Thursday, October 23, 2014

I have become a part time psych nurse

I wonder why nobody seems to care about mentally ill patients? It is evident in the fact that patients are being housed in emergency rooms because there are no beds available. That's happening in our ER.  It has now become routine to house people for hours, sometimes more than a day.

Funding has decreased for mental health, so patients don't have access to services on an outpatient basis. Just like physical illness, if your condition isn't managed it gets worse and becomes a crisis and sends you to the emergency room.

There are less psychiatrists.  Apparently they aren't paid as well as they used to be, especially in hospitals.  The profession is less attractive because most psychiatrists have essentially become medication managers rather than the therapists they used to be.

Reimbursement for psychiatric patients is less than those who are physically ill making hospital reluctant to increase bed space.

I don't see any of the above changing anytime soon. So the situation will get worse.  We will be part time psych nurses trying to manage patients for hours on end, sometimes overnight and beyond. Patients will lay there with nothing to do, getting more agitated because of it.  They will get bad care because we don't have time to care for them. Our wait time in the ER will increase because there are times when 30% of our beds are occupied by psych patients.  It is more dangerous for the staff because after sitting for hours, sometimes these patients get agitated and start acting out and become violent.

So ERs have become part time psych wards and I have become a part time psych nurse.

Tuesday, October 21, 2014

nurses have perverse sense of responsibility and loyalty

The administrators at Dallas Presbyterian where the ebola patients have been treated are scrambling. From what I have read only 30% of the hospital is full.  It seems nobody wants to come to a hospital which fumbled so badly.  Can't say I blame them.

Well, everybody knows that a hospital can't survive at 30% so its panic time. It is time to trot out the nurses who are willing to be on TV and say what a wonderful place our hospital is, led of course by the head honcho nurse at the hospital.  They held a press conference praising the hospital essentially saying that those damn radical nurses who said we weren't prepared are wrong, wrong, wrong.  We are a great hospital, so there. This is essentially like saying to someone who is going to intentionally harm you: Its OK, I love you anyway.

Unfortunately, this kind of behavior is typical for a lot of nurses. Oh, the poor hospital, they tried their best, they didn't do it on purpose. Instead of standing up for ourselves and demanding that we be protected, we say to ourselves they are doing the best they can.  Then we go forward and put ourselves in harms way because we are so wacked we are willing to sacrifice ourselves out of some perverse sense of responsibility and loyalty.

Will this hospital recover? They are apologizing profusely left and right. They are shitting their pants about law suits, because they know they will be filed.  They are already mounting their defense. I saw on the internet that the CDC said they were following their protocol, now the CDC realizes that it was inadequate. Our bad, not the fault of the hospital.

Dallas Presbyterian is finished. This will bankrupt them. The public won't forget this for some time.  When they do, it will be too late, the hospital will be closed.

Dear Mr. hospital administrator: you know that ebola patient at the triage window? Good luck with that.

The thing about the ebola crisis is that nurses are at the mercy of hospitals that worry more about the bottom line than they do their own workers. They are playing the odds.  What are the odds that a patient will come into our hospital?  Near zero. Therefore, we won't spend the money on training and isolation suits that are needed.It would be a waste of our money.  We will cover our butts by saying we are "following CDC guidelines".

We will make the training voluntary. We will tell the staff basically: all you have to do is put the patient in isolation and all of our experts we have on call will come to your area and take over. Never fear. We got this.

So here is how I interpret this: When the patient appears at the triage window, I give them a mask to put on. I take them immediately to the designated room.  On the way to the room, I get their name and birthdate. I put them in the room.  I put them in the computer.  Then I call the hospital experts and wait for them to come. I note in the computer that the patient  has no respiratory distress, able to walk independently to room, etc.  In other words, they aren't near eminent death.  I also note that they have been placed in the room and experts called per protocol.

Then we wait, because if you think that I am doing anything beyond that, you are fooling yourself Mr. hospital administrator.  If you aren't going to train me and give me proper equipment, that will be the extent of my involvement.  Good luck with that.

Sunday, October 19, 2014

bedside nurses are the experts on how to safely care for a patient with ebola

It turns out Thomas Duncan sat in the emergency department for 30 hours. More than a day. Despite the fact that the second time he came in they immediately knew he had come from Liberia. They isolated him. He sat there for 24 hours before they even did an ebola test.  Then it takes 4-6 hours for that to come back. Did the hospital have the capacity to do the test?

I'm trying to think of why it took so long for the ebola test..  My only conclusion is the doctor didn't think that ebola could have possibly come to the United States, so they weren't thinking in terms of ebola.  They thought of other things, did labs, CT.

So I'm sure that this guy was treated as a typical, perhaps, contact precautions. Since he had no respiratory symptoms, droplet precautions were probably not used.  So that means paper gown and gloves.  Thats it.

As an ER nurse, I'm thinking about what happened in the ER.  Did his nurse have other patients? I have a feeling they did. This guy was sick yes, but not sick enough to be one to one if they weren't treating him as an ebola patient.  No doubt several nurses took care of him over the course of 30 hours. They went in and out of the room many times.  Lab drew his blood, no doubt no special precautions were taken.  He had a CT. He had to go through the halls to CT. He contaminated the CT machine.

No one has talked much about the emergency department part of this. The focus has been on inpatient care because that is where the nurses have become ill.  It is miraculous no ER personnel have not become sick. Little attention has been paid to what should happens when someone shows up at the triage window with symptoms and recent travel.

Most emergency rooms are congested tight spaces.  Mine sure is. My first thought with all of this was: where would we take off the isolation gear?  Not in hall, thats for sure.  Fortunately, my ER has figured out a place with more room to put this patient, with an area outside that could be used for removing gear.

These are the kind of small details that have to be thought of. You can't have an ebola patient in the middle of a busy ER. Would we shut down the ER?  Would we allow other patients to keep coming in? The public would want to know if there was a potential ebola patient in their midst. Do you keep a potential ebola patient in the ER until they turn up positive?  Or do you immediately put them in ICU?  Is ICU ready?  Do they have an area that is empty?  Do they have the equipment ready?

There are a lot of questions. The problem with this is that the people in charge are not the ones who care for patients. They do not think of the details of patient care that we deal with every day.  Bedside nurses should be involved in preparing for something like this.  They aren't.  This is typical of medicine.  All of the daily changes to our practice are decided by people who haven't cared for patients in years. That fact is what makes working as a nurse more and more difficult. This is just one more example.