RECEIVED VIA EMAIL FROM A FRIEND, AND FELLOW RN IN NORTHERN CALIFORNIA, ORIGIN UNKNOWN BUT I EXPECT IT IS ALL TOO TRUE. SADLY, THIS IS WHAT OUR SOCIETY IS BREEDING.
Dear Editor,
>
> I am a nurse who has just completed volunteer working
approximately 120 hours as the clinic director in a Hurricane Gustav evacuation
shelter in Shreveport, Louisiana
> over the last 7 days. I would love to see someone look at
the evacuee situation from a new perspective. Local and national news channels
have covered the evacuation and
> "horrible" conditions the evacuees had to endure
during Hurricane Gustav. True - some things were not optimal for the evacuation
and the shelters need some modification.
> At any point, does anyone address the responsibility (or
irresponsibility) of the evacuees?
>
> Does it seem wrong that one would remember their cell
phone, charger, cigarettes and lighter but forget their child's insulin? Is
something amiss when an evacuee gets off the bus, walks immediately to the
medical area, and requests immediate free refills on all medicines for which
they cannot provide a prescription or current bottle (most of
> which are narcotics)?
>
> Isn't the system flawed when an evacuee says they
cannot afford a $3 co pay for a refill that will be delivered to them in the
shelter yet they can take a city-provided bus to
> Wal-mart, buy 5 bottles of Vodka, and return to consume them
secretly in the shelter?
>
> Is it fair to stop performing luggage checks on incoming
evacuees so as not to delay the registration process but endanger the volunteer
staff and other persons with the very
> realistic truth of drugs, alcohol and weapons being brought
into the shelter?
>
> Am I less than compassionate when it frustrates me to
scrub emesis from the floor near a nauseated child while his mother lies nearby,
watching me work 26 hours straight, not
> even raising her head from the pillow to comfort her own
son?
>
> Why does it insense me to hear a man say "I
ain't goin' home 'til I get my FEMA check" when I would love to
just go home and see my daughters who I have only seen 3 times this week?
>
> Is the system flawed when the privately insured patient must
find a way to get to the pharmacy, fill his prescription and pay his co pay
while the FEMA declaration allows the uninsured person to acquire free
medications under the disaster rules?
>
> Does it seem odd that the nurse volunteering at the
shelter is paying for childcare while the evacuee sits on a cot during the day
as the shelter provides a "daycare"?
> Have government entitlements created this mentality and am I
facilitating it with my work?
>
> Will I be a bad person, merciless nurse or poor Christian
if I hesitate to work at the next shelter because I have worked for 7 days being
called every curse word imaginable,
> feeling threatened and fearing for my personal safety in
the shelter?
>
> Exhausted and battered,
> Sherri Hagerhjelm, RN
Friday, September 26, 2008
Sunday, September 21, 2008
A Draining Kind of Day
Some days are absolutely draining, mentally I mean. Yesterday was one of those and I still feel absolutely exhausted even though it wasn't that busy.
My first patient was an incredibly ancient one who was cared for by family at home. She was brought in for 'weakness.' First of all, let me say how much I hate that chief complaint in the elderly. Weakness can be caused by a million different things - cardiac, stroke, UTI, pneumonia - so of course we have to do a long, complicated workup which, in this case, turned up nothing. There was nothing to admit her for so I called the family and told them to come get her. That is when the trouble began - they didn't want to get her, she was too much for them to handle anymore so they thought they would just dump her on us and let us handle it. This is a lot more common than you would think - apparently America thinks that the ER can fix any problem, medical or not.
So we had to get social services and discharge planning involved. The patient did not qualify for admission and if she needed to be placed the appropriate way to deal with this is to get her PMD to arrange that. Adult protective services got involved and ultimately the family was told to come NOW or face prosecution for abandonment. Arrangements were made with the PMD to get him to follow up with getting the patient into a SNF. This whole deal took HOURS to settle, not to mention two doctors, a nurse, a charge nurse, a social worker, an APS worker and two discharge planners. Ridiculous.
Then I had a psych patient who was on a hold that no one would take. He'd been in all the hospitals in most of California and been such a problem that none of them would accept him so we were stuck with him. How about a mandate from the government that forces psych facilities to take all the psych patients like EMTALA forces us to see everyone? How come they can pick and choose?
Anyway this guy was a complete dick. He was using the system to get a few hot meals and a bed for a couple of days - by saying he felt like killing himself. He didn't have a plan, he was well known for this and he was also positive for methamphetamine on his tox screen, what he really needed was a jail cell. He would not stay in his room so a security guard had to sit outside. He pissed on the floor, threw his meal tray at the wall and basically made life miserable for all. He also liked to scream obscenities- always pleasant for our other patients.
Then to make the day complete I had another patient, also incredibly ancient, with metastatic lung cancer who had no advance directive. Yep, you guessed it - the family wanted everything done. Instead of a pain-free, dignified death we got to torture him with needles and tubes and intubation etc so that he could live another couple of days in pain. Fabulous.
Thank God I have a few days off now, I'm going to need a little recovery.
My first patient was an incredibly ancient one who was cared for by family at home. She was brought in for 'weakness.' First of all, let me say how much I hate that chief complaint in the elderly. Weakness can be caused by a million different things - cardiac, stroke, UTI, pneumonia - so of course we have to do a long, complicated workup which, in this case, turned up nothing. There was nothing to admit her for so I called the family and told them to come get her. That is when the trouble began - they didn't want to get her, she was too much for them to handle anymore so they thought they would just dump her on us and let us handle it. This is a lot more common than you would think - apparently America thinks that the ER can fix any problem, medical or not.
So we had to get social services and discharge planning involved. The patient did not qualify for admission and if she needed to be placed the appropriate way to deal with this is to get her PMD to arrange that. Adult protective services got involved and ultimately the family was told to come NOW or face prosecution for abandonment. Arrangements were made with the PMD to get him to follow up with getting the patient into a SNF. This whole deal took HOURS to settle, not to mention two doctors, a nurse, a charge nurse, a social worker, an APS worker and two discharge planners. Ridiculous.
Then I had a psych patient who was on a hold that no one would take. He'd been in all the hospitals in most of California and been such a problem that none of them would accept him so we were stuck with him. How about a mandate from the government that forces psych facilities to take all the psych patients like EMTALA forces us to see everyone? How come they can pick and choose?
Anyway this guy was a complete dick. He was using the system to get a few hot meals and a bed for a couple of days - by saying he felt like killing himself. He didn't have a plan, he was well known for this and he was also positive for methamphetamine on his tox screen, what he really needed was a jail cell. He would not stay in his room so a security guard had to sit outside. He pissed on the floor, threw his meal tray at the wall and basically made life miserable for all. He also liked to scream obscenities- always pleasant for our other patients.
Then to make the day complete I had another patient, also incredibly ancient, with metastatic lung cancer who had no advance directive. Yep, you guessed it - the family wanted everything done. Instead of a pain-free, dignified death we got to torture him with needles and tubes and intubation etc so that he could live another couple of days in pain. Fabulous.
Thank God I have a few days off now, I'm going to need a little recovery.
Wednesday, September 17, 2008
The Moments when nursing school meets real world
ImpactED Nurse remembers being a new nurse and meeting the real world.
"And so I began to realize the difference between what we should do, and what we must do."
We are just finishing orienting this years crop of new nurses. It is always challenging to pry them away from their wide-eyed idealism and prepare them to practice safely in the real world. The world where you have more tasks than anyone human can possibly do so you have to learn to prioritize your time to meet the patients needs while somehow completing the mountain of paperwork that JCAHO has created. Paperwork that does nothing to improve patient care but has ensured that the nurse spends less and less time at the bedside where she is needed.
In nursing school a simple Foley catheter insertion may take 45 minutes to set up the sterile field and prep the patient without breaking sterility. In the real world it takes about 5 minutes.
In nursing school an IV set up and insertion can take nearly 30 minutes - in the real world it only takes about 10 minutes and if the patient is crashing- about 2!
In nursing school a sterile dressing takes 15 or more minutes - in the real world it takes less than five.
School teaches you all the necessary theory and steps so that you can safely and effectively cut corners and still achieve the same results.
This years graduates have made the long journey from wide-eyed idealists to competent, efficient nurses. Let's join together and welcome them to the trenches.
"And so I began to realize the difference between what we should do, and what we must do."
We are just finishing orienting this years crop of new nurses. It is always challenging to pry them away from their wide-eyed idealism and prepare them to practice safely in the real world. The world where you have more tasks than anyone human can possibly do so you have to learn to prioritize your time to meet the patients needs while somehow completing the mountain of paperwork that JCAHO has created. Paperwork that does nothing to improve patient care but has ensured that the nurse spends less and less time at the bedside where she is needed.
In nursing school a simple Foley catheter insertion may take 45 minutes to set up the sterile field and prep the patient without breaking sterility. In the real world it takes about 5 minutes.
In nursing school an IV set up and insertion can take nearly 30 minutes - in the real world it only takes about 10 minutes and if the patient is crashing- about 2!
In nursing school a sterile dressing takes 15 or more minutes - in the real world it takes less than five.
School teaches you all the necessary theory and steps so that you can safely and effectively cut corners and still achieve the same results.
This years graduates have made the long journey from wide-eyed idealists to competent, efficient nurses. Let's join together and welcome them to the trenches.
Monday, September 15, 2008
Why non-emergencies shouldn't be in the ER
Suburban Doc has a powerful post about the reason we aren't here to practice 'get it now, have it your way' medicine.
Saturday, September 13, 2008
How Low Can You Go?
Grandma has terminal breast cancer that has metastasized to her bones causing agonizing pain - she is in our ER tonight because her pain is out of control. She has a great oncologist who has prescribed her plenty of Morphine so why is her pain out of control? Because her grandson has been stealing her morphine and taking it to get high.
So tell me again how narcotic abuse doesn't hurt anyone.
So tell me again how narcotic abuse doesn't hurt anyone.
Thursday, September 11, 2008
Tuesday, September 9, 2008
Futile Care
Nursing home patient approximately 999 years old, give or take a year or two, full code of course, demented as hell comes in as we like to say FTD (fixin' to die.) She is dry as a bone, tongue looks like beef jerky. Her rectal temp is 95.1 degrees - an ominous sign, meaning she has been sick long enough that her immune response is all used up. Hypotensive with a BP of 63/37 and a heart rate of 172. She also weighed about 72 pounds. Loving family wants everything done.
NOTE: if you truly love your grandma/mom/aunt/sister etc. don't make us torture them to death performing painful, unpleasant and often undignified things to try to save them when their quality of life is zero to begin with. If you do - may you be damned to eternal hell.
We are miraculously able to get an IV in and begin some fluid resuscitation. We put in a Foley to obtain a urine sample and to measure urine output. I insert the Foley and at first nothing comes out, I am about to remove it - thinking it is in the vagina - when out oozes a thick, horrible smelling brownish red material that is so horrible smelling that it makes a couple of us gag.
She makes a slight improvement and we sent her to the expensive, oops! I mean intensive care unit where she died later in the day from overwhelming sepsis.
And the nursing home nurse wanted us to believe that she had been fine up until that morning.
NOTE: if you truly love your grandma/mom/aunt/sister etc. don't make us torture them to death performing painful, unpleasant and often undignified things to try to save them when their quality of life is zero to begin with. If you do - may you be damned to eternal hell.
We are miraculously able to get an IV in and begin some fluid resuscitation. We put in a Foley to obtain a urine sample and to measure urine output. I insert the Foley and at first nothing comes out, I am about to remove it - thinking it is in the vagina - when out oozes a thick, horrible smelling brownish red material that is so horrible smelling that it makes a couple of us gag.
She makes a slight improvement and we sent her to the expensive, oops! I mean intensive care unit where she died later in the day from overwhelming sepsis.
And the nursing home nurse wanted us to believe that she had been fine up until that morning.
Sunday, September 7, 2008
Remember the basics
We got a patient by ambulance awhile back that arrived with a police escort and in four-point restraints. He had been found laying in the middle of the road, screaming incoherently and became agitated and combative when the police tried to remove him from the road.
The police assumed he was a psych patient and/or on meth.
The EMS providers assumed he was a psych patient and/or on meth.
The ER nurse AND the ER MD assumed he was a psych patient and/or on meth. He was a transient and had never been in our ER.
The routine screening labs were done and some Ativan was given without much effect. About the time more sedation was going to be given the lab called with a critical value - the patient's blood sugar was 23!
1 amp of glucose was given and Viola! the patient was awake, alert, oriented and cooperative. It turns out he was a diabetic and had used his insulin as usual and was trying to beg enough money to get some lunch - the reason he was in the middle of the road.
Things are not always what they seem. Sometime new staff take everything at face value and forget the basics of ER nursing.
ALTERED MENTAL STATUS CAN BE HYPOGLYCEMIA UNTIL PROVEN OTHERWISE! ALWAYS CHECK A BLOOD SUGAR! It only takes a minute or two
The police assumed he was a psych patient and/or on meth.
The EMS providers assumed he was a psych patient and/or on meth.
The ER nurse AND the ER MD assumed he was a psych patient and/or on meth. He was a transient and had never been in our ER.
The routine screening labs were done and some Ativan was given without much effect. About the time more sedation was going to be given the lab called with a critical value - the patient's blood sugar was 23!
1 amp of glucose was given and Viola! the patient was awake, alert, oriented and cooperative. It turns out he was a diabetic and had used his insulin as usual and was trying to beg enough money to get some lunch - the reason he was in the middle of the road.
Things are not always what they seem. Sometime new staff take everything at face value and forget the basics of ER nursing.
ALTERED MENTAL STATUS CAN BE HYPOGLYCEMIA UNTIL PROVEN OTHERWISE! ALWAYS CHECK A BLOOD SUGAR! It only takes a minute or two
Why Can't Johnny Spell
I am troubled by how many of our patients are functionally illiterate. In my ER the patient fills out a half-slip of paper that they give to the greeter with their name, reason for visit and primary doctor. Some samplings:
staff infeksion
stomack ake
spazzms
amonia
How is it possible in a nation with billions of tax dollars spent on education so many Americans cannot read or write properly?
What is even sadder is that many of those that are illiterate are on welfare or disability - which came first? Are they unemployable because of their illiteracy or were they too lazy to work in school or in the real world?
staff infeksion
stomack ake
spazzms
amonia
How is it possible in a nation with billions of tax dollars spent on education so many Americans cannot read or write properly?
What is even sadder is that many of those that are illiterate are on welfare or disability - which came first? Are they unemployable because of their illiteracy or were they too lazy to work in school or in the real world?
Wednesday, September 3, 2008
Wild Morning
We had 5 different law enforcement agencies bring in 6 people (one officer brought in a two-'fer) five different times for medical clearances and legal blood alcohol draws between 0917 and 1104 today.
How come we didn't get invited to the party?
How come we didn't get invited to the party?
Tuesday, September 2, 2008
I Refuse to Leave
I'm orienting a new nurse, he's very smart and will make a great ER nurse someday but is still filled with the sweetness and light that they instill in nursing school and it is hard to watch his shining idealism take a daily pummeling.
Take for instance today, we had a patient who lived 45 miles away and had bypassed 4 other hospitals to come to our ER for treatment of their chronic back pain. RED FLAG! I don't care what lame ass excuses you give us - if you passed up 4 other hospitals we will immediately assume you have worn out your welcome at the other three. Sorry but that is just the way it goes, normal people don't drive long distances for no reason when there are other hospitals, clinics and urgent care facilities with in easy reach.
So the initial story was that the narcotics had been stolen but no, the police had not been notified. I offered to call the police so that a report could be made and the story changed. The doctor offered a small dose of narcotics if the patient could produce a ride. Multiple stories we given about rides coming that never showed up. I sent him to the waiting room to find a ride and told him to let the greeter know when he had one. A little while later the greeter called to tell me that the patient had a ride so I brought him back to the room. I was questioning the woman that he brought in when I started getting a funny feeling about how she was acting. When confronted she admitted that she didn't know him but had been offered $20 to say she was his driver. At that point I confronted the patient along with the doctor and the patient was told to scram. He refused.
My orientee stood by, wide-eyed, as our off duty police officer came to escort the patient from the premises. Instead of going quietly like a reasonable person would when faced with a six foot, four inch armed police officer he put up a fight. Next thing I know the patient is being tasered in the middle of the ER hall, four cop cars show up code three and the patient, I mean prisoner, is subdued, hog-tied and taken to jail, screaming profanities and spitting all the way.
Drug seeker-1, Wide-eyed idealism-0
The sad thing is that we in the ER face these situations on a regular basis. These drug addicts easily obtain narcotics from various doctors, clinics and ER's. They quickly become addicted and they visit more places to obtain more drugs. Slowly they find themselves cut off from source after source. Increasingly desperate they become dangerous to us, not all ER's are as fortunate as us to have off duty police in the department. In addition to being a threat to our safety they divert resources away from the truly ill and cost the taxpayers billions in health care dollars for unnecessary visits.
Sad, isn't it.
Take for instance today, we had a patient who lived 45 miles away and had bypassed 4 other hospitals to come to our ER for treatment of their chronic back pain. RED FLAG! I don't care what lame ass excuses you give us - if you passed up 4 other hospitals we will immediately assume you have worn out your welcome at the other three. Sorry but that is just the way it goes, normal people don't drive long distances for no reason when there are other hospitals, clinics and urgent care facilities with in easy reach.
So the initial story was that the narcotics had been stolen but no, the police had not been notified. I offered to call the police so that a report could be made and the story changed. The doctor offered a small dose of narcotics if the patient could produce a ride. Multiple stories we given about rides coming that never showed up. I sent him to the waiting room to find a ride and told him to let the greeter know when he had one. A little while later the greeter called to tell me that the patient had a ride so I brought him back to the room. I was questioning the woman that he brought in when I started getting a funny feeling about how she was acting. When confronted she admitted that she didn't know him but had been offered $20 to say she was his driver. At that point I confronted the patient along with the doctor and the patient was told to scram. He refused.
My orientee stood by, wide-eyed, as our off duty police officer came to escort the patient from the premises. Instead of going quietly like a reasonable person would when faced with a six foot, four inch armed police officer he put up a fight. Next thing I know the patient is being tasered in the middle of the ER hall, four cop cars show up code three and the patient, I mean prisoner, is subdued, hog-tied and taken to jail, screaming profanities and spitting all the way.
Drug seeker-1, Wide-eyed idealism-0
The sad thing is that we in the ER face these situations on a regular basis. These drug addicts easily obtain narcotics from various doctors, clinics and ER's. They quickly become addicted and they visit more places to obtain more drugs. Slowly they find themselves cut off from source after source. Increasingly desperate they become dangerous to us, not all ER's are as fortunate as us to have off duty police in the department. In addition to being a threat to our safety they divert resources away from the truly ill and cost the taxpayers billions in health care dollars for unnecessary visits.
Sad, isn't it.
Monday, September 1, 2008
The Future as portrayed by PIXAR
I went and saw Wall-E, very cute BTW. I got a good laugh out of the humans which are portrayed as hugely fat, spending their days on special floating chaise lounges equipped with a TV screen that sits right in front of the persons field of vision and a cup holder for their GIANT sized cups of liquid food. Their feet, never used, have dwindled away to practically nothing because they have lost the ability to walk.
I did a Google search to see if I could find a picture and instead I found a lot of controversy over the films portrayal of fat people. It seems a lot of people took offense to PIXAR's portrayal of these future humans.
Get real. We are already a nation of fat people, what exactly do we think the future holds? I'm one of the fat, I'll be one of the first to admit it. And I know exactly why I'm fat - I like to eat, have no will power and don't like to exercise. I'm not going to blame society, hormones or stress, the shape I'm in is my fault and I'm very honest about that.
When I was a child a large soda was 16 ounces. Now a large is 48 ounces or more - many people suck down 2 or 3 of those a day. Soda has an average of 100 calories per 8 ounces, that adds up pretty quickly. Remember when you went to McDonald's and got a regular cheeseburger, small fries and a 12 ounce soda? Now you have the Double quarter-pounder, the extra large fries and the 32-ounce soda. Our society has become super-sized and the consequence is a dramatic increase in hypertension, diabetes, back problems, joint replacements and all the other medical and physical problems caused by obesity.
In health care it used to be rare to see a patient over 300 pounds and now we see them routinely. Weight loss surgery is in such high demand it is many hospitals new cash cow. Type two diabetes is being seen with increasing frequency in children!
So the funny fat people on Wall-e? All too possibly a portrayal of our future, sad but true.
I did a Google search to see if I could find a picture and instead I found a lot of controversy over the films portrayal of fat people. It seems a lot of people took offense to PIXAR's portrayal of these future humans.
Get real. We are already a nation of fat people, what exactly do we think the future holds? I'm one of the fat, I'll be one of the first to admit it. And I know exactly why I'm fat - I like to eat, have no will power and don't like to exercise. I'm not going to blame society, hormones or stress, the shape I'm in is my fault and I'm very honest about that.
When I was a child a large soda was 16 ounces. Now a large is 48 ounces or more - many people suck down 2 or 3 of those a day. Soda has an average of 100 calories per 8 ounces, that adds up pretty quickly. Remember when you went to McDonald's and got a regular cheeseburger, small fries and a 12 ounce soda? Now you have the Double quarter-pounder, the extra large fries and the 32-ounce soda. Our society has become super-sized and the consequence is a dramatic increase in hypertension, diabetes, back problems, joint replacements and all the other medical and physical problems caused by obesity.
In health care it used to be rare to see a patient over 300 pounds and now we see them routinely. Weight loss surgery is in such high demand it is many hospitals new cash cow. Type two diabetes is being seen with increasing frequency in children!
So the funny fat people on Wall-e? All too possibly a portrayal of our future, sad but true.
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