Tuesday, November 30, 2010


.....must have been a REALLY slow news day in China.

Rapid Door- to- Doc Update

I had no small amount of fun with Dr. Roboto the other day as I did a 4 hour Princess shift. Because he disdains hanging out at the nurses' desk with the rest of us lower life forms, he always scurries back to his office in the back between patients; we use an intercom to call him; me more obnoxiously than others, obviously.

Roboto is absolutely insistent that patients are put into rooms and he is called immediately; no problem. There is, as previously noted, quite often a lag between the completion of triage and the completion of registration. This was remedied by simply putting the unregistered patients in the rooms and calling him to come see them. We were really busy; so, after awhile he was so confused he didn't know whether to shit or wind his watch since, say it with me TRIAGE IS MUCH QUICKER THAN REGISTRATION. I had every room filled and nobody registered. Not that I was trying to prove a point or anything.

Not having anyone to blame but himself for this, he tried to take it out on nurses, shocker. All these times are noted on discharge; triage time, time to room, time of doc visit, etc., etc. Many of the docs note their times on a worksheet which is usually kept with the chart; Roboto, being the secretive weasel that he is, prefers to keep his notations to himself and hides them in some secret pocket of his prissy little lab coat. Then he keeps it for quite awhile, many times until long after the patients are discharged off the computer, which is a nursing task. For sanity's sake, we nurses try to keep track of the time that the doc visits. Or we make it up. Whatever. I am usually pretty good about those notations, but Roboto, now pissy because we are pummeling him, said we shouldn't be putting any times down unless it coincides with his exact time. I said we can't do that because you hide your notes it slows everything down on our end, besides, I can look at a clock to see what time you enter a room.

Challenge time; says he, "What time did you put for that patient I just discharged then, since you weren't at the desk?"

I looked at my note; "1:46 PM. What did you write?"

(Addressing left clavicle)"mmm, hrmm, mumble mumble....1:46 PM".

Monday, November 29, 2010

Maxine Lives!

I have nothing especially newsworthy or bizarre enough to post about. I offer an older entry for your perusal and enjoyment.

You know Maxine; the cartoon character that graces numerous emails (especially from my mother- she just LOVES Maxine). She is that crazy old bat with the bunny slippers who dispenses knowledge from the bottom of a wine glass. One of my patients turned out to be a seeming prototype for Maxine, minus the bunny slippers. I happened to pick up the phone for a patient advice call. We get dozens of these every day, and since the bottom line is come to the ER because we aren't allowed to give any actual common sense information, we tend to take turns. The caller said that she had experienced bilateral wavy lines in her vision which lasted about 30 seconds, and she had a mild headache. She said that she called her opthamologist who told her she should get right to the ER because she could be having a stroke. Sound advice. She was looking for confirmation, I guess, and also wanted to know if she would "be sitting in the waiting room for hours and hours". After informing her that the visit would take as long as was necessary, she agreed to think about it.

About 2 hours later she lands in my room. Longish gray hair, hiking boots instead of bunny slippers, but I'd know that sneer anywhere: yup, it's Maxine in the flesh. And cantankerous as hell. Won't get undressed. Won't let me draw blood. Won't let me start an IV. Won't let me do an EKG. Won't even sit on the bed. Stands in the doorway with arms folded across her chest. She is ANGRY. Dr. Dewshe Bagghe takes this one (oh, joy), talks with her for a bit and gets her to agree to 1) an EKG, 2) Labs, and 3) a head CT.

The tech accomplishes the bloods and EKG, but Dr. Dewshe, master of communication that he is, conveniently forgets to tell me the CT is with IV contrast, so in I go to start a good-sized line. That done, it is time for her CT. I tell her she needs to take off her hair appliances, earrings, necklaces, etc. She asks if the CT is "the one that's a tube". I explained the CT, and she seems a bit more relaxed. I told her I needed to take her to CT in a wheelchair, expecting a huge fight, but she relented. I notice a book she has in her lap, and ask her how she is liking it as it is something I have read (some off-beat fantasy about dragons, I have eclectic tastes in lit.). We chat about books on the way to her test, and I tell her I will see her in about 10 minutes.

Upon her return, I check her vitals which are all normal, and comment that at 74, she appears many years younger than that. This prompted a really great conversation about life and living it, how she walks the woods with her 3 dogs daily, is an avid reader, and manages to learn something new everyday. She was afraid she WAS having a stroke, and nothing made her more afraid than the prospect of losing her intellect, mobility or especially her independence. I thought she and my mom would get along great. Now, my mom is 75 and another go-getter who will sneak a flask onto the senior citizen bus trips; they tend not to serve ETOH. God forbid mum and her cronies don't have a little wine with lunch. Actually, I want to be just like her and raise as much hell as she does when I am her age. Her Christmas card was her on the back of a motorcycle on her 75th b'day, an event at which she and 6 of her friends drank the rest of us under the table. And remained pretty sober at that; maybe they were just pickled.

Anyway, Miss Maxine was given the good news that her CT was fine. Naturally she was opposed to hospitalization and signed out AMA. But before she left, she kissed me on the cheek (2nd time in 32 years I've allowed that), thanked me profusely for being so kind, and went on her merry way.

I hope she is out there raising hell.

Addendum: I saw this lady recently, she is alive and well, and raising her own hell. Good for her! Also, she remembered me and made it a point to tell me how much she appreciated my effort to keep her informed without making her feel like an idiot. Good for me!

Saturday, November 27, 2010


Triage complaint of the day:

"Not Better"

The 16 year old with the hysterical mother had a sore throat and had been on antibiotics about 16 hours, was not febrile, drooling or sicker; just not better.

Guess you didn't actually fill the prescription for the "Magic Pills"

Friday, November 26, 2010

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

...had been "allegedly assaulted": translation, someone beat the crap out of him; says he, "they cheap shotted me". Uh huh. He had a bloody nose, a lacerated lip and the beginnings of a nice shiner. Nope, he didn't want to report it to the local constabulary. It was a struggle for New Cindy to triage him because he was on his phone. Incessantly. I loathe this type of behavior and don't tolerate it myself. Must be the school nurse in me, but I have no problem telling a 24 year old to quit acting like an ass. Since we were looking at xrays and sutures we wanted to get this show on the road so we could finish and leave sometime before 1 AM. Keep in mind that we won't hurry through care, but we do like to actually get to the treatment part of the festivities expeditiously. For those of you with a cell phone glued to your ear and who can't go more than 4 seconds without texting your oh-so- important minutiae, listen up: unless you are Steve Jobs, Bill Gates or are on the verge of discovering either life on Mars or a cure for cancer, IT CAN WAIT. Seriously.

We were working with a relatively new doc, Parvati; she is so great. She loves having the opportunity to work in a less frenetic ER because it gives her time to actually talk with the patients. For someone who has been working in a ER for years and years as I have, her viewpoints and attitude towards patients and patient care are refreshing. Many people are so impressed with her that they ask if she has a private practice.

Parvati saw the patient immediately and ordered the appropriate xrays. The whole time the phone was hanging off his ear like an appendage. Mary took him around the corner to get started on his films.

10 minutes later, Mary came out, clearly frustrated. The patient was not cooperative and had been putting her off in order to "take this one call, it's important". Um, no. You do not have a job, children or anything going for you at present. Your "cheap shot" was likely the result of a drug deal gone bad.

Now pissy, I marched down to the radiology department and in my bitchiestmost persuasive command voice advised him that he needed to put the phone away NOW, and that the doctor was waiting to treat him. Besides, I told him, "you are being extraordinarily rude". He put the phone away and Mary got to work.

Since our doors are literally locked at 11 PM, I was quite surprised to hear the outer door open. The patient's mom and dad had opened the door to let in an equally annoying younger brother. I admonished them not to open the door for anyone without checking with me first since we were actually closed; besides we just are not comfortable with random people wandering around when there is no secretarial staff to keep an eye on things in the waiting room. Secretaries get to leave at 11 PM unless we really need them. Along with windows, we nurses just don't do registration, it's complicated and frankly, I don't want to learn it since I already have a fair amount of secretarial work that takes away from nursing tasks.

Parvati had a happy little talk with the idiots parents about what she was going to do and mentioned how rude and obnoxious talkative he was on his phone. It should come as no surprise that the idiot parents thought it was funny; "Oh, that's our moronic progeny little darling, he LOVES to talk, haha!".

Um, did I mention that he had no insurance? 1 hour of weekend and night shift differential at time and 1/2 for 2 nurses and an x-ray tech as well as high quality medical care for which we will not see one thin dime. Yeah.

God Bless America!

Wednesday, November 17, 2010

You Want Me on That Wall...

I am the gatekeeper; now, apparently, I am the timekeeper as well.

It has become the (marketing) rage to tout "Door to Doc" times in the ER under 30 minutes. Essentially, this means that you are GUARANTEED (Ha! Hahahahaha!) to see a provider in under 30 minutes from the time you walk into the department. I am frankly amazed that this declaration is not immediately followed by "....or your visit is free!". Assuming that the patient is one that actually pays the bill.

Rapid Door to Doc is not a new concept, just one the many stupid bandwagons that Suits (and other disguised boxes of hamsters) utilize when they worship at the Altar of Customer Service. It was being given a trial run along with copious billboard advertising at Utopia Medical Center before I left there 4 years ago. We had a fast-track, but the 30 minute "Door-to-Doc" was a bit of a joke. Under an hour, maybe; but unless you were really sick, had chest pain, were holding a severed extremity in triage or bleeding from your eyeballs in general did you have any hope of being placed in a room in under an hour. Never mind seeing the provider. We did much better on doing EKG's in under 5 minutes since we just did them in triage, although we then had to do a room to room search for a provider to initial it. Shouldn't that count? I thought so. Anyway, while the average ER employee would love to have every patient sitting in front of a doc within 30 minutes of hitting the door, in reality, it isn't practical and merely serves to set us up for failure.

I have been told that our Door-to-Doc times need to be 20 minutes, per Dr. Roboto, our medical director; this is the same individual who lacks adult social skills and has been the cause of 6 docs quitting in the last 1 1/2 years, but doesn't see this as attributable to his lack of leadership qualities. Naturally, the first thing to be looked at is NOT the registration process, but triage. It is not the fault of registration clerks that more idiot questions are added to the registration process on a daily basis; I feel badly that they have to ask really stupid questions such as "do you receive Black Lung benefits" and "if a monkey can climb a greased pole in 10 seconds, how much does a pound of butter weigh?, and "do you like cheese?". I get that these are very important to the kind of treatment patients receive. Really, I do. But registration generally takes at least 10 minutes if patients haven't been to our facility and if Helen is doing the registration. Subtract about 1/2 of that if anyone else is doing the job. To add to the mayhem, on weekends and after 5 PM there is only one registration clerk who must also register out-patients. However, Dr. Roboto now says that triage, not registration needs to be streamlined. The man is a rocket scientist I tell ya.

Naturally there are patients with complicated medical histories that are the exception, but by and large an experienced ER nurse should be able to triage quite rapidly; it takes organization and the ability to multitask. In our ER we are all very experienced; with the possible exception of Southern Cathy and Sherry who like to engage people in conversation about their kids, pets and past lives, most of us are very efficient.

To prove my point that the problem lies with the registration process, for the last week I have noted my triage time, as well as the time triage was completed. This has averaged 5-6 minutes for me; I can do a frequent flier dental paineur or migraineur in less than 4 minutes if they aren't on any other meds. After triage, the patient is registered unless it is someone who needs to go right back to a room; that time gets noted as well as the time the provider actually picks up the chart and enters the patient room.

Keep in mind that we are do not have electronic charting in our ER, and probably won't until the end of the present century, so that is a lot of time notation.

Five to six minutes worth of quality triage time. And if there are no other patients I triage them right in the treatment room and have the secretaries register them whenever. Right back to a room, how great is that?

Dr. Roboto doesn't think it's so great, but that is no surprise to me; anything that is actually, well, nursing is trivial; particularly if it requires any skill or concious thought other than blind order-following. A nursing assessment? Insignificant. Nursing process? Unimportant. Critical care skills? Inconsequential. Any nursing input at all? Trifling, unnecessary, worthless.

Roboto's actions scream contempt for nursing in a big way. No wonder nobody likes him. I think a couple of my co-workers have actually switched shifts so as not to work with him. I doubt his own mother can stand him; can't imagine how he can be married and have kids. But hey, he brings on a lot of his problems himself; who can take a man seriously who uses a pocket protector, never wears scrubs because he thinks they are unprofessional, has a fussy little circum-oral beard (door knockers?), talks to his clavicles, wears glasses attached to a little chain and wears a little teeny kid's backpack (probably filled with Fruit Roll-Ups, juice boxes, and jelly sandwiches with the crusts cut off). Also he lacks a sense of humor, which, to me is the worst offense. I am at my best and most passive aggressive self in his presence.

None of the other docs are committed to this lunacy, which is just as well; why put the extra pressure on people for the sake of another marketing ploy with unrealistic expectations? Sicker patients will always get seen as quickly as possible, most in well under the arbitrary 20 minute time frame.