Who?

The staff-reduction-cost-saving measure is to have only one nurse in triage when there isn't enough staff for the rest of the department.  Truthfully, we could actually use 2 nurses and a dedicated tech most of the time.  We routinely run at about 114% capacity with a 4 hour wait.

My third shift in a row being alone for 87% of my shift was a steady stream of complaints such as rash, febrile kids, and chest pain.  With a couple of weak and dizzy and a rapid a-fib or two along with frequent flyer depression/suicidals.  We use a language line for the non-English speakers which always takes about 4 times longer to triage.  With a paucity of techs most shifts, or because they have been pulled to sit on suicide watches, I have to do my own EKG's.  The line of patients waiting to be triaged just kept getting longer.  

One patient was a name dropper.  Sigh.  That doesn't do anything to make me change my triage process.

Name dropper pt: "My neighbor is Nurse X, do you know her?  She's the head of all the nurses?"

Nurse X is a clinical leader on one of the med-surg floors.  I know who she is.  Definitely not head of all nurses.

I cocked my head as if considering, gave him a quizzical look.  "Mmmm, nope.  I don't know her".

Name Dropper: (disappointed) "Are you sure, she has a really big, important job".

Me; (knowing whatever I say next will be reported back to the neighbor, and not giving a rat's ass)
"Sorry, no.  People that far up the food chain as you say never come down here.  We frighten them".

Name Dropper had chest pain intermittently for about a week, and after a strenuous workout at the gym resulting in chest pain, consulted the neighbor.

I start the usual protocol, EKG, labs, xray, knowing that there won't be a bed for a few hours.  At least unless the diagnostics indicate a heart attack or whatnot.

I got some pushback for the cardiac protocol, he let me do the EKG, but wasn't sure if the labs and xray were really necessary "because I don't have insurance".

I waste little time, offer that the consequence for not doing so could result in death, and have pretty much moved on to my next impossible list of tasks.  Name Dropper decides to consult with Very Important floor nurse before moving ahead.

Me:  "Ok, well let me know what you decide, you can have a seat in the waiting room while you make your phone call".

Got an email from my manager a couple of days later.  "Nurse X doesn't understand why you told her neighbor that you didn't know her".

Response:  "More importantly, does she know me?"

On practice

I don't routinely do port access.  I once had a bad experience in which a frequent flyer gastroparesis patient, who was also fond of drinking alcohol and was just, in general, a gross individual, sat bolt upright to vomit (spit into a vomit sack) just as I was pushing the needle in.   Scarred me for life.  Seriously, I have port PTSD.

I CAN do it.  I CHOOSE not to.

So when my patient asked me if I was good at ports, I had to tell the truth.  "It's not my best skill", and hit up my zone mate to do it for the second time that day.  I was willing to try it because it looked like an easy one.  She wasn't willing to let me practice.  I was fine with that.

We call it nursing "practice", but when it comes to patients, nobody really wants us to actually PRACTICE on them.

You don't always get the best wherever you go.  You might expect it, but it is a statistical improbability that you will always get it.   Not the best meal, not the best mechanic, not the best teacher.  Not the best hospital. Not the best doctor.  Not the best nurse.  Sometimes you get adequate or mediocre but working on it, or just enthusiastic and learning.   Sometimes you get adequate or mediocre... and just happy to get by.  Even the best role models can't do miracles with the material they have to work with.  The nurse/doctor/lawyer who graduated dead last in the class and passed the boards or the bar is STILL a nurse/doctor/lawyer.

Think about it.

Every nurse on the planet has practiced on patients. Every.  Single.  One.   First patient, first injection, first IV, first code.  First birth.  First death.  First everything.  You don't get better at something unless you do it repeatedly, over and over and over until there is a comfort level.

That said, nobody in health care these days is working in an environment in which actual practice, with the goal of improvement, is encouraged.  Speaking from that place, we all know that perfection is expected from patients and mandated by administration, office dwellers,  and keepers of clipboard minutiae. These folks sequester themselves in their spic and span patient-free ivory towers with the sole purpose of writing how-to's, decision trees, step-by-step procedures, and check- off lists.  All of which serve to create distance from fall-out, (or create a fall guy) when things go off the rails and something untoward occurs. Their work is never done, for there will always be some scenario that was not considered.  Also, shit happens.

Practice does not necessarily make one perfect.  That is impossible.  Practice might make one competent, or safe, or prove that more practice is necessary.  It might even prove that the teacher is not right for the job.  There is lots to learn, but the biggest lesson is that no amount of preparation guarantees perfection.

Nothing is perfect in health care.  That is the only absolute.

House of God

I used to work with a doc who would continuously refer to the Rules of the House of God.  This was a novel, written in the 70's.  You should go read it, if it's still in print, it's doubtful it would be published in this day and age.  For non-jaded health care people, it's dark and full of scurrilous behavior. This doc always used to say that it should be required reading for anyone who works in an ER.

 The House of God outlines a set of rules that are still occasionally referenced by people old enough to remember it. Here they are:

1. Gomers* don't die.
2. Gomers go to ground.
3. At a cardiac arrest, the first procedure is to take your own pulse.
4. The patient is the one with the disease.
5. Placement comes first.
6. There is no body cavity that cannot be reached with a #14 needle and a good strong arm.
7. Age + BUN = lasix dose.
8. They can always hurt you more.
9. The only good admission is a dead admission.
10. If you don't take a temperature, you can't find a fever.
11. Show me a medical student who only triples my work and I will kiss his feet.
12. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion
13. The delivery of medical care is to do as much nothing as possible

*an acronym for "Get out of my emergency room" - refers unkindly to old or chronically ill patients who used to sit on a resident's service for weeks awaiting placement in another facilityy in the good old days.  Like, the 1970's.

So I was thoroughly shocked to hear one of my current ER docs,  (probably in his mid 40's, sort of a know-it-all and borderline douche) refer to one my zone mates patients as being unable to go home, and needing a nursing home placement (see rule number 5).

"Yeah", he said airily, "that is one of the rules of The House of God.  Are you familiar with that?, probably not. You're too young.  It should be required reading".

Since he was speaking to my colleague who is in her mid-20's, she did not know.  I interjected.

Me:  "Oh, I used to work for a guy who was a med school classmate of the author, Samuel Shem, in medical school back in the 1970's.   He said it should be required reading too".  I proceeded to rattle off almost all of the rules, having been compelled to memorize them years ago.

The kids promptly started looking for the book, available on Amazon.

Dr. Know-it-all, taken aback, who thinks he is a trivia God: "Wow, you remembered almost all of them".

(Wanders away).

A rehab/nursing home sent a demented patient for a fall.  History of many falls, a hip fracture, and of course, on Coumadin.  He hit his head.  Automatic head CT.

His family member arrived 20 minutes after the ambulance, in a mad tizzy, having been left to cool her heels in the waiting room until he could be triaged and assessed for serious injury.  We almost never (aside from parents of minor children) let ambulance-follower family members into the treatment area right away.  Visitors are strictly limited, and are told by the front desk people that it will be about 10 minutes AT LEAST  before they are escorted back.  We largely get the most pertinent information from the EMT's and paramedics that bring in the patient anyway, and you will shortly see why. 

Me: "So what happened today?"

"I told them to put on his hat because it's very cold out, and dress him warmly!  Look at the shirt he has on, that is not the one I wanted to have him wear!"

The patient was talking a merry blue streak about absolutely nothing.  I inquired as to whether this was the normal level of mentation for him, but the wife kept up with the nonsense about the inappropriate seasonal wardrobe choices that had been made on his behalf.

"He had flannel pajamas on earlier, and a turtleneck, but for some reason they took that off!"

Me:  "Can I confirm his medications and allergies with you?":

"I have no idea if he even had breakfast today!  And those are not the socks I put out for him!"

I resignedly moved on to inquire as to the patient's normal level of activity:

"What if he has to go to the bathroom? I don't know if he has had his bowel movement today!"

I gave up.

She followed me out to my work area, asking about when he would have his scan, when he would get lunch, if her doctor had been notified, if he could have a blanket, urinal, glass of water, TV on channel 8, the heat turned up, the lights turned down, a bag for his belongings, does he need to have an IV.

Here is a small public service announcement.

A rehab is not an acute care facility.  The assistants are taking the vital signs, performing toileting runs, and bringing meals.  They do all of the necessary personal care.  The nurses bring meds and do assessments.  The nurses generally don't see the patients all that much on a shift.  That is a good thing.

And I know this how?

I recently had a family member in rehab.  As a nurse, I am pretty hip as to what is needed in terms of day to day medical stuff.  I have a good handle on the care she received as an inpatient in a acute care facility.  Again: rehab (clap)is not (clap)  an acute (clap) care (clap) facility.  After a couple of minor tussles regarding medication on the first day, (thus likely earning me a reputation as bitchy  pushy) I was quite pleased the care.  The aides are polite, pleasant, and do all the things we as RN's signed up to do but don't have time for anymore, such as making people comfortable.

Beating them up because there weren't exactly 16 blueberries on the oatmeal is just being a douche.

My hat is off to these hard workng ladies and gentlemen for making sure my family member got food she could eat, was kept safe, clean, warm, and comfortable.