Monday, August 25, 2008

Compassion Saturation

Burnout. We have all experienced it, and if you haven't you are either 1) Lying, or 2) haven't been a nurse that long. Sometimes it is helpful to take a step back, step out of the department, take a vacation, or take a break from your particular brand of nursing insanity.
I have always had at least two jobs, sometimes 3. It always gave me a bit of perspective and, I think, made me a better nurse; or at least better emotionally equipped to handle the crap du jour, knowing that the same stuff goes on everywhere. The grass may not be greener, but it is possible that there may be a bit less crab grass if ya know what I mean.

While I have always worked in the ER, some of my other "day" jobs have been a Visiting nurse, school nurse, working at a tiny ER on my days off from Utopia ER. I also taught CPR and First Aid courses as a road show with other ER nurses. Hey, it got us out of the ER and kept us off the street. Besides, my students were always mad for ER stories of brave saves by Community CPR trained civilians. Plus they wanted to pump us for gory ER dirt. There but for the grace of...well, you know the rest. Anyway, the point is not to fear change. It's a good thing every now and then.

When a change of venue isn't possible, letting off a bit of steam is always helpful. ER staff are nothing if not creative when it comes to inside jokes in order to cope, and every ER I know has their own moronic brand of humor. Heck, every corner of the hospital has their own coping mechanisms. It's universal.

The other day one of our new ER attendings, a Hopkins trained lad, was discussing his plan for one of our frequent flyers. Now, I could have told him that she has had 16 visits in the last 90 days, but he has that information at his disposal with a mere few keystrokes. I could have told him exactly how many milligrams of Dilaudid it would take before she would ask for a turkey sandwich, the TV on channel 13, 5 warm blankets, and finally to go out for a smoke. But hey, I don't want to appear jaded in front of Dr. New Guy (whom I really believe will be a tremendous asset) and since he was most sincerely telling me his plans, which none of the old fart docs ever do unless I back them into a corner, I didn't want him to think I was uninterested in what he had to say. So after he rattled off the labs he wanted, I very sweetly asked "serum porcelain level?"**

With that he bellowed with laughter and dragged me over to the department's only copy of the Harriet Lane Handbook, the pediatric bible (which, by the way, came from Hopkins). He showed me that it did in fact have the normals for serum porcelain.
You know you're going to look it up. Be sure to check out the foot note, too.

** serum porcelain level =fictitious blood test.
Means that the patient (or the complaint) is a a crock of shit.

Saturday, August 23, 2008

Psych Pup

A while ago, I posted about a woman whose service monkey had been banned from various establishments because he was a bit of a biter. Yesterday we had a patient with her own psychiatric service dog. These are apparently legit, and are trained for a range of functions; check here for more information ( I am especially intrigued that the animal is capable of "reminding handler to take medication")

I have discovered that there are criteria for determining legitimate disability and therefore simply saying "I have a psychiatric disability" doesn't entitle one to disability status. By the same token, announcing that your skittish Irish setter, whom you have dressed in a Celtics cap, green sweater, and a hand embroidered scarf declaring your canine a "service dog" does nothing to further either your cause or that of your animal.

Unless these actions simply make your case.

Thursday, August 14, 2008

Packing 'Em In, and Stacking 'Em High

Sigh. The beancounters are at it again. I truly believe that there must be some kind of...well, prize, or premium for winning whatever idiotic beancounter contests they are involved in.

During times of high volume Upper Level Management,who watches the ER board from a computer waaaaaaaay up above us, keeps a close eye on the Scoreboard. This Eye in the Sky so to speak really knows whats going on in the ER. Really. They know how to find it since they were there for the rededication after the renovation 2 years ago. Said Management, having read all of the People Magazines as well as "How to Manage a Hospital for Dummies" knows how long each and every patient has sat in the waiting room. My, they truly seem to have the Big Picture, don't they?

I'm thinking that there must be some kind of beancounter Sweeps Week, because the Eye in the Sky has been particularly vigilant this week. MANY calls to the ER to let us know that patients ARE IN THE WAITING ROOM FOR A LONG TIME.
Eye: Patient 1 has been in the waiting room for 2 hours. He needs to come to a treatment room NOW.
Me: Um. Well. That individual has been in the ER 4 times this week for Insincere Detox (translation: homeless, it's hot out, and the shelter is not airconditioned).

An hour later, the Eye in the Sky, omnipotent, omniscient, and omnipresent calls down again.
Eye: Patient 2 has been in the wating room for 2 hours and 20 minutes. He needs to get into a treatment room NOW.

Me: Well. Ahem. We have just had 7 ambulances roll in over the last 25 minutes, one is a v-tach arrest who is having the Big One, there is no cath lab available today, so the patient has to go down the highway. Oh, and we got an overdose, 2 more chest pains, a DKA, the police with a guy in shackles, and possible stroke. Scary Catholic Medical Center is on diversion and we are getting the overflow. We're a little busy. Stop calling me.

An hour later, the beancounter and entourage decide to make a Cameo appearance in the ER to Size Up the Situation, and Make a Plan. This is accomplished by the most insidious of all creations, the Ambush Huddle. Never has there been a more time-wasting activity than having the beancounters assess the situation, THEN tell you how to do your job.

Imagine the ER as a game of Monopoly. There you are, playing the game according to the rules; you are going on your merry way, buying up Utilities and Railroads, landing on Park Place and putting up houses and hotels. You are regularly passing Go and collecting $200.00. You have your strategy. It's cool.

Now imagine that in the middle of the game, sitting there with your hotels on Park Place and Boardwalk, you are told that the rules have changed. Now you are told that you will no longer be able to collect all of your $200.00; or only get it sometimes. And you have to put houses on the railroads and utilities too.

It is chaos. The halls are lined with people who have not yet been seen by a provider, as well as the really sick ones who are in rooms. The beancounters don't tarry long; obviously their place is directing the battle from a position of safety.

So, with Beancounter Sweeps week shaping up, the good news is that we have managed to shave a whopping 2 minutes off the average waiting time.


Yep. 2 minutes. And for what? The waiting room is empty, the ER halls are full, the nurses are overwhelmed, the docs are overwhelmed, it is crowded and unsafe; it is difficult to navigate around all of these hallway dwellers and their posses who want a warm blanket and a turkey sandwich. The most pitiful thing is that the patient's have been sold a bill of goods by being placed in a hallway bed. It's like Disney World; you wait 2 hours in the queue, and when you finally get to what seems like the entrance to the ride, what do you find?

Another queue; another 2 hour wait.

Monday, August 11, 2008

Excuse Me??

Overhead page:

Code Brown, ICU! Code Brown, ICU!

Easily 8 heads pop out of various rooms in the ER.


"What was that page?"

"Did I really just hear that?"

"Did someone really just page a Code Brown to the ICU???"

FYI, a Code Brown refers shall I put this emergent, usually accidental, generally explosive, and often voluminous emission of fecal matter which requires some assistance for cleaning. Or when someone puts on the emergency call light in the bathroom.

A quick call to the page operator served to clarify the following page:

DOUG Brown, ICU! DOUG Brown, ICU!

Friday, August 1, 2008

The Best Hospitalist

I loooooooooooove our hospitalists! I've said it before, I'll say it again. And again. And Again.

Dr. Tulango (his real name is kind of the same as a dance, so when he is is on we say something like 'today, we dance the Tulango with joy, for Andy is with us and we celebrate!" Silly and stupid, but what fun is work if you cannot have a laugh or two?

One of the frequent fliers was on his admit list. This patient is manipulative and abusive. She refrains from taking her antihypertensives for days at a time, then comes to the ER with a BP around, say, Patent Pending/120. She complains of severe headache, gets dilaudid (a lot for her 15 out of 10 pain), Zofran, a whole bunch of labetolol and gets admitted to the ICU. They kick her out when her BP is back to normal and they are tired of giving her narcotics (allergic to toradol, etc. You get the picture). So she figured out a nearly foolproof method to buy herself a couple of days of room, board, and narcs. Administration eventually came up with a plan: if her BP was within a certain range, she would get oral antihypertensive meds, a visit with the case manager, and no narcotics.

This time there was some kind of loophole, because although her BP came down to an acceptable range, the ER doc felt compelled to admit her. Enter Dr. Tulango. Always very concientious, he went over the medication reconcilliation with the patient; it included a HUGE dose of methodone as well as oxycontin. Hmmm....... After some investigation and a chat with the patient's PCP, it was confirmed that no, there was no oxycontin prescribed by him and the methodone was 4 times what it should have been. Dr. Tulango was anxious to speak to the provider who scripted her these meds, but when she was confronted for the name of the provider she ripped out her IV, made disparaging remarks about Dr. Tulango's parentage and ethnicity, promised to go straight to the mayor's office...and stormed out. Normotensive, non-narcotized and feeling abused. OK, so you lied about it and got caught. Get over it.

Like I said, I looooooooooooooooooove our hospitalists!!