Thursday, November 17, 2016

Most days the ER is chock full of frail elders accompanied by family members whose mission is never, ever to let their  mom or dad die.  Nobody wants to say goodbye to a parent.

Even if it means doing unspeakable things to keep them alive.

To be clear, "alive" is not the same as "living".  Something everyone should think about.

So it was cool to have 91 year old ex nurse as a patient with all of her marbles, a sense of humor, and a cool daughter who was happy to let me be her mom's nurse.

Over 70 years ago (SEVENTY!) she went entered "nurses training" as it was called.  Now, nurses are "educated".  Think about that while you and ponder why endless courses in nursing theory is absolutely relevant to caring for patients.

There were some surprising similarities in our history.

 "I worked as a secretary for a couple of years, then got bored.  If I had gone straight out of high school,  I would have been finished with my training in time to serve in the War in some way, but it was over before I finished."

My plan was to finish nursing school and join the military (Navy was my preference), and go to Vietnam.  The war ended in my first year of school.

"I worked in a Veteran's hospital for awhile.  Those guys worked really hard to get themselves on track.  It wasn't easy".

I worked in a rehab right out of school.  Then I married a Vietnam veteran

"Of course when we were in school, it was the students who staffed the night shift.  There was no way they could have functioned without students.  God I hated night shift"

Me too.  As a student I worked as an aide at night, or "sat" as a private duty.  I could study or read while rich geriatric patients slept.  The night nurses were all young and mostly new grads.  They were cool.  They warned the students when the dreaded night supe was near.  She was mean.

"The only thing I never, ever wanted to do was work in maternity.  All those screaming women, vaginas and crying babies, no thanks"

My sentiments exactly.

I helped her up to the commode.  When she was ready, I rearranged her things that so that she could get back into bed. "Wait, I have to put on these godawful granny panties".  Note that they were granny panties, not Depends.  I loved her.

Of course many of these older adults are quite funny. I had another 90-year-old who, after being transported for being lethargic (note: she had already been given her nighttime medicines including sleeping pills)  suddenly awoke and demanded food. "What is there to eat around here?" She asked .

Me:  "well I can go and look and see what there is in there kitchenette. I might be able to find you some pudding".

Granny:  "Pudding??! Pudding is not a friggin  meal!"

Run for it, Marty!

One of our docs is deadly slow.  He has one speed.  He cannot be rushed.  He cannot be compelled to move at any other pace than that which he sets for himself.  There is no emergency that cannot be handled at a steady rate.  I have never heard him raise his voice, become rattled, sweat, bark at staff, or handle any issue without careful thought and consideration.

We do a lot of protocols when its busy anyway, even more when Dr. Glacier on.  Although you gotta love him, he is brilliant, loves to teach (be it medicine related or any one of millions of interesting factoids).  His lack of speed is not the most admirable quality when the patients are piling up.  The other docs kind of resent this practice and have a tendency not to pick up charts as quickly when one of their number is seen as not pulling their weight.  Thus resulting in a lot of waiting as the charts are racked.

Auntie is particularly annoyed by this.  As the resource/charge she becomes frustrated when departmental flow is at a standstill and dispositions grind to a halt.

Auntie directed yet another ambulance to park their haul to a hallway bed for the third time in 10 minutes.

"If he moved any slower he'd be moving backwards!", she fumed.

Which is what makes time travel possible.

Wednesday, November 16, 2016

Help me. Please.

I love the front desk clerks.  They are really good about alerting the triage nurse about which patients have checked in with chest pain, shortness of breath, or who "just don't look good".  They are also really good at pegging the drama queens such a those who drape themselves over the desk panting and moaning.   The clerks have a supply of surgical masks to offer the rudely coughing public as well as Lysol wipes.  I don't really blame them for wanting these patients out of their work area expeditiously.  I don't want them in my work area, either.

They are also really good at deflecting the Perpetual Complainers.  I never mind when they tell people "I'll have the nurse speak to you".  But mostly they can handle things quite well.

They see all, and know many of the repeat offenders who cause problems.  They quietly alert our Security team that they may want to "stand by", just to have a presence.  Or the police.

But once in awhile someone is manning the desk who has little experience or is just a tad clueless.  Or both.

Eva.  Sigh.

Eva will interrupt ongoing triage assessments, EKG's and private conversations for anything, no matter how mundane.  Chest pain?  Yes, interrupt me.  Shortness of breath?  Absolutely interrupt me.  Can I get a blanket/water/cab voucher for the lady in the wheelchair?  Hell no.  Not now, dear.

The other day Eva froze solid when I asked her to call a help alert and security for a patient who was "unconscious and not breathing" in a car.  "And call out back for some Narcan", I called as I went out to save another life.

Help didn't come for a couple of minutes.  Waiting.  No help alert.  Just me and the cyanotic  unresponsive patient and the female in the back seat who was helpfully filming the entire experience on her cell phone. As I held open his airway the driver of the car, who claimed he just found him unresponsive and didn't know him, helpfully urged me to "just get him out of the damned car, bitch!"  Security was busy putting yet another out of control, dangerous psychotic patient in four-point restraints.  "Narcan!" I hollered to my co-worker who was pushing a stretcher up the incline.    I recognized the patient from a previous appointment with death 3 days before, also miraculously saved by interventional Narcan.

Eva and I had a little discussion about what was meant by a help alert, and NARCAN.

"I just thought you meant I should call back and get you some help. I didn't know I was supposed to tell them someone had stopped breathing.  And I asked for someone named something-Ann, but. They didn't know what I was talking about because Ann doesn't come in til later".

Sigh.  On the plus side the patient lived, his Appointment with the Reaper postponed. For now.

Tuesday, November 15, 2016

The cost of doing business across unit lines

Another Friday afternoon, another adolescent  psych patient who had made controversial statements in school and was promptly sent to the ER for evaluation.  Friday's are a bad time to come to the ER for a psychiatric evaluation.  It was likely that this young patient would be spending the weekend in the boring ER, eating pudding with a cardboard spoon, watching boring TV, and not allowed to use the cell phone.  I am of the opinion that school counselors should not be allowed to see students on Friday afternoons.  My independent anecdotal study points to Friday afternoon as prime time for making regrettable statements resulting in ER visits.

The ER is a bad place for kids on weekends as we are overflowing with acting out professional psych patients, intoxicated individuals who have fallen off bar stools, and plain dangerous people.  It is not all that safe for staff.  So quiet adolescents get quite an education and maybe not so much attention.

I sent the tech in to get vital signs on this kid, a skinny 15 year old.  The tech seemed unconcerned that the BP was 66/28.  She shrugged, "I took it three times, so...."

I went in search of the appropriately sized cuff.  Nothing.  Not a single correctly sized cuff in the entire department.  I trudged up to pedi to beg for one.

Anne is the night charge on pedi and is known to be territorial.  I get that she needs to keep track of pedi belongings, but sheesh.  She came within inches of requesting a criminal background check for me to "borrow" the necessary hospital equipmet to properly care for a patient would have been on her unit had they the staff to do the necessary safety 1:1 psych watch.

I returned to the ER with the BP cuff, now 15 minutes past my quitting time, and gave report to one the kids on nights.  I handed her the cuff and asked if she would please go in and take the BP that I was quite sure wasn't in the toilet.

"Anne gave this to me.  I had to fill out an application and give her one of my kidneys, my cell phone number, and promise my first born child.  She asked which nurse would be taking over care of the patient, including last name.  I am trusting that this will be returned to pedi undamaged".

Then, trusting soul that I am, I brought it back myself.  The day nurses can give up one of their kidneys.  Or kids.

Thursday, October 27, 2016

On evaluations and raises

I continue to work about four hours a month per diem back at Ye Olde Medde Center.  They would like me to work more, but….no.  It is different now.  Most of the same people, but with just enough….differentness to make it not a place to really want to call home.  And not to be too literal, but the place was torn down and rebuilt.  Just saying.  So I continue to fill in quite casually for staff meetings, an occasional sick call, or cover a couple of hours so someone can have an evening or afternoon off.  Hey, it's urgent care, not too much stress, 911 is on speed dial and nurses don't even have to call the mother ship anymore.  The provider does that.  Mostly I just like to stay connected with some of the old team and get gossip about the mother ship.  The galactically inefficiently run mother ship.

Sherry had my annual review ready on my most recent short shift.  Insert eye roll.

Ah, the review.  Invented by corporate clipboards to say as much nothing as possible on a random performance grid based on nothing that has anything to do with the actual ability to perform the job.  Made up by people who can't DO your job.  For a 2 cent raise if you're lucky.

 I just don't play the game anymore.  Setting personal goals, peer reviews, doing my own evaluation….I just say no to any of it.  You're the boss, you get paid the big bucks, YOU do my evaluation.  I really don't need this job, and you can stick the 2 cent raise.   My only goal is to make it to retirement in way less than 4 years, alive and in good health.

This requisite "discussion" of my job performance was pure theater:

Sherry: "Well, your review is excellent as usual, but I'm sorry to say there are no raises this year"
Me: (feigning surprise, horror, incredulity) "Seriously?  Even with all the recent layoffs of upper and middle management?!".
Sherry: (feigning administrator persona)  "No, sorry.  Across the board, no raises"
Me: "Strong motivation for improving morale, wonder why more institutions haven't thought of it.  Not even a pizza party?"
Sherry: (shifts in her seat and changes subject) "So, I have nothing but good things to say, but need one or two things from you.  Do you have any goals, educationally or professionally?"
Me: (pretending to think it over): "Nope"
Sherry: "You don't make it easy".
Me: (grinning) "You are a terrible manager, you take way too many vacations, and you let people push you around.  You are an outstanding clinical nurse, I hope they make the Kool-Aid delicious for you".
Sherry: (defeated) "OK.  I'm just going to write that you "contribute to keep staff up to date regarding ER trends"

What a laugh.  I keep them updated, alright.

As an urgent care, the Medde Center no longer sees the horror.  No gunshot victims, no stabbings, no SIDS babies.  No dangerous psychiatric patients or drunks.  Yet they appear to enjoy living vicariously through me for same, and beg for stories when I spend time there.  And I guess consider themselves lucky not to have to deal with any of it even though it really is pretty boring there, not even an interesting SVT to fix from time to time.  Not like the old days when it was an ER and they came actually brought ambulances with codes that sometimes survived, and traumas that needed helicopters.  Good times.

The annual  reviews at Pseudocity....that was different.  I put a scant amount of effort into my review there as it is a job I need, although I still say no to goals.  And we did get raises this year.  I thought it was an across the board 3%, but discovered accidentally that it was not.  Lazy Nurse announced a 2% raise.  I wisely kept silent, although the Karma Monitor in my brain was loudly applauding and whistling.