Sunday, March 12, 2017

Magic is for real

I have always believed the ER is not the place for brand new nurses to try out their wings.  Too stressful.  Way too much to learn.  Sets them up for failure.  Better to have some med-sug experience under their belt before jumping in the frying pain with both feet AND their hair on fire.

All of the new grad nurses who have started out in my  ER are on their 2nd or 3rd health-care related career.  Some have been paramedics who have gone on to nursing school.  Some are EMT's, or paramedics, LNA's, and a handful of unit coordinators who have done that job while in school.  These here are the Sacred Cows with varying levels of knowledge, hands-on training of some kind, skills not necessarily achieved in nursing school.  The "have to hires", their orientation is very, very long,  and includes months of training wheels.  It's  really an extra six months of nursing education, as they are nurtured, supported, mentored, watched, encouraged, allowed to take baby steps until they are fully mobile, upright, standing-on-their-own-two-feet nurses.  They are not merely loosely supervised and used as additional staff.  Some do well, some do well eventually.

Every once in a blue moon, though, there comes one new nurse so rare, so extraordinary you wonder if they have been reincarnated from a previous nursing existence.  The total package, equally comfortable with the providers, nurse colleagues, and patients.  Confident.  Makes good decisions and, most importantly, asks great questions.  Takes great care of patients.

It has been about 16 years since I recognized a brand new nurse with such excellence.  She was an EMT, then  paramedic, to RN.  Got her BSN, MSN and is now working on her PhD in nursing.  She was a great nurse right out of the box.

Now, in my department, I have met such a Unicorn.  Marvel at the beauty.



Saturday, March 11, 2017

That's all I have to say about that

I was invited out to dinner with some folks from the department, including a couple of nurses and one of the resident low-level paper pushers who is also a nurse.  She is a nice person, but has more interest in paper pushing.   Plus yelling at all of us when our BLS is about to expire.  I call her Bean, short for Beancounter.  Every day there is another directive or rule change.  Or a new "checklist.

Bean was bemoaning the fact that people were not compliant using the newest checklist devised for stroke patients.  I found stacks of them placed in specially labeled folders at each triage desk, in the critical rooms, and at every single computer in the department.  Yet nurses were not using them consistently and Bean was frustrated.

"What can I do to get people to use these checklists?" Bean asked plaintively.

Ok, since you asked:

"It's another stupid thing, Bean.  Just another thing to do that takes the focus off the patient places it on the paperwork".

Bean (horrified):  "But these are so important, like doing neuro checks every 15 minutes!"

Me: "Bean, seriously?  Do you really think these things aren't being done for the patient?  Do you think we aren't assessing continuously?  Shouldn't the focus be on the what's going on with the patient and not simply writing it down and wrapping it up pretty?"

Bean (piously): "If it isn't documented, it isn't done".

Me:  "Right.  I've seen you doing the postmortems on all these checklists, and never in recent memory can I recall anyone being told that they have done a good job, either with the patient or on the checklists.  Each time we get a STEMI, stroke, trauma in which the paperwork is more of an issue than the care of the patient, we grab the paperwork and say "yep, wonder how long it will take for someone to yell at me for what I did wrong, or I get a nastygram from administration".  See, we're damned if we do and damned if we don't.  There is little motivation to get the paperwork done to order.  We're beat up with this shit, Bean".

Bean: (stunned): "You don't understand with pressure we get from above…"

Oh, please.  Boo fucking hoo.

Me: "I get that you take heat from admin, and then you have to torture us.  I do.  It's a suck job I wouldn't want, but you asked how to get people to fill out your checklist;  I've merely told you we do the best we can.  But what you haven't asked is how to help us be in two places at once, doing paperwork in real time and being at the bedside.  That's all"

Since I appeared to be ready to get on the table and jump up and down, one of the other nurses agreed with me then promptly changed the subject.

Probably won't be invited to dinner again.


Friday, March 10, 2017

On prioritizing

As we all know, cubicle-dwellers at the semi-administrative level generally have little in common with us clinical-types.  Jean spends a lot of her time in the office, although she spends a significant allotment of her day sitting at the desk in the clinical area.  Taking up space.  About 7 feet from most patient rooms.   Which is kind of scary when you consider that she is responsible for educating the young'uns about policy, procedures, and definitive form completion.  Aside from an occasional couple of hours in triage, I haven't ever seen her actually commit any patient care.

The other day Jean gestured for me to come over to her as she sat at the desk.  It was apparently not clear that I was busy, I guess I appeared to be loafing as I stood warily watching a ranting heroin overdose who was, through the miracle of Narcan, now insisting on leaving, unfazed by his brief episode of death and "had things to do".  Security was in the room trying to reason with him, I was poised to run, or at least yell for back up.

I indicated to Jean with a terse shake of my head while giving the 2 finger "I'm watching" sign.  She stood up, walked over to the adjacent med room door, which connected with the room I was in, and locked both, effectively cutting off any alternative emergency exit.  WTF.

"If the patient decides to go into the med room, now he can't get in"

Me: "So what?"

Jean: "Well, the med room would be safe"

Me:  "Did you consider that it might be necessary for ME to have another way to get out of the room?"

**crickets**

Sunday, February 12, 2017

Winter is coming

We are deep in the bowels of winter, cold, stormy, piles of snow, no sunshine.  No place to walk.  No place to park the car at work.

And sick folk.  Soooooooo many sick folk.

My ER, nay, the entire hospital, has been bursting at the seams for weeks on end.  Not with flu, although there is plenty of cough, cold, sore throat, etc.  It's chest pain and abdominal pain and COPD. Plus falls, elderly gone to ground humans who have apparently been targeted by Gravity as easy marks.

The waiting room has looked like Calcutta, without Mother Theresa, for days on end.

We have had three times the usual number of psych patients.  These aren't in-and-out depressions or quick psych admits; they are psychotic or suicidal.  They are lining our hallways.  Some wait a week, two weeks, almost three weeks for a commitment bed. They are acting out and who can blame them, it is not a therapeutic environment and their soul-sucking behaviors not only distract us from legit sick people, they make it dangerous for the staff.  The screaming, cursing, button pushing, stretcher banging, shit throwing behaviors….I can't concentrate.  The patient load has increased, management  could care less that the work assignment is sometimes doubled because "they aren't much care".  The fuck?  They need meds, make endless demands, and with each request the patient sitters pass it along to the nurse.  I am concerned about making mistakes because of the distraction.   They have added a part time psych nurse practitioner during the day, but are not staffing the night shift with social workers at least 3 nights per week.  If you come in suicidal at 5 PM, and there are a couple of people ahead of you for evaluation, forget it.  You will be medically cleared by 7, but after 10 they won't see anyone else and YOU will have a cozy bed in the hallway for the night listening to the cacophony.

I get that there is an opioid crises, but we are seeing one or two heroin overdoses a day, about 5 drunks, a sprinkling of people looking for detox,  and 9 or 10 depressed patients with suicidal thoughts at minimum. Add in a couple of actual psychos off their meds and arriving with cops and commitment papers and we are well over the edge.   I am not a psych nurse, I don't have the temperament, I don't enjoy it,  I'm not trained for it.

 I can't wait for retirement and it is still a few years away.

This is winter.  It's here and it's not going away.

Friday, December 16, 2016

Why we're depressed

I brought a patient in from triage and gave her to one of the Kids on the medical side.  "This woman is the prototype  for Debbie Downer and Eeyore".

"Tell me".

"Every question leads to a tale of sorrow and woe.  Ask her any question.  Anything.  It will be the worst thing that has ever happened to anyone.  Ask about allergies?  I get a list of 20, and I had to hear about Every.  Single.  Reaction.  Each reaction lead to another set of complications.  Each complication to a debilitating condition.  Each condition to an endless series of Unfortunate Events.  And then there was a fire in which all of her oxycodone was burnt up.  It took me 39 minutes to triage her.  I feel like all the joy has been sucked out of me and all the fairies are dead. "

"So you're saying I'll never smile again.  Damn"