Wednesday, October 20, 2010

Dear (fill in the blank), an Open Letter

Dear Parent who Smells Like an Ashtray:

Get real. When I ask you if your asthmatic child is exposed to second hand smoke at home and you reply no, please know that I think you are full of shit. You may claim to only smoke outside your home, but I will be needing a nebulizer treatment after spending three minutes in your presence. You reek, as does your child who is presently wheezing like an old Chevy.

It is your choice to improve your chances of developing lifelong respiratory ailments and/or lung cancer; it is not your child's. Grow the fu#k up.

And please refrain from the sob story about not being able to afford your child's inhaler, it just lacks authenticity when butts are over $5.00 per pack.

Yes, I know the irony is lost on you.



Tuesday, October 19, 2010

Ya Gotta Use Bait

There has been some talk about how to increase (insurance having) patients at our ER; that is, without spending a ton of money. Marketing came up with a health fair to accomplish this.

Our recent weekend health fair (Mandatory Participation, haha!) took place on a beautiful Saturday; all of the components were in place. There were bike helmet fittings and $10 bike helmets available for purchase, what a deal. The usual giveaways that people love. Fingerprinting. Free bike inspections. Free car seat inspections. Drawings for free stuff. A farm stand with awesome looking fresh veggies for sale. Free vision checks and BP checks. FREE healthy turkey hotdog (Jennie-O, DELISH) and veggie burger lunch with all the fixin's, and a CRAZY rock climbing wall that was a useful babysitting device for one of the marketing divas. And the face painting was very popular with the little ones.

All of this good stuff in place right next to a playground where kids were involved in soccer and baseball. Yet, we had basically nobody attend. Why?

1. Poor advertising.

2. It was held IN BACK of the building where nobody goes. NOBODY. EVER.

The rock climbing wall was a crazy hit among the kids who did attend. I managed to sell 10 bike helmets. The bike inspection guy only did one bike inspection, and I think that was for one of the marketing people who felt bad and went home for her own bike.

Not one person from marketing asked those of us who lived and worked in the community for input on what might work to get people to attend. I just don't understand that.

You can bet that the first thing on the list for next year is have it OUT FRONT where people can see it.

Oh, and balloons. That was my idea. Balloons and much bigger writing on the sandwich boards that can be seen while driving.

Sunday, October 17, 2010

What? Just 'Cause I Don't Drink the Koolaid?

A couple of weeks ago I was looking at the schedule and noticed that I had not received any charge pay for the entire month of Sept, and was apparently not in line for any in October. We are such a small shop that it is just "gimme" cash and is usually distributed equally among us. It is not a ton of money, but since they pay us through a peashooter anyway, an extra $20 or $30 a week at least pays for coffee or a manicure. Whatever.

I also noticed that SIC had received wayyyyyyyyyyy more of it than anyone.

It was a moment of WTF-ery that I felt deserved investigation. Since it was on a weekend and my boss wasn't around, I left a note.

The next day I got a call from Mikki. Apparently, at the last staff meeting my boss announced that charge pay would be withheld for anyone not up to date with competencies, a fact that was not shared with about half of our small staff. SIC sure got the memo, I observed; how convenient.

Our competencies are fairly useless, consisting of a monthly rhythm trip, like so:

So the idea is to identify the rhythm, count out the distance between each of the little teeny squares to determine the intervals and a whole bunch of other useless shit, then declare if/how it should be treated. Waste of time.

I hadn't done a single competency for the whole year; or the year before that. I think because I was in school, my boss sort of gave me a bye because I always do my certifications like BLS, ACLS, PALS, and TNCC. Now she was changing the rules of the game and drawing a line in the sand: if you want money, cough up the competencies.

Mikki knew I was a little pissed about this, not so much as holding charge pay hostage but how it was a big secret that seemed to benefit one or two people; she was practically hysterical. "Don't quit!", she begged, "you can copy mine, I just gave then to Sherry 'cause she hasn't done them either. Really, I mean it!".

As if I would quit over this. Or copy. I just didn't do 'em because I thought they were stupid. Sue me.

My contention is that surely, other knowledge might be more useful, such as inservices or competencies for stuff that we hardly ever see BUT MIGHT ACTUALLY NEED. Like what's in the delivery kit, how to prime the fluid warmer, or how to set up and maintain the IO (intraosseous) equipment (you really don't want to know what that is if you aren't medical, trust me). Other knowledge it might be good to know is specific to our unique facility such as a review of what to do with a deceased person after hours, or should we share our supply of lactated ringers with a local vet for use on a horse. Yes, we actually had a request for a case of IV fluid, unfortunately we only stock about 4 of that kind.

Did I break down and do competencies? Yep. We had 3 (THREE!) patients last Saturday night and I did every one of them, then stuffed them in the the boss's inbox which effectively pre-empted my written rant. Money talks and bullshit walks; OK, so I drank the Koolaid. If for no other reason than to prevent SIC from getting more $$ out of it.

Wednesday, October 13, 2010

Triage (defined)

Triage: a process of prioritizing patients based on the severity of their condition

Now I not only have to contend with patients who challenge my 30+ years of triage experience, now I am having to defend them to people I work with. In my small facility, there is a triage process as it pertains to the order in which patients are registered by the secretarial staff. In a perfect world, it would be first come first served. This would be followed by the ones with the biggest mouths, the most dramatic, or the most whiney.

ER patients and outpatients alike must register with the same secretarial staff. There are two until 5 PM, then there is only one. Helen, lord love her, is thorough but slllllllllllllllooooooooooooooowwwwwww. The lab and xray outpatients are sometimes bumped for registrations, appropriately, for patients who need to be seen in the ER sooner rather than later. Sometimes the docs are just antsy to see patients; sometimes we just want to get them in and out because we can.

Yesterday, I triaged a pale 6 year old with a head bump; he had vomited several times. Aside from a mildly elevated heart rate, he looked about as OK as he could. Still, I didn't feel I wanted him to sit in the waiting room while Helen registered several outpatients. As I exited the triage area, Helen intuited that I needed this child registered without delay and kicked the outpatient xray in front of her back to the waiting room.

Several minutes go by; Lee,the xray tech was in my face, abrupt and inappropriate as usual; "Do you ever think about how the patient might have felt? He was already seated. I know we are supposed to give preference to the ER patients, but do the outpatients always have to be bumped for every dental pain and boo-boo?"

Whoa, back off there. I waited for my blood to stop boiling, took a deep breath, calmly looked up as she loomed over me, then let her have it

"Lee, I understand your frustration. I am sure you got endless shit from the outpatient; not to mention it makes your numbers look bad, so I am sure there is a certain amount of self-preservation here. The reality is, it is my decision and mine alone when it comes to the order in which patients are registered; it is based on my clinical judgement. It is my license but more importantly it is based on doing what is right for patients who need care sooner rather than later, as well as common sense which you seem to be lacking today. Before you stick any more of your foot in your mouth you should know that this kid is head injured, pale and vomiting, which handily trumps your outpatient. That's all you need to know. Don't you ever question my clinical judgement again; you will lose, I assure you. Now get out and go fill in some forms or something".
She left sputtering but firmly in her place.

The Talker had heard the whole thing; "Wow", he said, "Well done".
Yeah, see definition.

Monday, October 11, 2010

Today's Last Patient of the Night.....

....arrived at 10:30 PM. His complaint? "Vomiting Blood"

He and his two adolescent girlfriends giggled and texted and acted like idiots in general. I wouldn't dream of revealing his last name, but let's say if I had to pick a name out of a hat, it would rhyme with "Douche" (as in douche bag...which he was).

His triage note: "ate at Wendy's, then started vomiting blood. Pt. states he always vomits blood when he eats at Wendy's".

Yes, I know, I know. ...but why state the obvious here? You know me better than that, so I shall be withholding my comments; however, Meredith Grey has a few words to say on this issue. I will step aside to allow her perspective:

"Maybe we like the pain. Maybe we're wired that way. Because without it, I don't know; maybe we just wouldn't feel real. What's that saying? Why do I keep hitting myself with a hammer? Because it feels so good when I stop".

Thank you, Dr. Grey. I suppose your discharge instructions would include opening a nice big can of this:

Sunday, October 10, 2010

Remember Essie?

From a few days ago? Well, my stroll down nursing Memory Lane jogged another nugget.

Essie got a new roommate at some point, who was ambulatory. And sneaky.

Bessie used to roam around at night. In those days we didn't have fancy patient alarms and monitors when patients went on the lam; we used a device called the the Posey Jacket, or Posey for short. This was a little mesh vest that zipped down the back and was tied to the bed; the patient had the ability to roll to either side, but it kept them from getting out of bed and into mischief (or going to ground and breaking a hip). It was, for all intents and purposes, a restraint device, although it sounds like a torture device, which I suppose it was since we aren't allowed to use it anymore. But it was never meant to be punitive, merely to keep the patient safe.
I have a point; I promise.

Posey's were difficult to get out of, but not impossible, in fact many of the elderly were quite adept at it. Bessie was what we referred to as a Houdini, master of the art of escape. One night all of the staff were involved in two simultaneous crisis situations, and Bessie's frequent bed check was missed. Sure enough she was on the loose.

But instead of raiding the pantry for sugar packets as she usually did, Bessie had another mission going; she had collected the dentures of every patient she could find and had placed them in a pillowcase. One dozen sets of dentures had been liberated from their Efferdent soup. To make matters worse, we were alerted to Bessie's larceny by the yelping from one of the male patients with whom Bessie was trying to get in bed.

THAT went over well. I don't really know how the day shift managed to reunite the teeth with their owners, but they did.

Mini Around Town, Part II

Milltown is just full of people this weekend. There is a Pumpkin fiesta on the town round with food and frolic; the economy can't be that awful since people and families are out in droves spending money. Just a ways out of town is a pumpkin launcher, hay rides and a corn maze. It's a beautiful fall weekend, just perfect for being out of doors. Mr. EDNurseasauras and I went out for breakfast, then tooled around for a couple of hours. Alas, I am working the entire weekend so I have a lot to squeeze in today.

As it is fall, we dog walkers must now share the woods with hunters. Of course I dress Tina and myself in the kind of day-glo orange color not found in nature at this time of year; still, I just don't feel safe on weekends frequenting areas in which hoards of individuals in full dress camo and toting weapons of mass destruction pile into pickup trucks and swarm over my usual hiking spots. That's OK, I just avoid the high-profile areas on weekends; not many hunters around during the week a-shootin' at Bambi and all his little friends.

Today I went to an old historic village site from colonial times that has been converted to public domain hiking. It is truly a beautiful area with miles of maintained trails, rolling hayfields, and wetlands. There was not a cloud in the sky as Tina and I made the rounds of all the rock walls where chipmunks hide.

Tina spotted a man coming up the path accompanied by a dark grey toy poodle. I recognized this as "Killer Poodle", owned by the property caretaker whom I've never met. "KillerPoodle" is a yappy little thing who resides at the caretakers cottage. He is infallibly found outside in the front yard, and barks and growls at anyone who passes by. Hence the name; I refer to him a "KP" for short. After our dogs had greeted each other in typical doggie fashion, Tina was off digging a hole on the other side of yet another rock wall. I made conversation with the caretaker dude about the usual New England topic of conversation (the weather) and asked him the usual questions about his canine friend.

"Well, he is about 8 years old. This in Niki II; Niki I is on the other side of the wall. He sort of came with the property, he was here before I was", said caretaker dude.

I was pretty sure I had only seen one KP on previous trips to the Village and looked over the wall to see if Tina had found any other little companions. As caretaker dude continued to speak, I realize that Niki I was, in fact BURIED on the other side of the wall. Typical old yankee humor. Niki I's grave was complete with a headstone with the obligate dates of existence. It was decorated with an engraved bone and pretty little pebbles; "Good Dog" was engraved on the bottom. Stay. Good boy.

KP ran off with his master, and Tina and I continued our search for chipmunks before I had to go to work.

Note: when we arrived home, the cat had caught a chipmunk. Tina prompty comandeered the catch. Sharing: good girls!

Saturday, October 9, 2010

Today's Last Patient of the NIght....

.....was in his mid 30's, had a host of medical problems including stroke, alcoholism, diabetes and, since he was with his mummy, I am assuming he also had an impressive list of social deficiencies. It was 10:45 PM.

He needed a note because he missed his court-ordered community service.
The reason?

"I just didn't feel like going".

uh huh....

Friday, October 8, 2010

What Does That Mean, Anyway?

People often talk about how nurses are doing "God's work". Most days I disagree.

I do not believe it is "God's work" to take verbal abuse from a 39 year old with back pain (chronic) who plays football (every Sunday) and shows up the following Monday (every week) with excruciating pain. Why were we getting verbal shit? The physician, having looked up the patent's last five visits prescribed possible chiropractic treatment, ice and heat, ibuprofen and to moderate his activity; it was suggested that perhaps playing tackle football was not in the patent's best interest. Further, the patient was told that the physician was reasonably sure that none of the Patriots presented to the ER on Monday after a game looking for Vicodin. The patient was, of course, outraged and demanded the name of the physician's boss so he could complain; and, since he didn't get any treatment (except for some common sense advice) had no plans to pay for the visit. Oh, and he left his free-care application in the room.

I sure don't feel like it is "God's work" to look up the number of Medicaid for an able bodied 18 year old female who didn't have insurance but was too old for Healthy Kids and not in school. She had presented for a lump and bleeding "down there"; turns out it was a friction injury. Naturally she insisted on having her skanky boyfriend present for the inevitable pelvic exam. Why do these young girls go for these bozo's? Blecch.

For that matter, it surely cannot be "God's work" to put up with morons who twist a toe, ankle or elbow, or break a fingernail and high-tail it to the ER without first attempting ice, elevation or ibuprofen. If you are walking on it, using it to hold your cell phone to text message the world that you are in the ER, or slugging down a gallon of iced coffee from Dunkin's, it most likely NOT fractured. Especially if this is your 5th or 6th visit for a silly complaint this year. It is disheartening that there is so little common sense in the world.

You cannot convince me that it is "God's work" to document 30 (THIRTY!!) allergies for one patient, relatively few of them actual allergies; the only things that were missing from the list were "clouds" and "dirt".

On the flip side, there are some instances when I feel that, while perhaps not "God's work", I can glean, ever so slightly, a sense of satisfaction or accomplishment. To be honest, it is precisely those instances that keep me doin' what I do; in a sea of rude, unappreciative, nasty, stupid, violent, threatening patients and family members that strain my sanity and keep my eyes in a continuous roll, I am occasionally able to use my experience and skill to achieve something positive.

I kinda have a tendency to hold on to those moments like a lifeline on those days that I want to slap the ears off someone.

(This is my 100th post by the way, and I wanted to keep it as upbeat as possible!)

Thursday, October 7, 2010

"Pink is My Signature Color"

Oh, lord, did I have a flashback.

I was asked to do a blood draw in the outpatient lab on a "tough stick", something I am always happy to do; if it can get done in one rather than repeatedly poking the patient, I am all for it. As is the patient, I'm sure.

She was elderly and was decked out completely in pink from head to toe, including a little pink cloche hat (who even knows what a cloche hat is, anyway?). Sorta like this:

In fact, exactly like this but with only one flower.

Mae was so cute and tiny. Pink flowered blouse, pink sweater, pale pink pants and pink flats with a clip-on flower. She had on bright pink lipstick and had the most beautiful clear blue eyes with a devilish twinkle.

Mae was sporting a sassy pink cane with pink breast cancer stickers, and a pink ribbon breast cancer pin or three. Because she'd had a mastectomy some years ago, we were only able to use one arm--hence the difficulty.

I introduced myself and told her that I was there to help Lynn, the lab tech, get her blood test done.

"So, they called in the top dog, eh?", Mae said with narrowed her eyes and a slight curve of her lips to indicate she was teasing.

"Well, let's see what we can do; no promises, OK?"

She studied me with her little head tilted under the cloche, glancing at me out of the corners of her eyes; the last time I saw an expression like this, it was done by Essie who tortured me in my very first job as a nurse.


I had taken my State Boards (now called NCLEX) out of my home state, thanks to our nursing school director giving us the wrong deadline for application...idiot. So, I was able to take this two-day test (now done by computer with the results immediately available) in the state of NH where I went to school, I could take it with my friends which was a bargain. The downside was that the tests were only given twice a year in those days. If you failed, you were done for six months. In addition, the results took about 4-6 weeks, which was torturous to say the least. But, if you were fortunate enough to get a job, you worked as a glorified nurses aide and could do everything except pass meds; it was worth the crappy pay, and you could also do charting and sign your name "EDNurseasauras, GN" (for graduate nurse).

Since I was back in my home state of Massachusetts, I not only had to wait 4-6 weeks to see if I had passed or not but had to apply for a reciprocal license so I could practice in Mass., which was another 4 weeks or so. In the meantime, I was hired at a rehab hospital. One day of orientation, one day following the RN around, and then I was on my own for the next three weeks, expected to take a full patient care assignment of 6 or 7 patients, which my nursing program had prepared me to do (yeah, diploma programs....the bottom of the food chain as far as education, but prepared to be a nurse right out of the box). Management was biding it's time until I received my Mass. license so I could be in charge. Yes, as a puppy nurse with merely a couple of hundred hours of experience I was to be the sole RN on the floor with one LPN and 4 aides. Three months of 30 hour weeks as a charge nurse in my Leadership course, the finale of my education had also prepared me for this as well. Hind sight only makes me realize how potentially dangerous it could have been, however, it all worked out and we all managed together to give good care.

Although it was a rehab hospital, there were relatively few patients with rehab potential on my floor. We had head injured young people in comas who were complete care and needed tube feedings, etc.; respiratory patients who were basically sent there to live out the rest of their lives on oxygen; a couple of men with cerebral palsy who were wheelchair bound and total care because of their contractures; one woman with some mysterious paralysis-type of thing with a bed-sore that needed to be packed a couple of times per day. There was one brain-injured man who had tremendous mood swings and angry outbursts caused by prolonged oxygen deprivation. He had experienced a cardiac arrest and survived, but in those early days when we had just started not letting people die by doing CPR there was perhaps a lag between the the length of time he was "down" and when he was "saved". He certainly was not the same 43 year old person he had been before he was admitted to my unit as his anguished family constantly reminded me.

I also experienced my first death as an RN. With a nurse's aide who was afraid of dead people, I performed post-mortem care using the directions in the shroud kit. Yes, we used a toe tag. Heidi, the aide, was also my roommate at the time. She had nightmares about this.

There were several older adults with dementia; these days, such patients would not be placed on that kind of floor, but that was the 1970's after all. One of these was Essie Poisson, who was in her late 80's or 90's. In her occasional moments of lucidity she would talk about her days dancing in the Ziegfeld Follies, elaborate Broadway musical shows with gorgeous young women, beautiful costumes and headdresses with towering plumage. Essie, like Mae, was usually dressed all in pink.

Of course, in Essie's less than lucid moments, everything was a fight. The most stressful part of my evening was 1) getting Essie into bed and 2) getting Essie's dentures out.

Essie would give me that side-glance, narrow-eyed, "bring it" devilish look and challenge me to remove those dentures; it may have been stressful for me, but damn if it didn't seem like the highlight of Essie's day. I do believe she looked forward to it.

Essie would resist the removal of those dentures with more enthusiasm than I thought possible in a woman of her frail appearance; underneath lurked steel armor and determination to match.

She shrieked "help, police, murder!!" with all the gusto she could muster, but the dentures ultimately spent the night in a denture cup in a marinade of Polident; she never drew blood but that didn't stop her from trying.

Once in her nightgown, fluffed, puffed, lotioned and soothed, Essie behaved as if nothing was amiss and would always politely ask for a cup of custard before she went to sleep. I retreated, drained, to the nurses station for a cup of coffee and begin my charting. What I really felt like was a stiff drink.
So with nostalgiac if not fond thoughts of Essie in my mind, I drew little Mae's blood.

But out of habit I kept my eye on those teeth....