putting the G in ghetto

Okay here's a new one.  I think I saw a drug sale go down in our ER lobby.

So its a pretty nice evening. I'm at the triage desk. There is a guy sitting in the lobby - acquaintance or something of one of the patients.  Here comes an inpatient rolling an IV pole. He goes over to the guy sitting in the lobby  I swear I saw I saw money change hands.

Earlier the guy with the IV pole had come up to the triage desk asking for a pass for his wife to get out of the parking ramp.  So he's probably buying dope to give to her or they are gonna use dope together outside.  Am I being paranoid?  Probably not.

Oh BTW, it turns out the guy sitting in the lobby (probable drug seller) is with another guy who is here trying to get narcs for his back pain. He is busted for using a false name. He was probably there to get more drugs to sell

The shit that goes down our ghetto ER.

I betcha didn't know...

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Thanks for reading the blog.

YOU ARE BUSTED

Let me start out by reinforcing the fact that I AM EVIL. That has already been well established. With that in mind, I have to say that I get a perverse delight when we bust a drug seeker. Its like I want to go around and high fiver my co-workers.  Yeah! Score one for our side!

I am continually amazed at the sheer stupidity of some drug seekers. I mean seriously, you are telling me that you have an anaphalactic reaction to ibuprofen, toradol,, vicodin.....could it be that you want P-P-P-Percocet?!!!  Ding ding ding!  One point for me.  The holidays are so much easier with a little perc on board.

And whats this you have no ID and have never been here before and your name is Bob Johnson. The thing is the Doc recognizes you as Stan Smith he saw 2 months ago.

Exit stage left.  Life is good

yuck

drug seeker FAIL

What is lower than being a failure as a drug seeker?

Lets set the scene:  You have a headache. Never had one before and IT IS SO BAD.  "I don't know what's wrong with me!!" (Cue look of alarm).  You had even gone to your doctor and were given a non narcotic prescription which you tried....but alas, you had what could only be described as an anaphylactic reaction that involved your throat closing up.  Did you seek help with your anaphylactic reaction at the nearest ER?  No you went home, drank a lot of fluids and it resolved on its own.  Wow..

Do you have any allergies?  Why of course you do and they are all to the medications that are a non-narcotic choice for pain.  Here's the thing: You have the same anaphylactic throat closing thing with all of them.  You tell me about 8 of them and state "I have more but I can't remember what they are"...

You are taken back to a room where you tell the NP that the headache may have resulted from the terrible fall you took at work (the plot thickens)
.  By the way, you say, "I work in the medical field".  So you couldn't possibly be drug seeker/surely you'll be sympathetic because of that (the whole comraderie of medical workers thing)/I know what I'm talking about when it comes to this allergy idea.

Grade: FAIL

You really need to refine your presentation.      

the blood curdling scream

Ah yes...Its time to give report on your patient. You have a room number. The patient can finally get to a more comfortable bed. If only it were that easy...sometimes it seems the floor nurses have made a science out of how to delay getting an ER patient. So here it is..the top ten strategies employed to delay taking report:

1) Nobody home: No one answers the phone...at all.

2) Limbo move: Put you on eternal hold.

3) The switcheroo: Different nurses answer the phone and transfer you to other areas where the nurse taking report supposedly is. You end up back at the desk eventually.

4) The stunner: The HUC "accidentally" hangs up on you.

5) Housekeeping reverse play: Housekeeping has not arrived, just started, cleaning the room.

6) The CTD* defense: One of the patients on the unit is crashing and all of the nurses are involved, no one is available. (* circling the drain)

7) The dodge: The nurse "just transferred a patient", "just got another patient", they will "call you back".

8) The surprise play: As you are giving report, the nurse puts you on hold to talk to the charge nurse about whether this patient is appropriate for their unit.

9) The delay: The nurse is on break, at lunch or dinner and the buddy is way too busy to take report.

10) The shift changer: It is an hour before, or an hour after shift change. The nurses are all in report, they are doing their first assessments, the patient will go to the oncoming nurse after shift change, etc etc.

If you hear a blood curdling scream echoing through the halls of the hospital its probably an ER nurse who can't give report...

dangerous nurse staffing is gonna kill your dad

In the past year legislation has been introduced nationally regarding nurse patio ratios.  This will be a long time coming if it ever happens at all.

Our ER staffs by volumes.  We have, for the most part, good staffing.  During the day shift it sucks.  We desperately need another nurse.  Something bad is going to happen.

When we get a critical patient it requires two nurses as a norm.  In the early morning hours we have 14 beds open, we have 3 nurses on.  Most of the time the 14 beds are full.  When that critical patient comes, that leaves 1 nurse to take care of 13 patients.  Often times the charge nurse is out in triage helping the one nurse out there because it is so busy.

Later on another nurse comes on the side with 14 beds. So now when we have a critical patient, there are 2 nurses to manage 14 patients.  It is not until 3 pm that the staffing becomes adequate.

I work in a hospital that specializes in cardiac care, stroke care.  The patients we see in our ER are complex.  They are not your in/out laceration, ankle sprain type patient.  Add to this an order happy medical staff and you get the picture.

It is commonplace in the ER to have 2 critical patients in the ER at the same time.  This ties up 4 nurses in a 35 bed emergency department.  Good luck to the rest of the nurses caring for those other patients.

This is a dangerous situation.  To think that our management expects 1 nurse to monitor 13 patients when there is a critical patient during a period of the day is crazy.  Or to expect 2 nurses to manage 7 patients each during another part of the day, is ridiculous and dangerous.  It is an accident waiting to happen.  That accident is coming any day now.

Now add this scenario onto the drive for patient satisfaction.  How satisfied do you think those other 13 patients are when they have 1 nurse to care for them?

exit stage left

People don't make sense.  You wait 2 hours in the waiting room, are finally brought back. It is busy, you don't get an xray ordered for about an hour.  You are up to go over there.  You dramatically announce that "I am leaving, I've been here 3 hours"  blah blah blah.

What kind of sense does that make? You are about to get what you came for.  Now you are being a martyr. By the way, did I mention that you had to be put in a wheelchair on arrival due to your pain.  You were brought to the room in a wheelchair.  There you are though, snagglepuss (heavens to Murgatroyd) , exit stage left, walking out just fine. Interesting...

ER patients kind of remind me of snagglepuss.  

you rat faced embicele

When the tide turns in the ER, it can be an ugly thing. You know the patient is kind of a wacko, but you go along with all their aches and pains in an effort to just get the visit over with in the least stressful way possible for everyone concerned. So everything is honky-dorry and you are the patients new best friend, la dee dah. You are the most wonderful nurse who ever lived. And then it happens......something does not go the way the patients way and BOOM!!! New patient....a transformation from sweet, polite, best friends to THE PATIENT FROM HELL!!! The transformation is instantaneous and usually involves shouting, dramatic announcements: I"M LEAVING!!! Okay....hey I thought we were friends...

A patient comes in with some kind of cellulitis/fungus ( there's fungus amongus) thing on their feet. Oh by the way I have carbuncles (abscess like things that drain nasty goop) on my head, and I have an open sore with VRE (organism resistant to some antibiotics) on my derriere. Oh and by the way, I tip the scales at 350. The patients takes their shoes off and the bottom of her feet are black. And I am thinking to myself ICK!!! (You know that feeling you get when you are emptying a commode full of doo-doo). It just sends a shiver up my spine. In the end, said patient was going to be admitted and everything was copacetic. So, being the nice nurse that I am, I offer the patient something to eat (she's gotta keep her strength up after all). She chows down and in comes Miss Resident to do a history and physical. Miss Resident says to pleasant patient "Hey dude, there you are chowing down on a sandwich. I thought you were hurlin' so much, you were blowin' chunks all day!" (Or something to that effect) "I guess you can blow this pop stand and make tracks back to yo' crib after all".

This is when pleasant patient turns a bright shade of red, steam comes out of their ears and shouts: "I knew you weren't going to admit me, you rat faced imbecile" (or something to that effect). "Chill out, fool, let me get with the ER doc" says Miss Resident. "I'm out" says pleasant patient. (Cue dramatic exit music). Moral of the story: When someone seems too polite, too sweet, thinks you are the best nurse who ever lived, calls you ma'am, be afraid be very afraid and look for THE TIDE TO TURN....

march-december romance

I must say this has happened to me a few times over the years..

I go off the deep end

Is it too much to ask that the clocks in the ER all have the correct time?  I mean the daylight savings "fall back" happened 8 days ago. Don't these people plan for this?

I am being psychologically damaged by clocks that are actually still one hour ahead.  Picture this: Its busy, I glance up at the clock and am delighted it is almost 3 pm, half way though this God awful shift!  Then I go out to the main nurses area only to realize that it is actually closer to 2 pm. I am  stunned, speechless.  WTF"???!!! IT IS NOT ACTUALLY 2 PM instead of 3 PM.  Oh hell no. I burst into tears, wailing for a good 15 minutes. I'm inconsolable.

I am so upset that I ask to go home. I am told that is not impossible.  The despair turns to anger in an instant. Damn them. Damn this hospital.  And to think I bounced into work this morning, whistling a happy tune (har)...

your dad is a doofus

I was gnarly last week, I admit it. Working too much with too few days off. No time for recovery of sanity.

So its my last day before a few days off. The black cloud that was hovering over me is slowly lifting. Then HE comes in. Doofus Daddy.

Red flags:

1) Medics wanted to give me report outside the room

2) From the time he arrived and was transfered to the cart, he made this WOOOOOOOOOOOO!!! sound while sitting there with his eyes closed.

3) Daughter arrives and does not want to go into room with Dad.

4) He normally gets care at another hospital.

So we manage to get throught the first few minutes. I am entering stuff in the computer and He is rambling on about all of his medical history back to the Mayflower. And I let him ramble. Half listening. Not really caring what he is saying.

I didn't give him the call light. I'm no fool. At some point he requested to have the call light and I had to hand it over. Mistake.

Periodically throughout the visit I hear WOOOOOOOOOOOO!!!

At some point daughter leaves in disgust.

First he will go home. Then he will stay. Then he will go home. Finally a bed is ordered. I consider making a run for it out the door.

I actually maintain my patience remarkably well. One thing about the ER, eventually even the worst patients leave. Besides, I'm off for a few days starting the next day, so its all good

are nurses being worked to death?

Here's an interesting development.  A man has filed a lawsuit against the hospital that his wife worked at, claiming that she "was worked to death".   He stated in an interview (CNN): the hospital was"regularly understaffed, causing some nurses, including Jasper, to work through breaks and pick up additional shifts"   "Additionally, she was routinely called into work while off duty because she was one of the few nurse qualifiied to work the unit's dialysis machines, according to the lawsuit." She fell asleep, veered off the road and hit a tree and was killed.

Will he win the lawsuit?  Probably not.  No doubt they will say she could have chose not to work extra, could have got another job. At least the lawsuit has put a spotlight on working conditions for nurses.

Hospitals staff hospitals at the bare minimum these days.  At my hospital they staff only for the patients that are there at the time.  They do not staff for admits.  So lets say its Monday and there are surgeries and ER admits...they count on discharges to happen for the floors to take those patients.  Often times that means ER and PACU are sitting on patients. ER waiting room fills up due to back up.   Direct admits are told to stay home until a bed is available.

Hospitals count on nurses to work extra to fill holes in the schedule.  And they do.  Lots of nurses work extra shifts.  Imagine if all the nurses in the country decided to not work extra shifts for a week.  Hospitals couldn't function.

Finally, how many times have you gone without a break or delayed it a few hours?   You willl do that hundreds of times over the course of your career just as a norm.

So here is a picture of the nursing staff of this nation: Exhausted from 12 hour shifts and nights, working extra hours beyond their work agreement, working nights, often not getting a break. Stressed out. These are the people who are caring for todays complex patients.

I encourage you to share this blog post around the internet.

get ready to rumble...its a cage match!

Ladies and gentleman...welcome to anywhere USA local emergency room on a friday night..  Tonight we have a four man cage match. Tonights goal: WHO WILL FINALLY DRIVE THE ER STAFF NUTS?  Lets get started...

In this corner is a woman who has been dying for the last 50 minutes prior to arrival but the medics won't let her die because middle aged people aren't supposed to die so young.   Within five minutes of arrival we let her die.  Then we hear the wailing begin.

In the opposite corner is a drunk who just called his nurse a "lard ass" and a "monkey" and oh by the way doesn't, shall we say "like" the race of the security officer watching him.  Delightful.  Oh and there are no detox beds.

In the next corner is a junkie who I am pretty sure just shot up in the bathroom because now they look a lot more relaxed then they did earlier.

And in the last corner is a 400 pound woman who is "too weak to get up", demands a bedpan and is having diarrhea. God help me...

Me, I gotta put my money on the 400 pounder...

women are veterans too

Give to Fischer House

excuse me....uh...fuck good samaritans

I hate good samaritans.  Why?  They feel the need to call 911 when they see a drunk sitting or laying on the sidewalk.

Dear good samaritans:

I hate to break this to you but drunks live on the sidewalk.  When they are too drunk to stand they sit down or lay down, often going to sleep.  They aren't hurting anybody.  I know they are unsightly.  Not something you want to see in your pristine city, but they are a fact of life.  So leave them alone to sleep it off.

Sincerely

Madness the nurse
on behalf of all ER nurses everywhere

You see Mr/Ms good samaritan, when you call 911 the medics are obligated to take them to the emergency room. They don't have a choice.  They can't leave them sitting there.  They bring them directly to us, your neighborhood ER.  When you are sitting there with elderly mom and hear that person shouting: "FUCK YOU! GET AWAY FROM ME!!" that is the drunk you called 911 about in all their glory.  Here's the thing that yelling is not going to end anytime soon.  It will continue sometimes for hours.  So sit back and enjoy the fruits of your good samaritan efforts.  Its only right you share in the experience.

No doubt that drunk has peed all over themselves. Yup thats them throwing food into the hall as you pass by. Just missed you huh? Uh oh...they took off their clothes...darn it...you didn't need to see that.  Here's the thing, detox is full.  They will have a starring role in the ER all night til they stumble out in the early morning light down to the street to beg for a few quarters for thier next bottle of listerine.
 

the dawn of a new ER day

I start my shift at 9 am.  I come in the ER entrance. ( I observe how many people are walking toward the entrance, how many cars are parked at the entrance.  There are five and two respectively.(CLUE #1 that this day will probably suck).

I look down the hall and see if any nurses are sitting at the triage desk.  They aren't, meaning they are busy. (CLUE #2 one that this day will probably suck)

 I never walk through the department when I get there. I go around it. Trying to postpone the inevitable I guess.  As I walk to the staff lounge, I see the ambulance board where the rig numbers are listed and the room they are going to.  There are five (CLUE #3 that the day will probably suck).

I go to the assignment sheet and look to see where I will be. I am on the end we all hate and then charge n
urse later (CLUE #4 that the day will probably suck)\

I look to see who I am working with,  I am am working with Nervous Nelly and Jumpy Jack, I grit my teeth. (CLUE #5 that the day will probably suck).

I go to my assigned area and look to see what doc is on.  Its Orville the overorderdering maniac. (CLUE #6 that the day will probably suck).

I look at the patient board.  There are two alcoholics sleeping it off. Granny in room 2 is yelling: "NURSE! NURSE!"  I recognize 5 frequent flyers on my end. (CLUE #7 that the day will probably suck).

I get report from my co worker who gives me a group of patients  from hell with families to go along with them. (CLUE #8 that the day will probably  suck).

The charge nurse comes by to say there are essentially no beds in the hospital. (CLUE #9 that this day will probably suck).

I am charge at 3 pm and we are down 2 nurses and staffing MIGHT have one for us...(CLUE #10 that this day will probably suck).

And to think, I haven't even seen a patient yet...

another mass shooting...*yawn*

It seems like shootings that capture national attention have become the norm.  There's a different one every week. They capture our attention for a day and that's it. Its funny how there are 32,000 gun deaths in this country a year, but we don't give attention to that.  It has to be a big splashy shooting or multiple victims for us to notice.  But..hey... I'm getting away from the point of this post.

It is really beginning to infuriate me how every time there is a mass shooting, the subject of mental health comes up.  There is talk implying that if only this person had received proper help it could have been prevented.  Politicians talk about need for "mental health care reform".  Blah blah blah.  Soon that dies out.

What infuriates me is that the average American has no idea about how bad the mental health care system is in this country.  They don't realize that mental health problems are treated very differently from physical health problems.  If you want counseling it will have to be pre-approved by the insurance company who will put a limit on the amount of visits.  Then there is the fact that there is a shortage of psychiatrists.  Good luck finding one or getting a timely appointment.

Then there is  hospital mental health treatment.  If you come into the ER in a crisis, your visit will be 4-6 hours.  It may extend up to 24 hours if there are no beds available.  You may end up in podunk city, 200 miles from the ER you came in to.  You may be transferred there because there are no rooms at our ER. Sometimes there are no beds in the state.  Then you stay in the ER, up  to that 24 hours.

Shy is mental health in such a state?  Lack of psychiatrists. Insurance companies don't want to pay for it like they do for physical problems.  A big part of it is the attitude toward mental health in the United States.  It is still considered a personal failing. You should be able to pull yourself up by your bootstraps and stop whining. There is a huge stigma.  We fear people with mental illness. For shits sake, there is talk of having a national registry of mentally ill people that can be accessed if they try to buy a gun. Well, good luck with that since half the population is on antidepressants.

My point?  Lets just stop the bullshit.  This country is not ready to really deal with mental illness. For it to be treated on the same level as physical illness, it would take a huge cultural change. That's not going to happen anytime soon.

the love of money is the root of bad patient care

I've been an ER nurse for an eternity.  Seen a lot of changes.  Seen a lot of changes with our doctor group.

When I started in the ER our docs weren't board certified ER docs, they were internal medicine.  As a nurse group, we had a great relationship with them.  They respected us, valued our opinion and because of that we gave really great care.  The doctors back then worked for the hospital.

Down the road they decided to form a group and contract with the hospital.  Thats when the changes began. Eventually they started hiring only board certified ER docs which is as it should be.

These two changes - the group separating and contracting with the hospital, hiring ER docs only, changed our ER.

This is only my perspective but when they formed their own group, it changed them.  It seemed to become more about the money.  When you contract with someone, you have to make the contractee happy.
What makes the hospital happy? Happy patients. Getting them to come back. Making money for the hospital.  Using the hospitals high tech equipment.

What makes a patient happy? Obviously, they want to feel better.  They want you to calm their fears that something awful is wrong with them.  They expect you to do things for them: run tests, relieve their pain, reassure them.

Now in this day and age, making them feel better takes the form of relieving any kind of discomfort RIGHT NOW.  Pain 4/10 here's some dilaudid.  Hint of nausea, zofran.  IV for everybody.  The days of giving you an ODT zofran, a vicodin and letting you drink water are gone.  More complex interventions make the patient happy, the more interventions the higher the level of care, the higher payment for the doctor and the hospital.  There is a money incentive to do excessive testing, over the top treatment.  Thats what our doctor group does these days. I realize that this is the norm in ERs across the country.  Is this kind of care good for the patient?

The other change, the coming of board certified ER docs changed it too.  Having worked in a hospital on call that trains ER docs, I saw the difference from our ER.  The docs separated themselves into their own area, having little interaction with the nurses other than around patient care. There wasn't the collaboration like at my hospital.  Basically the nurses were task monkeys.  They were there to carry out the doctors orders, their opinion wasn't sought out.

So that happened at our hospital too.  The docs and nurses no longer collaborate with each other like we used to.  It has affected patient care.

Then in the last couple of years, anticipating decreased reimbursement, our docs decided to start hiring PAs and went with the pit boss model.  The PAs see all the patients and collaborate with the staff doc.  PAs are a lot cheaper to employ, allowing that profit and salary to be maintained by the docs.

The introduction of the PAs has had a negative impact on our ER.  PAs, at least in our ER, are not collaborators.  They collaberate with the doctor and thats about it.  They have not been receieved well by the nurses, further alienating the relationship between the docs and nurses.  Once again, all of this has affected patient care.  Not in a positive way.

The point of this blog post: As money becomes more and more the center of medicine, the best care for the patient falls by the wayside, replaced by the pursuit of profit.

gimme that damn call light

This is me about five years ago.  What can I say?  I believe that a nurse should look like a
nurse and that includes the hat..