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.

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.
So?
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.

Wow.

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.

Excuse Me??

Overhead page:

Code Brown, ICU! Code Brown, ICU!



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

"What?"

"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 to........how shall I put this delicately........an 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!

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!!

You Are All In My Book...No, Really

Most of my colleagues think I am either A) Shitting them, (not) or B) Scared shitless (you should be, especially you, Dr. Dewshe Bagghe) that I am writing a book about the ER and they are all in it. It has become such a joke that when someone is observed doing or saying something funny or idiotic, or we have an especially interesting night, I get "well, that's a chapter for your book right there!". Indeed, some people could be an entire chapter. There are a few patients who could be a complete book; nay, an encyclopedia. Here is a chapter or two:
Medical Mysteries
"I swear I have no idea how that device became lodged in my rectum!"

"There is no way in hell I could be pregnant" (32 weeks of 15 year old not pregnant)


Heartbreaking

60 year old man, father of 3 and grandfather of 8 becomes pedestrian vs. auto casualty and dies 7 days after being struck by an unlicensed man having a seizure while behind the wheel because he chose not to take his anti-seizure medication.


Headbangers
"Why the hell should I wear a motorcycle helmet? This is New Hampshire"
(no helmet laws+ idiots= head injury)


Sick vs. Stupid
"I fell down and laid on the floor for three hours. Then I got up and called the ambulance because I didn't have any way to get to the hospital to pick up my Klonopine prescription"


Exemplary Patients
Shocking tales of patients who say please, thank you, and don't piss on the floor. Ok,there aren't many of these.


The Cheeto's Challenge
Clinical studies show that 16 year old's with abdominal pain and vomiting improve spontaneously by ingesting Cheetos in the wating room.

(Not) Catering to the Surgeon's Neighbor....
who gets to wait in the waiting room with sore ankle that she has had for 2 weeks. "If you truly believe your condition is worse than I have assessed and warrents more immediate attention, I will put your chart in the main ER. FYI, fast track is running 2 hours behind, the main ER is 4 hours behind. Have a nice day, and lose the attitude"

Tales from Chicken Little School of Nursing Management "The Sky is Falling, The Sky is Falling!!" Many tales of charge nurses who are willing to go on diversion because there are 15 people in the waiting room. Decisions based on quantity, not quality...erm, acuity.

I can't take credit for this one, but one of the nurses at work suggested a chapter How Nurses Are Stupid to Other Nurses by including some of the moronic incident reports by individuals with a vendetta and poison pen. Usually ICU nurses.


...oh, and in the Idiocy at the Top section, read about the medical CEO whom I encountered on a day when there were NO empty beds on the floors, I couldn't place the 5 boarding telemetry patients who eventually stressed and went home from the ER, as well as 6 post-ops, 1 Remicaid infusion and 2 blood transfusions; she thought that one solution to getting bodies out of the ER so we could get the 20 or so out of the waiting room was to ask pedi to take the demented 90 year old with pneumonia and MRSA. Sure!! Great idea!! I'm sure the little tykes and their parents would really benefit from that experience, not to mention the moms and babies there who overflowed from post partum. Sheesh.


************************************************************************************* I could do several chapters on Leadership.
Even though I have assimilated at Pseudocity Med Center, and the folks at Scary Catholic Medical Center satellite often beg me to come work for them, I continue to think often (and fondly) of my people at my last job. I had the best boss, truly a leader. She may not have done a ton of patient care, but she was out of her office and on the floor several times a day. She almost always knew what was going on, how long people had been waiting in the waiting room or in the treatment areas. It was a big ER, 35 beds and many staff, but she knew the strengths and weaknesses of every nurse, tech, unit coordinator, paramedic and even the docs. I haven't had a lot of mentoring in my career, but Jane was an inspiration to me. She encouraged me to take on more responsibility, and helped me to find my way as a leader.

I guess coming from such a, well, nurturing environment makes it that much harder to flounder around sans leadership. Yeah, the current boss is an RN with an MBA which is impressive; but I find the emphasis is more on the MBA portion. Don't get me wrong, she is a lovely person, and the business prepared nurse is, in my opinion, the future of nursing management. How else to be able to swim with the big fish and not get eaten by the sharks? It must be hard to have taken this path, there can't be a ton of RN's with MBA'a out there to mentor others.

However, without strong leadership from a nurse manager I can see the entire department slowly going to hell in a handbasket. Poor retention, call-outs, no shows.....some days it is downright painful to go to work. A recent nursing course had me write a "Dream Job Description" for a project. I wrote about my current job, with all the things I liked about my last job. That is a no brainer, cause I like my actual job, but wish there was more support for nursing to actually do the job. Is everybody stretched this thin?

I may never get the book off the ground, but it is fun to think about it. The next best thing is blogging. When the interesting/challenging/funny/ unbelievable/shocking/horrifying/ disgusting/exhilarating occurs at work, it pops into my mind "oh, I need to remember that". It's addictive, really, and a great stress reliever. It also occasionally helps to put things into perspective, which is more than I can usually hope for when I get home at night and Mr. EDNurseasauras is asleep and not available for debriefing. It sucks that most of my friends are now working the 3P to 3A shift and aren't available for 'Rita Rounds anymore, but my liver is certainly in a happier place; and, I'm sure the Pseudocity Police who would prefer seeing me working in the ER as opposed to being a patient.