spring in the hood

I saw 5 eagles soaring together round and round over the mississippi river today. I am going to take that as a good omen and signal that winter really is coming to an end.

Meanwhile back to the hood, where the hood rats are out in full force shooting at each other. Its like a rite of spring. Four shootings in the last couple of days. Two ended up in our ER, one died. Somebodys child, perhaps somebodys parent. Somehow the one who didn't die, but was shot, managed to drive the two of them in by car from about 6 blocks away. We lock down the ER in this situation, not knowing its gangbangers or if they are coming to the hospital for revenge. I have the feeling its gonna be a long summer

oh no you can't order that CT

Well it seems that if docs cannot regulate their use of such things as CT scans, the government is going to do it for them. For example, CMS (Center for Medicaid and Medicare Services) has decided that CTs ordered for nontraumatic headaches will not be paid, and in the future MDs may be financially penalized for ordering what they deem as unnecessary.

Another sign of the coming crash and burn of the healthcare system. There are three players in the coming meltdown:

1) Government and insurance payers who are starting to refuse to pay for what they deem as unnecessary tests.
2) Doctors who say they have to order such tests in order to avoid potential liability.
3) Patients who expect expensive tests to be done.

Radical change is coming, no doubt about it. Without it, the government will go bankrupt with healthcare costs and insurance premiums will become unaffordable. Malpractice awards will have to be limited or doctors are just going to have to deal with assuming more risks. Patients expectations will have to be drastically lowered.

In the end, government and insurers will drive change because, bottom line, they pay the bills. Its time for doctors to accept the changes coming to their practice. The fact of the matter is the days of docs ordering any test they want are gone. Their autonomy is decreasing. Its reality. You can accept it, work with it, be part of it or not. Research based medicine is the future.

Now don't even get me started on all the ridiculous MRIs being ordered in the ER...

wasting away in frequent flyerville

A small town hospital in my state decided to do something about the bane of every ER nurses life: frequent flyers. The ones that come up to the triage desk and you tell them to have a seat in the lobby, you don't need their name because it is etched in your brain.

Anyway, this hospital decided to hire a social worker whose job it became to identify these people and work with them to decrease their visits. She started with 24 people and reduced their visits from 294 to 178 in a years time. Saved almost 300,000 dollars. Many of the people had untreated mental illness or stress related problems, were unemployed or homeless. She hooked them up with psychiatrists or social workers, etc.

Why doesn't every ER do this? Sometimes I think that the hospital doesn't want them to stop coming. Medicaid money is better than no money I guess

UNCLE

UNCLE. Okay? UNNNNNNNCCCCLLLLLLLEEEEE!!!! I have been defeated. By this winter. I can't take it anymore. A few days ago the snow was melting, heading toward being gone. Then we had another annoying few inches which due to the cold temperatures remains on the ground. It has again covered everything. I am waving the white flag. Surrendering as it were. Okay winter you have defeated me. I give up.

I have lived here all of my oh so many years and this year did me in. It has gone on forever and I don't think its ever going to end. It may be permanent. It has made up for the last few winters that have been mild and had us saying hey maybe our winters are changing.

So I will be under the covers, feeling sorry for myself, and I won't come out until its all gone and I see tulips..

the day Joe died

Welcome to the wonderful world of drug abuse. Average intellectual requirement: that of a gnat.

One day a gnat surfing the internet, talking to the other gnats, hears about a new dope that will blow your mind, bend you into a pretzel, "you gotta try this man....." Somehow the gnat comes up with the scratch to order it on the internet from China or Vietnam or someplace. Once he gets it, he thinks to himself: hey I think I'll have a party and invite some of my other gnat pals.

So the day arrives and here come his gnat pals. A course his buds are down with the dope, in fact they can't wait to try it. They snort it. Some mix it with their Jack. We got us a Lucy in the Sky with Diamonds situation on our hands. Damnnnn this shit is great! shouts one of the gnats. Hey wait a minute whats wrong with Matt? He don' look so good. Shit he's having a seizure! MATT! Are you okay man!? Shit i'm outta here! Matt ain't the only one having problems, Sheila and Joe don't look too good either...One of the gnats calls 911. EMS and the cops get their and Matt is taken to the ER. He dies in the hospital. Sheila and Joe are in critical condition. The police round up the other gnats and they go to the ER too. In all eleven people go to the hospital.

The gnat who bought the shit? He's in jail with various charges, no doubt one of which will be negligent homicide at the very least. The other gnats will survive. They will be alive to mourn the death of their friend Joe, who by the way, had a son. The drug: 2CE. This happened in the last couple of weeks where I live.

assinine policy #456

Brilliant policy number 456: Thou shalt put all patients who are on cardiac monitors on a portable monitor who have to leave the department for CT or xray and have them accompanied by a nurse. A nurse with portable monitor shall acommpany any patient being admitted to their room post haste. This is thine edict from above henceforth from this day.

The scathingly billiant designers of our ER decided when they renovated 20 years ago to have our patients be on hardwire connected to the monitors. In other words, there is no tele pak. Now xray does not want wires on the patient especially for CXR because they will interfere with the picture. So that won't exactly fit with the put on monitor to go to xray or CT.

So you are telling me that a couple of nurses will be gone from the department with their patients in xray leaving the other nurses to watch their other patients. Makes sense to me. Nurses will also be gone transporting their patients to tele floors.

Xray and tele are across the hall from the ER. We have always removed the monitor from stable tele patients while they spent the 5 minutes in xray or CT. We have also sent stable tele patients up to their rooms with non nursing personnel. But no more....Joe Smith might have a PVC or something.

More assinine changes by those who don't actually DO the job. Of course all of this has to be done with the same amount of nurses. Guess I'll have to take less patients and that things are going to slow down to accomplish this task...how does your ER handle this?

twas a dark and stormy night...

This really isn't funny, and yet it is. Out at the triage desk are business cards and one set is one for our manager. So a not normal (!) person comes in and goes to a room that, shall we say, is not set up for normal (!) people. In other words, its a bed, a chair and not much else..

So said person is unhappy with the whole ER experience and the fact that alas, the ER staff does not have time to sit and listen at length to their tale of woe. Said person requests the complaint department. Well, as we all know, the complaint department has bankers hours. So said unhappy, woeful person is given the managers card.

So said person, clever and devious person that they are, notes the managers beeper number on the crisp, white card and proceeds to page the manager on with their cell phone. Did I mention it is 1:00 AM and manager is fast asleep no doubt dreaming up ways to make the staffs lives miserable (hahaha). Oh but manager, being the upstanding executive that they are, calls back and talks to unhappy, woeful ER patient. Reassures them, does that manager thing they do...everybodys happy right? Oh you foolish foolish reader...

Unhappy, woeful ER patient proceeds to call manager 3 other times during the night. And yes, upstanding managers call back to listen to unhappy, woeful ER patient every time. Now why the ER staff did not take unhappy, woeful patients cell phone, I don't know (some kind of bizarre payback...). Why the manager didn't ignore other calls I don't know. Now manager really isn't a bad person. I actually like them. I think they have the best interests of the ER and its staff at heart. Even manager does not have to go this far to please unhappy, woeful ER patient. The end

the wacko factory

You know you are having a bad charge shift when you finally get to dinner two hours before the end of your shift and a patient dies while you're at dinner. Now mind you the patient was a DNR, but still...when they came in they were alive.

You know you will have a bad shift when you are walking past triage and a perfectly healthy young patient is on the phone trying to get a free cab ride home paid for by medicaid. They wave me over. I am barely awake. I said "what". This charming young hood rat proceeds to call me a "RUDE ASS!" several times over...

You know you are having a bad shift when you are starting an IV and have to listen to someone who you know, from past experience, is a complete wacko, tell you about their imaginary life in which they are going to school to be a nuclear physicist, have met the president, etc. Yeah...okay...right...

You know you are having a bad day, when every other patient is a frequent flyer migraineur, fibromyalgic, back pain entrepeneur, bipolar PTSDer.

Oh and by the way, we're down 2 nurses and staffing don't have nobody..

don't hire smokers

I never have smoked. I really can't stand smoking or smokers really. It is all gross. I don't want to have to deal with breathing in your cigarette smoke. Honestly I think smokers are losers.

So now a Michigan hospital has decided not to hire smokers. Yeah for them. Smokers stink even if they smoke outside, they carry it inside with them. They stand outside the hospital looking like fools in below zero weather. Makes the hospital look bad. They take a lot of breaks. I have lost two coworkers to cancer in the last few years. Both were heavy smokers.

Two things irritate me about smokers. Now that they have been banned inside buildings, they stand outside, and you have to walk through a cloud of smoke to exit buildings. If you want to sit outside and eat at a restaurant, they take up the tables and make everybody miserable. I'm tired of looking at groups of these losers standing outside buildings.
The
Lets face it, if you are a smoker, you are becoming a leper. Smokers are addicts like any other addict. The difference is they are legal addicts. THey should have no rights. Their habit affects others. Secondary smoke kills other people. They should be viewed no differently than a crack or heroin addict.

the "standardization" of the CORPORATE "system"

I have been working at my hospital for a lot (LOT) of years. When I started back in the stone age, the hospital was a single hospital on its own. As years progressed it affiliated with other hospitals and went through a lot of name transformations. Soon it became a CORPORATION. It began operating like a CORPORATION.

Now I feel like I am a factory worker and the patients are widgets. In the last few years there has been a lot of "standardization" across the "system". What does that mean? It means that they want all the hospitals to be using the same products, doing the same things in the same way.

What brought these thoughts on you ask? I recently read a memo in which the CORPORATION has instituted in one hospital, with plans to "standardize" it across the "system", a uniform policy. All staff will have to wear a standard uniform. What's next a standard haircut? A standard hair color? Perhaps we should all parrot the same lines. Perhaps they could just clone us...

What is being lost in this CORPORATE environment of "standardization" and "systems" is the human element in medicine. Employees are human, patients are human. They really can't be "standardized" into a CORPORATE "system". Apparently administrators are "standardized" non humans who are thrive in a CORPORATE "system". How long til I retire?

Médecins Sans Frontières

I wonder what its like to be going along in your everyday life and then all of a sudden your town looks like somebody dropped a bomb on it. People you knew have died. Everything you have is destroyed including your house. Your job is gone. You have nothing but the clothes on your back. You have no food, no shelter. And its the middle of winter. Your kids are terrified. Every few hours there is another aftershock so you can't sleep. I wonder what its like..

My thoughts and prayers are with the people of Japan. If you are looking to donate to an organization that helps with medical care in situations like this, here is a suggestion: Doctors without borders It is a truly remarkable organization.

madness gets a dog

Well I went out and bought a dog for the blog. Named it gomer. See him over on the right? Gomer doesn't really seem to bright, but he's lovable. Go ahead and play with him. You know you want to. Give him a good ear scratch before you leave. He likes that.

no room at the inn

It has been so damn busy lately. In the last couple of weeks there have been basically no ICU beds. Its the ICU shuffle goin' on. The ICU shuffle is called who is the least critical of the ICU patients, and really shouldn't be moved out, but is the least likely to crash. Of course all of these decisions take hours. So the critical patients sits in the ER waiting for all this shit to be decided.

The alternative to sitting in the ER for hours is doing a bunch of interventions in the ER that imrove the patient and they can be downgraded from ICU to tele. That's going on too.

The last couple of days, there have been no med/surg or tele beds either. So everybody be sittin' in ER. Of course there are no additional staff in the ER to care for all these sittin' patients. The doors are still open and people keep coming. It is so bad that we have been going on divert for four hours (the mas) to ambulances, going off for four hours, going back on.

It has got to the point where there isn't even a code bed in the hospital and the ER IS the code bed. We have had a patient who coded on tele come to the ER because there are no ICU beds.

Here is my thought:
1) With the nursing negotiations last year and the bad economy, the hospital has not, until recently, hired nurses. The hospital is short staffed.
2) The hospital wants to try and manage with less nurses and so when there is a upswing in census everybody, especially the patients, are screwed.
3) The hospital are always reactive to this kind of stuff. Rather than having a sort of "crisis team" that meets in situations like this, thinks ahead about dealing with it, it waits til its a crisis point and then panics and does stuff. Seems like it wouldn't be that hard to have a plan in place.

Because hospitals are competitive with each other, there is no cooperation about managing these surges in patients and perhaps distributing them among hospitals, etc. Oh no, can't do that. This kind of thing really is a disaster type situation. When you have critical unstable patients sitting in ER for hours, making the ER staff short, that is a disaster. Perhaps we should start declaring an internal disaster to deal with it. Are you seeing a surge in patients lately?

will doctors become obselete?

Always a source of amusement, KevinMD, recently wrote one of his commentaries on why doctors are increasingly ordering more and more tests. He basically says that because of the easy access to medical technology (i.e. CTs, MRIs) and the fact that young doctors have grown up and learned with said technology, they have come to rely on it for diagnosis rather than on physical exam.

He sites an article in Time.com, written by a couple of doctors in which they state:
"Another reason for overtesting is simply that new doctors can't function without them. Lately, radiology tests have become a crutch: doctors in training are no longer taught how to distinguish patients who need testing from those who don't."

Another juicy quote from the same article: "There is actually a more subtle positive incentive: ordering a test — cost aside — takes less effort than spending the time to think about whether it's really needed."

Here is my thought: If so little critical thought goes into what could really be going on with the patient, and care is based on a symptom that triggers a certain test, why do we need doctors anymore? Surely someone who makes a lot less money, or a computer, could make decisions about ordering tests. An algorithm could be made in which symptoms are presented to a cheaper employee or computer, and a set of tests are ordered. Based on the results of those tests a diagnosis is made. Makes sense to me. Are doctors becoming obselete?

the doctor won't see you now

I was reading over on another of my favorite blogs: you can't fix stupid, about wait times in the ER and triage and such. In it she talks about one of my pet peeves: doctor signs up for patient to make the door to doc time look good, but doesn't see the doctor for an hour and a half. It is just another example of the bullshit that goes on in medicine. Who is in the middle of this exercise in stupidity, 3 guesses, me. Patient wonders where the hell doc is and I have lie about why they aren't seeing them.

She mentions that the scribes (doctor gofer and charter) sometimes sign the docs up when the patients are still in triage. Please God don't let our docs think of this...We already have one energizer bunny doc who sometimes comes out to triage to try and get the patients. Or he is standing in the doorway when we go to put the patient in the room. You might think that this is the doc being efficient, etc. but its about one thing: M-O-N-E-Y. The more patients they see the more money they make.

This what medicine has become folks. There is more emphasis on statistics and documentation than there is on patient care. If you are good at filling in boxes and blanks, you will go far.

is the world coming to an end?

What is happening in ER land? Things have changed in the last few years. Normal people don't seem to come to the ER anymore. Now when I say normal, I mean healthy people who are having some kind of problem like a broken leg or appendicitis or something like that. You know, people who are living a normal life and something happens to them that is an actual emergency. They seem to have found somewhere else to go. The demographics of the ER have changed. Here are examples of patients we get nowadays:

1) tragic tommies: quadriplegic on a vent with a colostomy, foley, portacath who has decreased LOC

2) nellie nursing home: elderly females who are demented who have developed decreased LOC

3) frannie fibromyalgia: middle aged females who have fibromyalgia, chronic fatigue, some kind of weird immune disorder, borderline personality who has decreased LOC (just kidding). Usually these people are there for some kind of pain somewhere in their pain riddled body.

4) hood rat richard: uses the ER as a clinic for STD, back pain, post MVA fender bender potential personal injury lawyer settlement bonanza.

In other words all of these people people (except hood rat richard who will probably warrant at the very least c spines) will usually get the 50,000 dollar ER work up special:

Lytes
CBC
troponin
UA (usually cathed)
CT
EKG
IV
meds
CXR

Where have all the normal people gone? Do they go to urgent care? Are they just not coming because they lost their job? Have they moved to Mexico? Are they in jail? Are they travelling the country warning of the end of humanity May 21, 2011? NORMAL PEOPLE WHERE ARE YOU????!!!!!

read new nurse in the hood

Here is a blog that I read daily. I wish she wrote daily because she is a good writer and I look forward to her blogs. Go visit new nurse in the hood.

the dichotomy of the ER

You can't move anything. Well maybe your eyeballs. A machine breathes for you. You can't talk. You are vulnerable and alone inside this body that doesn't work anymore. You used to run and laugh and frown and smile. Now you can do none of that. And the thing is you are a baby, as far as adults go.

This is your life now. Completely dependent on others. You must hope those who care for you are having a good day. You are one of the lucky ones, not in a nursing home. I wonder what your life is like. I wonder if you enjoy it. I wonder what you think about all of this.

I have thought of you since that day. Wondering about you. Thinking you didn't deserve this. Once you were a kid full of hope and joy. Then you grew up and drifted toward people who made you feel like they were your family. Then you caught a bullet and here you lie. I wonder what you could have been.

"Hey madness, the guy in bed 3 with the stubbed toe said he needs something for pain."

dirty snow

I feel most uninspired these days. It really is the dregs of winter up here. The snow is dirty, the sky is overcast and the world is in black and white. It has been a long winter. April is coming. Here's one of my favorite songs, appropriate for the times we are living in:

the madness guide to happy ER nurses

As y'all know I have been a nurse for MANY (many) years, mostly in the ER. Working in the ER is stressful and gets more stressful every day. Zillions of changes, mean patients, you name it.

How, you might ask, how have I lasted this long? Money. However, I would say the major factor in me staying in the ER, other than my innate need to help humanity (!), is FLEXIBILITY. In our ER, we do self scheduling. We decide when we want to work and hand it in to someone who somehow manages to make everyone happy. We do it by work clusters. The person (another staff nurse)who does our schedule works the same hours as me (9a-9P) and so do the people he makes a schedule for. Every work cluster (7a-7P, 3p-11p,etc) does the same thing. Somehow it all works out.

95% of the people in my ER work 12 hour shifts. There are no rotating shifts. Everybody works a straight shift including nights. This allows more days off.

I have come to the conclusion that in order to survive in an ER, you have to have at least 3 days off in a row, if not more, in a month. Most months I end up with 5-6 days off in a row. As I plow through the other part of the month, I look forward to the time off as a way of coping with the job.

After all my years in the ER, I have concluded if you want to last, you have to have these stretches off. 1-2 days doesn't do it. Day 1 of days off is spent recovering from working the last 2-3 days and decompressing from the job. Day 2 is when you start to forget about it, unless you have to go back to work the next day. Then you really never decompressed. I have the kind of job where the day before I am going to work I can feel myself ramping up to go back. So the day before a work day and the day after are sort of lost.

So managers, if you want happy, long term employees I recommend this:
1) Offer 12 hour shifts
2) Offer straight days, nights, evenings with these 12 hour shifts
3) Let your employees self schedule

This might seem like it would be impossible but it works. It has worked for many years in my ER.