you are cutting your own throat

We are about to get PAs (physician assistants) in our ER.  They will staff part of the ER part of the day.  They will probably take on more of the ER as time goes on. Big change. From what I understand, this is being done because our doctor group doesn't have enough docs to staff the several hospitals they cover.

I don't like this. Seems like docs should staff ERs.  Here's the thing: You are not going to believe this but they don't give a shit what I think, here they come.  Its reality. So I will adjust and so will everybody else.

However, I wonder if by employing PAs, doctors aren't cutting their own throats. Lets face it folks, the vast majority of ER medicine is not rocket science. With a little experience, you pretty much know what the problem is. So PAs will do fine with their background. In fact, I would say that PAs and NPs could easily staff most ERs with a doc to supervise and handle the critical cases.

So really, is this what the future holds? Perhaps.  Health care costs will have to be cut.  PAs and NPs are a lot cheaper, will cost hospitals less, insurance companies and medicare/medicaid less. You can pay a PA/NP maybe $125,000 versus and ER doc $250,000, thats a lot of savings.

Like I have thought for a while, the future of general practice is PA/NP and perhaps some specialty areas too.  

oh no

Oh no. What has happened to one of my favorite blogs: Nurse in the hood?  Please, come back to me.

task monkeys

My ER is changing.  It is changing like all of medicine is changing.  I have been a nurse a long time. Things were different when I started. It wasn't a corporate run environment back then.   There was more of a kumbiyah feeling. 

Now it is a business. Plain and simple.  Its hard to adjust to the idea that medical care can be a business, but there it is, whether we like it or not.

The thing is nurses haven't adjusted to this new environment.  We want things to go back to what they used to be.  To a time when we had more time with our patients, where things weren't so complicated. The thing is thats not going to happen.  We will have less time with our patients and things will get more complicated.

In my ER, like most ERs these days, the bottom line is volume, patient satisfaction, in other words, money. I'm not saying we don't do great patient care, we do, but doing great patient care means nothing if nobody comes, they aren't happy and the bills don't get paid.  Its reality.

I see our doc group adjusting.  They are expanding their business to other ERs, improving their skills, trying to make the patients happy so they will come back.  They get monetary incentives to see more patients.  Everything they do, efficiency wise, is tracked.  They are adjusting to the new environment and trying to thrive within it.

There is a lot of talk in our ER among the non doc staff about how they docs don't really care  about anything but themselves. They only care about making money.  People think they treat us like task monkeys.

My thoughts: Docs have recognized that in this corporate healthcare environment, they have to look out for themselves. Nobody else will.  Nurses don't recognize that, at their own peril.  Nurse are definitely more than task monkeys,  they are the cornerstone of the healthcare environment.  IF we as a group don't start changing, promoting our profession, taking care of our own interests in this business environment, we will be gone, replaced by task monkeys.

We have to recognize that don't DESERVE anything, we have to prove our worth, change with the times, embrace change, help to create it.  The question is: Do nurses care enough about our profession to save it?

tomorrow isn't guaranteed

You don't realize it. Your family doesn't get it.  The doctor and I know you are not going to live past the next couple of days.

All you know is that you are having pain. Your family is in a state of shock. The things they say, the questions they ask, tell us they don't understand the seriousness of it.  The doctor ackwardly tried to explain to you and them that things most probably will get worse soon and decisions will have to be made that no one wants to make. He asks if you have talked about how much you want down regarding resuscitation, intubation. You and your spouse are old, but like most people you haven't discussed it. 

When the doctor leaves, I tell you that you are in very serious condition. Nurses do that. We feel we need to bring reality in, so you can prepare, even if it is hard.  We are the translators for what is going on.  I ask about children and tell your spouse that the needs to call your, tell him what is going on.

Its hard to understand when you are so stable, still understanding some, talking. Its hard for you to see what is coming. 

You go up to ICU, your pain is getting worse. When you get to ICU things are starting to  deteriorate and the doctor is called and you will have immediate surgery. You will probably make it through it, but because of other medical problems you have, you won't make it much longer.  I think about what your family will go through.  You are the kind of person I am thinking about a couple of days later.
You are the person who reminds me life turns on a dime.   

no shit rains down

Something happened the other day. I'm not quite sure if it was real. I went to work as usual, walking into the hospital wondering what shit  would rain down on me  today. As it turns out I was walking into a magical fairyland. Yes people my saggy, baggy, ratty, dirty, rundown old ER had turned into something else that day. A place I didn't even recognize. It didn't look any differnt.

Something was in the air that day. Something that I hadn't felt for years.  I didn't even realize how different that day  had been until I was in the car driving home. I was humming, feeling tired, but good.  I didn't feel that ugly, bitter, angry "I hate this motherf---king job" feeling.  I actually felt kind of good.

Wait a minute......SCREEECHHHH!!! STOP THE PRESSES!!! Yes, people I actually felt good about my day at work that day. I felt like I had accomplished something, done something worthwhile. No, I didn't sit on my butt all day because people trickled in. It was a steadily busy, post holiday type day. Lots of grandmas and grandpas.

I had sick patients, really sick patients, they might die sick type patients.  The kind of patients you are still thinking about a couple of days later, wondering what happened to them.

The point of all this?  I actually took care of  REAL emergency patients.  Patients who truly needed help.  No whiners, seekers, fools, crazies,  drunks, dopers.  It was actually like you think an ER should be. 

I doubt it will ever happen again.....in fact it may never have happened at all....maybe it was a dream.

emergency room nurse saves life

I can save your life this Christmas.  Buy one of my bracelets on Etsy.  Everything in the shop is 15%off through Monday with the coupon code BLACKFRIDAY15 at checkout.  Click on beadnurse below pictures to go to my shop.

thanksgiving....happy

I'll have cuppa joe with half and half..

Just when I think I have heard it all in medicine, something else comes along to amuse, amaze and trouble...such as: I have seen this twice in the last couple of months. A doctor orders an infusion, YES I SAID INFUSION, of caffeine in order to avoid those pesky headaches from withdrawal of caffeine.  Both were given when someone was having surgery.

Okay....perhaps we should give a nicotine infusion, for smokers,an alcohol infusion, for alkies.  Maybe a chocolate infusion....the possiblities are endless.

if only Gerard Butler were a doctor

Even though I sometimes poke a stick at and make fun of doctors on this blog, I have the utmost respect for 15 out of 16 of the docs I work with (OK I'd like to dropkick number 16). That being said, I take you on a tour of types of ER docs:

THE ENERGIZER BUNNY - This doc (usually not too far out of residency) is sometimes standing at the door as you bring them to the room from triage. They are like a dog with a bone. AMOS ADD ON: This doc will initially order some stuff and then as that comes back he will order more tests and then more and then more....

THE ABSENT MINDED PROFESSOR - This doc is really too smart for their own good. When someone has vague symptoms they will go off half cocked looking into whether this could be some rare exotic disease. Wanders off easily. Messy.

JACKHAMMER JACKIE: They learned how to do an extensive history and physical in a short period of time and by God, they are going to do it on every patient. Patients is often confused and can't keep up when doc says: do you have this symptom? this? this? this?....in a rapid fire manner.

OVER ORDER OLLIE: This doc orders everything under the sun and then some. Damn it, I'm going to order everything, there's got to be something wrong with you and I'm going to find out what it is!! Keeps CT and MRI in business.

PANICKY POLLY: Voice goes up 10 octaves in any emergency situation. They are so nervous they make everybody else nervous too. Creates chaos at the beginning. She's the kind of doc you want to slap across the face and say: "Stop it! You're hysterical!" (Usually an internal med doc working in an ER - sorry IM docs)

MACHO MIGUEL: You set up everything perfect for that procedure and it goes without a hitch. But alas, macho miguel will point out one small thing that you should have done differently....to keep you in your place and reinforce WHO IS THE DOCTOR HERE.....

NANCY NICE: This doc is SO nice and kind to EVERY PATIENT. Never raises their voice. Never gets angry. You know one day they will probably go postal and it won't be a pretty sight...

NO BULLSHIT BILL: Doesn't allow those drug seekers to get drugs. Cuts off the chronic painers after a couple of pain shots. Throws out those abusive patients. The nurses best friend. Lest you think that ER nurses have nothing but negative things to say about docs, oh contraire dear reader...here is the ideal doc in an ER nurses eyes:

DREAM DOCTOR: Is very good at his/her job. Respects nurses. Goes to the doctor's lounge and brings back cookies. Occasionally gets the patient a drink of water or warm blanket THEMSELVES. Buys an occasional pizza. Has a sense of humor. Looks like Gerard Butler. Has that accent Been around a while, been there done that, doesn't get too excited about stuff. Calm under pressure.

The HELLHOLE, CRAZY TOWN, HOOD RAT PLAYHOUSE, SATANS PLAYGROUND

There are four areas in my ER.

Area #1 AKA the HELLHOLE

This area is where the drunks, dopers, old lady/man weakness, suiciders, people with 89 problems and now they got another one.  Its the patient who need to be cathed, put on the commode, need every test know to man. It has 2 critical rooms, one of which is right next to the desk.
Last week I sat at the desk, across from the desk while my patient kept shouting that I was a "bitch", "aren't nurses supposed to be nice?" All this because I turned down a request that this person made which couldn't happen.  2 psych rooms.  BTW, as a general rule I AM NOT NICE.

Area #2  AKA CRAZY TOWN

This area is twice as big as area #1.  The only thing I could compare this area is times square. Sensory overload.    It is loud, chaotic.  Too many people in too small of a space There is always a dull roar.  As a nurse, sometimes its hard to find a seat here. It is the kind of area, where when it starts ramping up, it really ramps up.

Area #3 AKA HOOD RAT PLAYHOUSE

This is the area where all the local hood rats come for their boo boos, drips, pregnancy tests, womitting x 1 hr, BACK PAIN!!!,  etc.  It is supposed to be a kind of urgent care area but of course it isn't.  People often stay here longer than in the main ER because everybody has to have a "liter of saline, zofran and  Dilaudid".  You know how diners have specials?  Well, the special in HOOD RAT PLAYHOUSE is saline, zofran and dilaudid. Working there makes you want to jump off the parking ramp.

Area #4  AKA SATANS PLAYGROUND
Ah, triage, every ER nurses nightmare.  You never know whats coming next. Sometimes the devil himself shows up at the window.  There is a lot of temptation in triage.  The triage staff is tempted to slap some people silly.  My tongue is always raw and bleeding after a triage shift, because I am contantly biting it. Unbelievable things happen in triage: heads spin and green vomit spews, people roll on the floor, there is screaming, weeping, many a tooth are gnashed. Its the seventh layer of hell.

And that, my friends, is my ER in a nutshell.

this is war dammit

This is war, people.  Stand back while we fight the almighty bed bug.

Hey I get it...the danger of spreading bed bugs throughout the land and throughout the hospital...no one likes the little critters.  But what I saw today makes me think that we have gone off the deep end.

First  of all, apparently there is a 15 page explanation of the hospital bed bug policy, which is very complex and intricate in a binder.  Who knew? 

Whats funny is that apparently we are now supposed to wear a disposible paper jumpsuit.  Yes, I said jumpsuit, a la Elvis or some shit. I mean that is how serious this has all become.  Here's the thing because the paper "jumpsuit" could not be found, someone brought hazmat disposable suits to wear. 
So registration goes in wearing a hazmat suit with hood up over their head.  They also had a mask on due to droplet precautions. I tell ya, what we go through to get insurance information these days.

So there is registration making their way into the room for those signatures.  Following them  lab, with same get up and hood and mask.  They look like they are entering some chemically contaminated scene.  It was bizarre to say the least.

I wish I had a camera..

Insanity

Only in  this insane place that I live can you go from 60 degrees (which in November here is miraculous,) to an evening thunderstorm, to 30 degrees and snow in the space of 24 hours...

BTW, honor the veterans today and make a donation to Fisher House.

nursing is bullshit

Top ten reasons why nursing is such complete bullshit:

1) In what other job are you expected be okay with being verbally abused? 

2) In what other job, is the leadership so bad? 

3) In what other job are you expected to go hours without a break and be okay with it? 

4) In what other job are you asked to give dope to a junkie? 

5) In what other job are you supposed to try and understand and empathize with someone who is threatening you? 

6) In what other job do you get 2 dollars more an hour to be in charge of a place where peoples lives can be on the line?

7) In what other job are you physically, emotionally, mentally exhausted at the end of most days?

8) In what other job could you get a life threatening disease but are given no raise for a year? 

9) In what other job are you exposed to junkies, criminals, sex offenders, psychotics, neurotics on a daily basis but you only hear from the management what you do forgot to chart some piece of bullshit?

10) In what other job do the mediocre advance to leadership positions? (see 2)

And that my friends is why nursing is such complete bullshit. The end. 

Sincerely, 

madness
the bullshit detective

triage-o-rama

Highest number of people waiting in the lobby to get in today: 22

Highest number of people in line at the triage window at one time: 10

Highest number of people in the ER at one time today: 52

Longest length of time someone waited: 3 hours

Most members of one family triaged today: 3

Longest time someone had a symptom they were being seen for: 2 years

Shortest time someone had a symptom they were being seen for: 1/2 hour

Percentage of people who didn't really need to be there: 90%

Dumbest reason to come to the ER: "I want to be seen for an std, I have no symptoms but something doesn't feel right".

Smartest reason to come to ER today: severe chest pain for 3 days

Amount of time left in the shift when I got dinner: 1 hour

Amount of times I felt like running screaming from the ER while working in triage: 12 - at least twice an hour

 

once upon a time..

Once upon a time there was a rocket scientist. Now this rocket scientist did not go to the dentist on a regular basis, who knows why. Well one day rocket scientist has a toothache. Now toothaches suck as we all know.

Well of course rocket scientist does not have a dentist, not using such services on a regular basis. Didn't think of going to the drug store to get something. Eventually rocket scientist decides that this toothache requires emergency intervention. So rocket scientist calls an ambulance. Yes, an ambulance. Now Mr/Ms. paramedic are obligated by regulation to take rocket scientist to the ER, code 58 (if we get stuck in traffic we don't care). Paramedics walk rocket scientist into ER triage. Rocket scientist is put in the lobby after triage. Eventually they are taken back to the fast track and put in a room. Within 5 minutes rocket scientist is on the light asking for pain meds.

And so the story goes on....Act 11 scent 28...enter stage left - nurse practicioner. Nurse practicioner won't give narcs for toothaches, bless her heart. When Nancy nurse goes in to discharge rocket scientist they are no where to be found. They have left without instructions, realizing no narcs are forthcoming.

Your tax dollars at work.
Fade to black....

Larry, Moe and Curly visit the ER (a typical Friday morning)

Hey I'm sorry if your life is shit, but that doesn't give you the right to become so enraged that you tear the reciever off the wall phone and throw it across the room hitting the wall. The wrath of madness will be upon you. You endangered us and we don't like that.

Hey I'm sorry you are a pathetic drug addict who told us you are suicidal. That doesn't give you the right to make a run for it. You are fast, but we are faster. It is our security's pleasure to tackle you out in triage. They live for that shit.

Hey, I am sorry that your life has gone badly, but that doesn't give you the right to light up a cigarette in the patient bathroom. That does not endear you to the staff or the other patients. The tenor of your visit has now changed. Not in a good direction.

How was your Friday?