the times they are a changin'

What an insightful article by Dr Gary Oftendahl on Kevin MDs blog. I don't often give docs credit (har har har), but his article is very interesting.

He makes a couple of very good points:
1) Those of us in medicine have ingrained ideas often taught in our training.
2) If it really hard for docs to give up the idea that they are "special" (his words) because that is what they are told by society and taught in training.

When you are in school and in training for medicine naturally there is a standard way of doing things,a standard of how the practice should be set up and take place. It couldn't be any other way because there are too many too teach. You are not taught to be open minded about medicine and the way it is practiced. You are not taught to "think outside the box". You are not taught flexibility and openness to change.

Here's the thing: As we all know, change is a constant in medicine. Health care moves faster and faster every day. Either you go with it or you are left behind. For the most part, we all accept that. The daily changes. We have a harder time with the flexibility and openmindedness required for the inevitable big changes that have come and ARE coming. Our role within medicine as different groups - doctors, nurses, techs, etc. may change drastically as medicine changes. Naturally we resist this. We want to have control over our professions. We fear irrelevance. The thing is I doubt that 20 years from now we will even recognize the medicine that we practice today. That is how big the change willl be.

Doctors have always been revered in our society. They have been put on a pedestal, rightly so I suppose, after all they are healers. They have been tagged special because of their position. They have, up until the last couple of decades, controlled medicine. Those days are gone. They aren't coming back. The fact of the matter is cost will control medicine in the future. Patients will control medicine. Hospitals are already catering to what patients want. This consumer (patient) controlled aspect of medicine will only expand.

Doctors are going to have to come down off of their pedestals. Sorry. They are going to have to realize that they are a PART of medicine, not the controlling factor in medicine. Right now doctors (and a whole lot of nurses and others) are resisting change. We will all have to be open and flexible and embrace change if we want a voice, otherwise the decisions will be made without us.

patience may be a virtue but I never was virtuous

What is worse than being a nurse having a family member in the hospital in critical condition? What is worse than having some knowledge about what is going on and having a family member in critical condition?

It feels like doctors don't really want to tell you much. They come in, tell you why things are the same as they were yesterday, blah blah blah. You want to grab them and shake them and say: WHAT THE HELL IS REALLY GOING ON HERE??!! But you can't. You will become the problem family. The nurses will hate you.

As a nurse it is hard not to second guess all that is going on. You see all the stuff, you know what it is, why its there. Every time you come in the room, you quickly asses what has changed. Okay IVs no change. Check. Vent settings - something changed - WTF?

I tell them I am a nurse from the beginning. I don't want to play games. I figure maybe the nurse will let me in more on things. But whats weird is nurses tend to parrot what the doctor wants you to hear: We have to be patient, we are making progress a little at a time, blah blah blah. I guess they have to. Everybody has to be on the same page.

I know there are nurses that come into a situation like this and they are like a bull in a china shop, questioning everything, judging everyones abilities, etc. There isn't any point in that. They really are doing the best they can. One thing that has struck me about the nurses is how kind they are, how nice they are. They care. That helps more than they will ever know. You know that if they are kind to the family you know they will be kind to my loved one. Nurses make all the difference.

a mispent youth

Lately I have been spending a couple of hours a day sitting in an ICU room in another hospital. I used to work in this hospital as a cherubic youth, oh those many years ago when I started college out of high school.

I was a dietary aide. Then I was a nursing assistant who swore she would NEVER be a nurse. I didn't want anything to do with all that bedpan junk. Then I was a "house orderly".

This hospital is a university affiliated teaching hospital that is big, does a lot of specialty stuff. They have since built a new hospital. The old hospital was a maze of buildings. As a house orderly, a glorified gopher, I ran the halls of that hospital doing gopher-like stuff. I took stuff from here to there a lot. Back then they didn't have tube systems to deliver stuff, so they used people like me get stuff from one place to the other.

Among the things I did was take bodies to the morgue. I remember carrying babies in my arms down to the morgue. Looking back now, I can't believe I even did that. We let the mortician into the morgue to retrieve bodies.

Thinking about the fact that I was about 19 and able to do this sort of stuff foretold the fact that I would inevitably end up a nurse. If I could tolerate dead bodies, I could tolerate all the stuff that comes with nursing. And lo and behold, here I am oh so many years later, back where I started.

for the drug seeker who has everything

Its never too early to start thinking about Christmas...

For that wealthy drug seeker..

the errant thumb tack

What are the odds of someone putting up a picture on the wall and having thumbtacks in thieir pocket along with their inhaler, and one of the thumb tacks getting into the mouthpiece of the inhaler, and when they use their inhaler, the thumb tack is hurtled into their airway and lodges in a branch of their bronchus? A zillion to one? And yet it happened.

Did I mention that they had to go to surgery to have it removed with a bronchoscope? Did I mention that they now have pneumonia and are intubated? Did I mention that they are also 5 months pregnant? Did I mention they have a 3 year old? Did I mention that their husband is currently over in the middle east because they are in the army? Fortunately things are a lot better and they will probably be extubated tomorrow.

If life is just and karma kicks in, I expect them to win the lottery next years just because they deserve it.

on the other side of the cart

When you are on the other side of the bed at the hospital, it gives you a whole new perspective. I have a close relative in ICU right now in critical condition. Trying to figure out what her real condition is, is difficult. When you have different doctors who say different things, you don't know what to believe. One tells you one thing and another tells you something else. ITs maddening.

It makes you realize how hard it is for families of critical patients. They really don't understand whats going on. The doctors assume they know little and so tell them little.

When you are in the room of a loved one who is sick, your senses are attuned to everything and everybody. The words of all the staff involved are heard and the way they are said can reassure or scare the shit out of the family. They are hanging on your every word and nuance, needing a sign that everything is OK. Needing a sign of hope.

What made the day easier today was a couple of the nurses telling us as we left that they would take good care of our loved one. Everybody assumes that good care will be given, but that verbal reassurance eases the mind a little bit.

saturday fun

I'm not much of an opera fan but the fountains in this are pretty cool. It is in Dubai, UAE. I spend 6 months in the UAE years ago.

don't go there girlfriend

Here's to the 23,000 nurses in California who went on a one day strike to fight cuts in their salaries and benefits. As far as I'm concerned nurses deserve twice the salary we get. Nurses keep patients alive 24/7. The complexity of our jobs and the amount of information we are expected to retain is unbelieveable. We deal with increasingly acute patients and the technology that goes with them.

If you don't think that nurses should, at the very least, retain their current salaries and benefits, you are a fool. Frankly, I wish you would get out of the nursing profession. Go volunteer your services some place. We don't need people like you. We need nurses who will stand up and demand to paid equal to the complexity of the job.

To those of you who don't like unions: If it were not for unions you would be out on your ass right now. Unions make it hard for a hospital to lay off nurses. Unions give us a voice in patient care. The only reason you make any kind of decent wage, have any kind of decent benefits, is because of unions. Unions set the standard of pay and benefits for nurses across the country. So even if you are not a member of a union, you benefit. I pay those union dues so you can have a decent wage and benefits. Don't even go there with me girlfriend...

plum tuckered

I really wonder who is going to work in the ER in the coming decade. As time goes on ERs are becoming more and more difficult to work in. The patient acuity has skyrocketed. There are more people living into their 90's accompanied by all the things that can go wrong by then. Medicine and technology are keeping people alive longer and longer. So the people with a myriad of medical problems present over and over to the ER.

A lot of people think ERs are places where you come if you have an accident, a heart attack, stuff like that. That's true, however the vast majority of our patients are people who are already chronically ill and now they are having some kind of other problem. Here is a typical ER patient these days: non english speaking immigrant with cancer with mets who is failing and the family presents with the patient. The family barely speaks english. There is confusion in the family about how much they want done. So they decide to do everything: labs, IVs, UA, xray. THis is the kind of person it is impossible to get an IV on. They really have no urine when you cath them because they are so dehydrated. The cultural divide between hospital staff and the family is wide, even with the assistance of an interpeter.

And that's just one patient of many with similar complex presentations. The days of sprained ankles and lacerations seem to have fallen by the wayside in ERs, my ER anyway. We have become mini ICUs. The thing about us is there is no staffing that takes acuity into account, ER staffing is based on volumes.

My days in the ER are numbered. I just don't want to work this hard under these kind of conditions for much longer. It is too exhausting. I had a nurse who just graduated from school tell me that she knows she won't last over the long haul in the ER because the acuity and the stress is too much. My advice: Don't stay for years and years. Its not worth the toll it takes on you.

on the short end of the stick

Dear Public:

Please be aware that when you come into your local ER, it may be short staffed. You may have to wait hours in the waiting room because a part of the ER is closed that would normally be open. There may be less nurses covering the areas that ARE open. That means that the areas that are open, the nurses may have 1-2 more patients than they normally do. Therefore, expect to wait for the interventions ordered for you. The fact is if you are not critical, because of short staffing, you may be ignored for some time. We may count on your family member to inform us if something has changed with you.

Don't even ask me about the short staffing that is going on upstairs on the inpatient side. Suffice it to say, things are probably worse up there. Plan on waiting some hours for an inpatient bed.

What's behind all of this? The economic downturn affected the hospitals too. Census went down. Now it seems to have headed back up. No nurses have been hired in about 3 years. So we are already way behind on having the number of nurses we need. Hospitals are now scrambling to increase their staff. In the meantime those of us still there struggle to take care of you.

Sincerely,

your overworked nursing staff

will the disaster be a disaster?

To continue the conversation about disaster preparedness in hospitals, particularly in emergency rooms...my question is: Why hasn't money been put into this end of emergency response to a mass casualty event?

Billions of dollars have been spent on "homeland security", even forming an entire department in the US government around this. The emphasis is on prevention mostly. However there has been significant money put into first responders, hazmat, etc. I have seen some of this affect us. There has been hazmat training, there has been a state wide emergency disaster system set up online that tracks patients and bed availability. This assumes the internet will be up.

I'm a bottom line type of gal. My interest is: There is a mass casualty, people start heading for hospitals on foot, in ambulances, in cars. How are we going to handle the rapid influx of patients? Practically, where will we put them, triage them, treat them? Do we have the supplies that we will need to deal with them? We supposedly have a couple of disaster carts. Somehow, I don't think they will be adequate. If there is a biological, chemical attack? Do we have the supplies for that in the form of medication? Medication specific to the agent involved? Who will make sure that people who are contaminated don't rush into the hospital? The most important question I have is: Why don't I, as someone who works in an ER, as an ER charge nurse know any of this stuff?

As someone who was in the military, in the medical field, I think that we should use the military, people who are already set up to deal with mass casualty to teach us how to do this. In the military we used to sometimes stage disaster drills that involved the civilian EMS system. This should happen more. Use the resources that are already there to teach us. Is this a realistic idea? Who knows. Something needs to happen.

We don't think about this much, unless we are reminded by a disaster or take a class that speaks to it. We put it out of our mind. Its too overwhelming to think about. We hope for the best. The people who rely on us in these kind of situations deserve more than our hope that it will go well.

working in an ER on 9/11/01 in NYC

This video is a little more than 45 minutes long but well worth watching. It tells the story of the medical response to 9/11 in New York City. There was a smaller hospital about 4 blocks from the towers that was innudated with injured patients. It gives a real feel for what a disaster of this kind of magnitude would be like...

being an ER nurse is really pretty cool

Whenever I take a class, I go back to just how interesting medicine is. It really is fun to learn new stuff, even if it is stressful sometimes. When I take a class related to emergency nursing specifically, I am amazed at what we do and often under really difficult circumstances. It makes me realize how much we have to know. When I think about the fact that we sometimes hold peoples lives in our hands, its humbling.

If I look at my job intellectually I think its really cool. I mean seriously not many people could do what we do. It takes a lot of skill. Here's the thing: Why does it feel so bad sometimes?

On a daily basis as an ER nurse, it is really difficult to maintain a perspective. Its hard to remember that we do a lot of good for a lot of people. People are greatful to us. The thing is, the difficult patients are the ones that tend to stand out. Lord knows, we see a lot of difficult patients.

Its because we are human. The vast majority of us really try to do our best. When someone is mean or abusive, we react like any other person would: We get mad, resentful. It hurts. We don't talk about this kind of stuff much in ER nursing. We're supposed to be tough, able to handle anything, We're supposed to be the kind of people who finish wrapping up the body of a person that we tried to save for the last hour, then move on to the next one in the blink of an eye.

If you say that those difficult patients don't bother you, you are lying. Of course they do. They wear on us. We wouldn't be human if they didn't.

So what do we do to be able to maintain a perspective? One of the best things we can do is go to classes within our specialty, go to conferences, in the case of ER nurses, go to the ENA convention. You have to get outside of your personal situation every once in a while, to realize how cool being an ER nurse really is.

I am always amazed at the knowledge of the nurses who present classes. It is really fun to see nurses who are dedicated to making our profession better. Getting together with other ER nurses who don't work in your ER, gives you a new perspective. My advice to anyone getting into ER nursing: Get out and participate in classes, join ENA, go to the convention. I know its not easy, who has the time? Make the time. It makes facing your shift in the ER tomorrow a lot easier.

I've been traumatized

I feel traumatized by the Trauma Nurse Core Course. You know that course we all have to take every 4 years? Am I just getting old or has this shit got harder? It feels a lot harder than ACLS/PALS. Seriously. Some of the questions on the written test were: WTF?

When I got the materials, there was a pretest as part of it. The first frickin' question was: "The following is a sign/symptom of a diffuse axonal brain injury:". Then there were options to choose from. My thought: What the fuck is an axonal brain injury??? Turns out its a big brain injury that leaves the majority of people dead or in a vegetative state. And that questions was only the beginning.

ACLS has lightened up quite a bit. It has become a lot less intimidating than in past years. They really want you to pass. TNCC is not like that. Its a lot of information and if you don't retain it, too bad for you. You go back to the remedial class. Heh.

I was waiting with another nurse to do the practical test where you go through assessment and interventions in front of the teacher. The nurse I was with said she felt like she was going to throw up. What's the point of putting people in that kind of condition?

By the way, I passed it. Now I have PTSD.

violins in ER

I took a class today on violence in the ER, a subject near and dear to all of us. Over the years I have seen people get hurt. A nurse was punched in the mouth in triage out of the blue. She had to get dental work. A patient jumped on the back of a co-worker. We had a guy who was so big, and apparently strong, that despite being restrained, was able to tip his cart over a couple of times.

This class was about techniques to employ if someone grabs you in different ways. They were good ideas, but am I going to remember them if someone grabs me? Probably not. We learned how to take somebody down with this beautiful scenario in which everybody has a different role and there is somebody to direct the whole thing. In ER, its usually a free for all and whoever is there helps hold them down and get them restrained.

The most interesting part was a new rule about restraints, every ER nurses favorite subject when it comes to charting. You now when you have to hold someone down to give them an injection so they will calm the hell down? Well now that action of holding someone down is considered a restraint and therefore, the doctor has to have a face to face with the patient, then
put an order in the computer. So unfortunately for docs, they can't sit at the desk and just listen while the rest of the ER staff is struggling with these people and trying not to get hurt.

That also means more charting for guess who? The nurse. Restraint charting has become a nightmare. It is long and complicated and requires assessments ever 15 minutes and the charting that goes with it. Another JCAHO piece of brilliance.

The next JCAHO inspection, whadaya say we restrain the clipboard carrier and then after 4 hours have them do all the charting for that four hour period? Of course while they are charting, they have 3 other patients (a chest pain, a drunk and a fibromyalgeur). The fibromyalgeur has her light on, the chest pains BP just dropped and the drunk just peed himself. Yeah..I like it....

we aren't ready for a major disaster

Seeing all the 9/11 anniversary coverage makes me think how we would handle a big disaster in my emergency room. I have always thought we are unprepared. I still think we are.

I have never in all my years in the ER had any training in disaster management. There are plans in place in a big binder and online. These are detailed plans that outlien how it all should go. No one ever looks at any of it. It would no doubt be a free for all.

We would handle it. We would have to. There would be no other choice. What scares me the most are the threat of chemical, biological, radioactive stuff. The idea that someone would contaminate the hospital before we would realize what we are dealing with. It also feels proposterous that we would be decontaminating people out in the ambulance bay. But what do I know?

The question is with all the money that has been put into homeland security, terrorism preparedness, it seems like little has been directed toward emergency rooms where the victims would end up. We really have no idea how it would all go, how it would be coordinated between us and other parts of the EMS. Why is that?

There have been some changes: We now have a statewide tracking system of bed availability that is reported every day. In any major event, we are notified what has happened, number of victims and where they are going. Thats progress. But its the actual care of patients that is not being addressed. I wonder if the planning for all of this will ever get to us, the people who will actually care for the victims.

Your thoughts?

the ER bitch follies

If you wonder why the ER staff is cynical.... If you wonder why the ER staff sometimes seems to be going through the motions...If you wonder why the ER staff doesn't greet you like a rich person going into Tiffanys, here's why: It is because of people like the woman who called my coworker "a fucking bitch" yesterday. She was a fucking bitch because the ER doc chose not to fulfil her dream of a script for narcotics.

These are the kind of people we are dealing with on a daily basis folks. Now I want you to imagine a job where you have to be highly skilled, a mistake may lead to death, peoples lives can be literally in your hands...then I want you to imagine that you just helped saved someones life...next person you deal with calls you a "fucking bitch" because they didn't get their narcs.

ER nursing in a nutshell.

don't get drunk off your ass on an airplane please

Here is a piece of advice to those traveling by air both domestically and internationally: Don't get your drink on too heavily while flying through the skies. You may end up in a city you don't want to be in.

We get a lot of people from the airport. For various reasons. People faint during the flight. Arrest during the flight. Get drunk during the flight. Go crazy during the flight. I have a new found respect for flight attendants who have to deal with all this junk.

The drunks must be the worst. Somebody gets drunk and out of control or passes out and they have to divert to get this fool off. A whole plane full of people have to be inconvenienced because you are an idiot or an alcoholic. Some poor medic has to drag your butt off and pour you onto a stretcher. Of course where they gonna bring you? Where elese? The ER. My ER. Where you will run up a bill of a couple of thousand because we have to make sure you are ok.

Then there is the problem of what to do with your sorry ass. We have to sober you up. We just love to do that. Then there is the problem of getting you back to the airport and back on a plane. You know what is particularly fun? When you come from another country and don't speak english. The nurse has to make arrangements for your flight and all the rest of the shit you need. We have to call an interpeter. And the thing is you are not even a citizen of this country.

Morale of the story: Keep your drinking to a minimum at 40,000 feet. We don't want to deal with the results of your idiocy. Too bad we can't throw your ass in jail.

the jail break

You know its gonna be a bad day when you note that there are overflow patients in the area you are about to open, and one of them is dead.

You pass triage and some guy is saying in a loud voice: "I just broke my Dad out of jail".

You pass a room and another guy is loudly telling a nurse that he, "just got out of the penitenary 3 weeks ago". He's drunk.

Okay there is a theme developing and I don't like it.

Its downhill from there ending with a drunk guy who doesn't speak english and proceeds to talk loudly for the next 2 hours in his native tongue and of course he is right near the desk...

bedbugs in triage

Why do people come to the ER for bedbugs? THERE IS NOTHING WE CAN DO FOR YOU. I am sorry you have bedbugs. Its an awful thing that no one wants. However, your bites can be treated by going to the drugstore. If you want to relieve the symptoms of your bites go to the drugstore and ask the pharmacist for some anti itch medication.

We don't want you to bring bedbugs to the emergency room. Then we will have bedbugs. We don't want bedbugs just like you don't want bedbugs. I can think of at least two occasions when we have had a bedbug skitter across the triage desk. GROSS. Not only have you brought us an unwanted vermin but now I am going to be scratching myself all day just because of the idea that a bedbug is living in triage.

When you come to the hospital with bedbugs we have to follow a special procedure. The room has to be specially cleaned now. Housekeeping does it. You know how slow housekeeping is. That room is closed until it is done. So grandma can't get into the ER. That's her sitting in the lobby waiting until your room has been cleaned.

SO PLEASE DON'T COME. Oh and while I'm at it, don't come for lice, scabies or "spider bites" either. Unless your rash is infected, go to a drugstore or call your own doctor. Thank you on behalf of ERs everywhere...