last year we got these new insulin pens, there is a needle that you screw onto the pen and then you push it down onto the patients skin until the plastic shield retracts before administering the dose. That part is important because if you don't do that the needle will not penetrate the skin and the insulin dose will get dripped onto the patients skin making you look like a complete moron.
We got a brief inservice on the device but then they didn't come for almost a year after that so of course everyone forgot everything they ever knew.
One day I came to work and they insulin pens had come. I read the instruction pamphlet and went into administer the insulin. I must have missed the part about pushing the device down onto the patients abdomen until the plastic shield retracts before administering the dose so I dripped the insulin on the patients skin. I'm thinking WTF just happened here? And of course the patient is looking at me like I am a complete dork.
I excuse myself and go into the med room and look at the pamphlet again. This time I see the part about the retractable plastic shield, I push on it with my thumbnail to see if it retracts. I'm still not sure what happened but the needle jumped out and bit me! So, now I've gotten a needle stick and even though I am sure that the needle never touched the patient I have to go through the process which involves testing the source patients blood. Thank goodness another nurse took over that patients care because I had totally lost face there.
AND, while I am waiting for the PA to see me I start to feel shaky and light headed. They check my blood sugar to find it to be 55! Good lord, will the humiliation never end?
It's been over a year and they still kid me about that day, and I still don't trust those insulin pens.
Last year we got these new insulin pens, there is a needle that you screw onto the pen and then you push it down onto the patients skin until the plastic shield retracts before administering the dose. That part is important because if you don't do that the needle will not penetrate the skin and the insulin dose will get dripped onto the patients skin making you look like a complete moron.
We got a brief inservice on the device but then they didn't come for almost a year after that so of course everyone forgot everything they ever knew.
One day I came to work and they insulin pens had come. I read the instruction pamphlet and went into administer the insulin. I must have missed the part about pushing the device down onto the patients abdomen until the plastic shield retracts before administering the dose so I dripped the insulin on the patients skin. I'm thinking WTF just happened here? And of course the patient is looking at me like I am a complete dork.
I excuse myself and go into the med room and look at the pamphlet again. This time I see the part about the retractable plastic shield, I push on it with my thumbnail to see if it retracts. I'm still not sure what happened but the needle jumped out and bit me! So, now I've gotten a needle stick and even though I am sure that the needle never touched the patient I have to go through the process which involves testing the source patients blood. Thank goodness another nurse took over that patients care because I had totally lost face there.
AND, while I am waiting for the PA to see me I start to feel shaky and light headed. They check my blood sugar to find it to be 55! Good lord, will the humiliation never end?
It's been over a year and they still kid me about that day, and I still don't trust those insulin pens.
Tuesday, March 11, 2008
Monday, March 10, 2008
Oh My God, there are drugs in our drinking water
Our drinking water has drugs in it. And as pointed out by Whitecoat Rants, not just drugs but drug metabolites which means pee and poo remains in our drinking water, yuck.
Just one request...........is there some way we can get a little more Haldol and Ativan in the water? From the looks of my ER today, we really need it. 1/2 of the patients this afternoon were being watched by a guard for various reasons, the notable exception is the guy who had 6 big strapping sheriff's deputies guarding him, he made the rest of the crazies look absolutely normal by comparison.
Just one request...........is there some way we can get a little more Haldol and Ativan in the water? From the looks of my ER today, we really need it. 1/2 of the patients this afternoon were being watched by a guard for various reasons, the notable exception is the guy who had 6 big strapping sheriff's deputies guarding him, he made the rest of the crazies look absolutely normal by comparison.
Sunday, March 9, 2008
Spring is Springing
For those of you who living in the snow-belt, you might want to skip the following post.
It was 78 today. The flowering quince, forsythia, tulip tree's, ornamental pears, plum and almond trees are in full bloom. The willows have leaves and the other trees have large buds that will soon be bursting open. The highway is lined with wildflowers and long, lush green grass. The birds are twittering and the frogs are singing.
I've had to mow the lawn for the third week in a row today.
I love spring.
And for those of you in the snow-belt, three months from now everything will be brown and California will be like a blast furnace - feel free to tell me about your lovely green weather then.
Time Limits and How America is Heading For Disaster
Thought provoking post by Mousie. Patients are supposed to be in and out of the department in less than four hours, admirable but not if you LIE about it. Massaging and fluffing your statistics will only hide issues, not fix the underlying cause.
This is a message America needs to hear. More and more hospitals - in an endless effort to cram more and more patients through departments that can no longer handle the load - are considering forcing their ER physicians to have a time limit on disposition decisions. Once again, an admirable goal but what can end up happening is patients bouncing back because of rushed, incomplete treatment or being admitted when they don't really need to.
Let's focus on the true issues - uninsured patients who can't find primary care, frequent fliers who abuse the ER, Medicaid programs that have no oversight - allowing covered patients to come to the ER as much as they like for non-emergent issues, lack of nurses to accept admitted patients, forcing ER's to hold admits. Lack of open rooms to accept inpatients and so on and so on and so on.
This flu season has been gruesome, giving us all a taste of things to come - and it ain't pretty. A nursing shortage already exists. Nurses are aging and retiring without new nurses entering the profession in numbers enough to replace them. This isn't a new problem - it has been known for OVER 10 YEARS! And what has been done to prepare for the future? Little or nothing.
Doctors are leaving primary care, medicare and insurance reimbursements are becoming so burdensome that doctors feel (and rightly so) why bother. That means more and more patients will be forced to use the ER as their primary care, further increasing the load on a system that is struggling now.
So in twenty years you can look forward to going to the ER and waiting for days, not hours. We are one pandemic away from complete and utter disaster now and in a few years it won't even take that.
This is a message America needs to hear. More and more hospitals - in an endless effort to cram more and more patients through departments that can no longer handle the load - are considering forcing their ER physicians to have a time limit on disposition decisions. Once again, an admirable goal but what can end up happening is patients bouncing back because of rushed, incomplete treatment or being admitted when they don't really need to.
Let's focus on the true issues - uninsured patients who can't find primary care, frequent fliers who abuse the ER, Medicaid programs that have no oversight - allowing covered patients to come to the ER as much as they like for non-emergent issues, lack of nurses to accept admitted patients, forcing ER's to hold admits. Lack of open rooms to accept inpatients and so on and so on and so on.
This flu season has been gruesome, giving us all a taste of things to come - and it ain't pretty. A nursing shortage already exists. Nurses are aging and retiring without new nurses entering the profession in numbers enough to replace them. This isn't a new problem - it has been known for OVER 10 YEARS! And what has been done to prepare for the future? Little or nothing.
Doctors are leaving primary care, medicare and insurance reimbursements are becoming so burdensome that doctors feel (and rightly so) why bother. That means more and more patients will be forced to use the ER as their primary care, further increasing the load on a system that is struggling now.
So in twenty years you can look forward to going to the ER and waiting for days, not hours. We are one pandemic away from complete and utter disaster now and in a few years it won't even take that.
Saturday, March 8, 2008
ERnursey's son is back on American soil, safe and sound.
Please keep all those who are not in your prayers.
Please keep all those who are not in your prayers.
One More Thought on the Medication Reconciliation Form
I hate it.
Seriously, whenever anyone even says the words to me I want to scream.
Why are people so lame? How can you take medications everyday and not know what they are? And, if you have been to the hospital 74 times and been asked to make up a list, when do you think you might get around to it?
Don't leave off your Viagra, I don't care if you need help with your willy but I do care if I give you a nitro for your chest pain and I kill you because you took Viagra which bottomed out your blood pressure. We need to know what medications your are taking to keep you safe.
And yes, Birth control pills are a medication. We may want to know that you are taking them especially if you are 21 and complaining of chest pain - it may speed up the diagnosis of pulmonary embolus - something we don't normally suspect in someone your age.
Don't forget to tell me that you take an opioid pain reliever, otherwise when I give you Nubain for pain it might be really unpleasant.
Medication reconciliation, bleah.
Oh and the VA - they sent us a patient today from the clinic that was minimally responsive but didn't send his medication list or any kind of history. So I called. Calls to the VA NEVER reach a human being. Several messages of increasing irritation later someone actually did call back. They told me they couldn't give us that information. 'But you sent him here.' didn't seem to carry any weight either. Several hours after he was admitted for metastatic cancer with new brain lesions we finally got a fax from them. Arggghhh!
I think people need to be implanted with a chip that contains all their information and when they come in we just scan it. Someone get to work on that will ya?
Seriously, whenever anyone even says the words to me I want to scream.
Why are people so lame? How can you take medications everyday and not know what they are? And, if you have been to the hospital 74 times and been asked to make up a list, when do you think you might get around to it?
Don't leave off your Viagra, I don't care if you need help with your willy but I do care if I give you a nitro for your chest pain and I kill you because you took Viagra which bottomed out your blood pressure. We need to know what medications your are taking to keep you safe.
And yes, Birth control pills are a medication. We may want to know that you are taking them especially if you are 21 and complaining of chest pain - it may speed up the diagnosis of pulmonary embolus - something we don't normally suspect in someone your age.
Don't forget to tell me that you take an opioid pain reliever, otherwise when I give you Nubain for pain it might be really unpleasant.
Medication reconciliation, bleah.
Oh and the VA - they sent us a patient today from the clinic that was minimally responsive but didn't send his medication list or any kind of history. So I called. Calls to the VA NEVER reach a human being. Several messages of increasing irritation later someone actually did call back. They told me they couldn't give us that information. 'But you sent him here.' didn't seem to carry any weight either. Several hours after he was admitted for metastatic cancer with new brain lesions we finally got a fax from them. Arggghhh!
I think people need to be implanted with a chip that contains all their information and when they come in we just scan it. Someone get to work on that will ya?
Change of Shift
I neglected to link Change of Shift this week which can be found over at Emergiblog. If you haven't already been there, head on over and check it out.
Thursday, March 6, 2008
More JCAHO madness
Well we had our JCAHO inspection this week. Oh, and by the way, they are now to be called Joint Commission. Good God, the lunacy.
In their ceaseless efforts to improve patient care (heavy sarcasm) they are concerned that we:
1. Tell them that we set our watches by the atomic clock every day.
2. Label lab specimens at the bedside even if we are in the way of the code team.
3. Have a policy that deals with, and a check off place on the crash cart check list, changing the batteries on the ZOLL. Apparently having the monitor tell you the battery is low and possessing some common sense just doesn't cut it.
4. They don't want you to call people by name from the lobby, apparently they want you to go out there and look at the one hundred or so people sitting out there and use your ESP to determine which 70ish year-old lady with "weak and dizzy all over" it is you want.
5. They are not happy with "patient does not know what medications he takes." on the medication reconciliation form, they want you to call all the seventeen pharmacies he uses (or even worse, the VA) or his doctor(s) and clinics. Because in JCAHO's world - patients get to be placed in a room where they lay quietly with stable vitals and never need any nursing attention so the the nurse is possessed of endless time in which to devote all her energy making ENDLESS, FUTILE FUCKING PHONE CALLS TO SATISFY SOME ASSININE AGENCY WHICH SHOULD BE OBLITERATED.
oh dear, I lost it there for a minute. Sorry.
I would like the ANA to do something useful with their lobbying efforts instead of endorsing Hilary Clinton, who seems to think that nurses are 'overpaid and under-educated.' Let's lobby to ensure that all JCAHO inspectors are PRACTICING nurses and physicians that exist in the real world and have some idea what is facing us. Practicing, as in working on the floors, not QRM or Utilization review. Real, live patient care consisting of more than 1000 hours a year. I bet if we put some of these yahoo's to work and they had to deal with their ridiculous ideas, there'd be some mighty big changes.
In their ceaseless efforts to improve patient care (heavy sarcasm) they are concerned that we:
1. Tell them that we set our watches by the atomic clock every day.
2. Label lab specimens at the bedside even if we are in the way of the code team.
3. Have a policy that deals with, and a check off place on the crash cart check list, changing the batteries on the ZOLL. Apparently having the monitor tell you the battery is low and possessing some common sense just doesn't cut it.
4. They don't want you to call people by name from the lobby, apparently they want you to go out there and look at the one hundred or so people sitting out there and use your ESP to determine which 70ish year-old lady with "weak and dizzy all over" it is you want.
5. They are not happy with "patient does not know what medications he takes." on the medication reconciliation form, they want you to call all the seventeen pharmacies he uses (or even worse, the VA) or his doctor(s) and clinics. Because in JCAHO's world - patients get to be placed in a room where they lay quietly with stable vitals and never need any nursing attention so the the nurse is possessed of endless time in which to devote all her energy making ENDLESS, FUTILE FUCKING PHONE CALLS TO SATISFY SOME ASSININE AGENCY WHICH SHOULD BE OBLITERATED.
oh dear, I lost it there for a minute. Sorry.
I would like the ANA to do something useful with their lobbying efforts instead of endorsing Hilary Clinton, who seems to think that nurses are 'overpaid and under-educated.' Let's lobby to ensure that all JCAHO inspectors are PRACTICING nurses and physicians that exist in the real world and have some idea what is facing us. Practicing, as in working on the floors, not QRM or Utilization review. Real, live patient care consisting of more than 1000 hours a year. I bet if we put some of these yahoo's to work and they had to deal with their ridiculous ideas, there'd be some mighty big changes.
We have had the same patient overdose on Baclofen three times this week.
Yep, you read that right, three times.
Two of the times we intubated her, the third not.
All three she had to go to ICU. Where she stayed until she woke up and signed out AMA, except for the last visit when she went to Psych - for one hour and 34 minutes. (I'm sure she got excellent psychiatric care in that amount of time.)
Each time she went home and called he MD's office for a refill AND GOT ONE!
What the HELL is the matter with people?
On the third visit, the ER attending called her MD and asked him that very question. And told him we were going to start sending him the hospital bill for her overdoses.
And before you get your panties all in a twist - the guy was giving her a refill for 120 Baclofen about every other day. You'd think someone might see a problem with that. Especially when he keeps getting a copy of the ER dictation.
Yep, you read that right, three times.
Two of the times we intubated her, the third not.
All three she had to go to ICU. Where she stayed until she woke up and signed out AMA, except for the last visit when she went to Psych - for one hour and 34 minutes. (I'm sure she got excellent psychiatric care in that amount of time.)
Each time she went home and called he MD's office for a refill AND GOT ONE!
What the HELL is the matter with people?
On the third visit, the ER attending called her MD and asked him that very question. And told him we were going to start sending him the hospital bill for her overdoses.
And before you get your panties all in a twist - the guy was giving her a refill for 120 Baclofen about every other day. You'd think someone might see a problem with that. Especially when he keeps getting a copy of the ER dictation.
Sunday, March 2, 2008
The New Customer Service Model
In reading blogs I've notice a common theme. Hospitals are expecting staff to do more with less. Less equipment, less nurses, less support staff, less linen and so on and so on. But still provide excellent customer service, which to their mind means service with a smile, a warm blanket and a TV.
BULLSHIT. (Pardon the language.)
This ain't a hotel. Good customer service in a hospital means that your nurse is highly skilled and knowledgeable so that if you begin to develop problems or complications they know what is going on and how to help you. It means that there is enough nursing staff so they have time to teach you about your illness, how to manage it, about your medications and how to cope at home - not just run into your rooms and quickly give you med's before running on to the next task. It means that there are enough aides and tech's to answer your call light quickly when it rings. It means there are enough physical therapists to work with you every day. It means serving tasty, healthy food. It means having enough ward clerks to answer the phones and take off the doctors orders. It means having enough pharmacy staff that medications can get filled and delivered quickly, not hours later. It means having enough discharge planners to REALLY plan for your discharge so that you don't end up in the ER later the same day. It means having enough housekeepers to really clean the hospital, not just polish the highly visible areas while the corners collect grime. All of this and more is what good customer service is to a hospitalized patient. A warm blanket may feel good but it doesn't mean squat when you are being given shitty care.
Shitty care is when all the nurses are new grads and travelers because all the experienced RN's have left to go where they are treated better. Shitty care is when you are given a cold meal tray because there isn't enough staff to pass them out. Shitty care is when there isn't enough staff to offer you a bath and change your linen's daily. Shitty care is when you put on your light and it takes a half an hour to get someone to answer it. Shitty care is when it takes the nurse 8 hours to realize that a heart rate of 160 may be a problem. Shitty care is when your doctor orders a new antibiotic and it takes the pharmacy 4 hours to deliver it to the unit. Shitty care is when the unit only has one house keeper to clean 30 rooms, rooms should be dusted and mopped every day, not once every three days. shitty care is when you have to sit in the ER waiting room for hours because they are holding admitted patients because there are no nurses upstairs to take care of them. Shitty care is what you will get at most hospitals these days because hospital administration does not care about the patients, they only care about the bottom line and profits.
BULLSHIT. (Pardon the language.)
This ain't a hotel. Good customer service in a hospital means that your nurse is highly skilled and knowledgeable so that if you begin to develop problems or complications they know what is going on and how to help you. It means that there is enough nursing staff so they have time to teach you about your illness, how to manage it, about your medications and how to cope at home - not just run into your rooms and quickly give you med's before running on to the next task. It means that there are enough aides and tech's to answer your call light quickly when it rings. It means there are enough physical therapists to work with you every day. It means serving tasty, healthy food. It means having enough ward clerks to answer the phones and take off the doctors orders. It means having enough pharmacy staff that medications can get filled and delivered quickly, not hours later. It means having enough discharge planners to REALLY plan for your discharge so that you don't end up in the ER later the same day. It means having enough housekeepers to really clean the hospital, not just polish the highly visible areas while the corners collect grime. All of this and more is what good customer service is to a hospitalized patient. A warm blanket may feel good but it doesn't mean squat when you are being given shitty care.
Shitty care is when all the nurses are new grads and travelers because all the experienced RN's have left to go where they are treated better. Shitty care is when you are given a cold meal tray because there isn't enough staff to pass them out. Shitty care is when there isn't enough staff to offer you a bath and change your linen's daily. Shitty care is when you put on your light and it takes a half an hour to get someone to answer it. Shitty care is when it takes the nurse 8 hours to realize that a heart rate of 160 may be a problem. Shitty care is when your doctor orders a new antibiotic and it takes the pharmacy 4 hours to deliver it to the unit. Shitty care is when the unit only has one house keeper to clean 30 rooms, rooms should be dusted and mopped every day, not once every three days. shitty care is when you have to sit in the ER waiting room for hours because they are holding admitted patients because there are no nurses upstairs to take care of them. Shitty care is what you will get at most hospitals these days because hospital administration does not care about the patients, they only care about the bottom line and profits.
Saturday, March 1, 2008
Pandemic
These last couple of weeks have given us a miniature taste of what a pandemic would be like.
It started off slow, first we noticed that we were seeing a lot more sick elderly, then we noticed our daily census increasing. Then our ratio shifted - normally we see about 1/3 of our daily patients in fast track, so say 50 there and 100 in the main ER, now it is more like 30 in fast track and 170 in the main ER. The hospital was full and we started holding patients. The number of holds and length of time we held them grew every day. Patients were sitting in the lobby 3 to 4 times longer than normal because we had half our normal beds to see way more patients than normal. The patient acuity keeps climbing, normally we admit about 18% of our patients and now we are admitting 25-27%. Then the ER staff started getting sick. So we were seeing more, sicker patients with less beds and less staff.
It wasn't pretty. Toward the end of this week the hospital census evened out and we started holding less people. Hopefully the crisis point is over.
I do know this: There is no way we will every be able to handle a major outbreak and I suspect that most other hospitals are in the same boat. But, in the great American tradition of burying our heads in the sand, I don't suppose anything is going to change.
It started off slow, first we noticed that we were seeing a lot more sick elderly, then we noticed our daily census increasing. Then our ratio shifted - normally we see about 1/3 of our daily patients in fast track, so say 50 there and 100 in the main ER, now it is more like 30 in fast track and 170 in the main ER. The hospital was full and we started holding patients. The number of holds and length of time we held them grew every day. Patients were sitting in the lobby 3 to 4 times longer than normal because we had half our normal beds to see way more patients than normal. The patient acuity keeps climbing, normally we admit about 18% of our patients and now we are admitting 25-27%. Then the ER staff started getting sick. So we were seeing more, sicker patients with less beds and less staff.
It wasn't pretty. Toward the end of this week the hospital census evened out and we started holding less people. Hopefully the crisis point is over.
I do know this: There is no way we will every be able to handle a major outbreak and I suspect that most other hospitals are in the same boat. But, in the great American tradition of burying our heads in the sand, I don't suppose anything is going to change.
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