Your'e Soaking in It

At Pseudocity we nurses work in pods.  We share rooms and general work areas,  and are given about 3-4 patients to care for (not including hallway beds which increases individual patient load).  It is meant to cut down on confusion and running around in general.  Some pods are more acute by nature because there are two critical rooms.  It is also a way to prevent one nurse from having, say, 4 chest pains, or 4-5 psych holds, or 3 or for vag bleeds at a  time.  Of course they try, but there is never any way to make all the assignments absolutely equal.  Some days you're the dog, some days the hydrant.

My pod mate and I had somehow gotten 3 of the nastiest  drunken frequently flyers. Their collective blood alcohol numbers equaled the national debt.

My change of shift assessment included the notation that my patient was pissing between the side rails onto  the floor.  And asking for a sandwich, and a change of socks whilst insincerely apologizing for pissing on the floor.

My partner found her personal drunk, who had spent the previous night and was discharged just 5 hours previously, standing at the sink.  Pissing.  And missing it badly.

"Um, you know, sir, people have to wash their hands in that.  Not cool.  And no, you are not getting any pain medication", said my partner.  

You would think that individuals who have had the equipment their entire lives would better be able to operate it, even while intoxicated.  Just saying.

Number 3 drunk, whom we shared because he was particularly nasty, insisted on a commode to piss in.    He actually managed to get some in it, but also took a monstrous dookie and used the  pillow case to clean himself up.

Me: "Hi, housekeeping?  I have 3 rooms that need to be cleaned.  Actually, they are flooded…..no, with urine…..do you have boots?  I'm thinking a firehouse would be good"

Note: I burned my shoes and scrubs in the driveway and took a shower with the backyard hose.  Needed new clogs anyway.

OK, So It's New to ME

I learned a new word today: incarceritis.  It's been around for some time, I'm told.  Guess I have just lived under a rock.

I heard it from the officer who brought in the individual from the courthouse after allegedly having  a seizure immediately following his sentencing (note:  I never want to know their offenses.  Besides, it just isn't relevant.  All I need to know is "violent", "grabby", or "just do what you need to do from the doorway").  

I try not to be judgmental but, when all the officers and EMS people tell me that is a stone-cold case of incarceritis before the patient even hits the room, it can be difficult.  Shaky Dude was rolled by (in shackles) and placed in a hallway bed.  My partner eyed this dramatic scene over the top of her ever-present half-glasses as she sipped her coffee.    "Incarceritis", she said knowingly.  She is rarely impressed by the antics of the general population.

Paramedic Pete:  "He wouldn't let me do vital signs, wouldn't let me do a fingerstick glucose because he didn't want me to cause him any pain, ditto on the IV.  Couldn't get any history, allergies, or med history"

Why?

Paramedic Pete: "He has been shaking the side rails, whipping his head back and forth, and faking a seizure, while also telling me he couldn't talk to me right now because he is having….a seizure".

Officer: "Yep.  A clear cut case of incarceritis if ever I saw one"

Alrighty, then.

My triage note included the patients first words to me, upon asking him what happened today

Shaky: "I need to make a phone call"

Me: "Not my decision to make, sir, this gentleman with the badge is the boss of your extra-medical activities this evening.  He says no phone calls until you get to the jail".

Eventually the doc saw him and suggested the complimentary head CT for aberrant behavior along with the usual assortment of lab tests for various medical maladies (and the presence of drugs in his system), whereupon Shaky stopped shaking and became perfectly lucid.  "Nope, I don't want any of that.  I'm fine.  I need to make a phone call, just let me make a fu*king phone call!"

Doc: "No sir, the officer has said you can do that when you get to where you are going.  Are you refusing any treatment or diagnostic testing that I have determined is  necessary for your seizure-like activity?  Because if so I will have you sign out Against Medical Advice"

Bye.  Incarceritis.  Use it in a sentence today.

This Post Brought to You By the Letters : A, B, C….

It's been my week for unhappy patients.  I collect them like dust.   Would that we could devise our own survey for difficult patients, wouldn't THAT be a hoot.

Some people just hit the door itching for a fight, pre-programmed to have some kind of issue. These individuals quite frequently come with potty mouth, bad manners, and a lack of patience in general.    They are disrespectful of staff and other patients.  Maybe it is defensive, based on a past experience or just having  a bad day in general.  I get it,  for many people it is literally the worst day of their life.

Or maybe they are just an entitled A-hole.

Regarding the Worst Day people, I give them a lot of slack and take it in stride.  As for the others, not so much.

A-holes seem to have a lot of similar characteristics, many of which, interestingly enough, begin with the letter A.  The Big A.  Which is just the beginning of the alphabet.

Some lead off with a clearly defined AGENDA, and  are often ARGUMENTATIVE.
They know exactly what they want, even if it is ABSURD.

 Some have lots of ALLERGIES.
 Usually to NSAIDS or every narcotic except Dilaudid.

Often they ANTICIPATE a fight for what they want specifically, and use words like "horrible bedside manner", "letter to administration", and "calling my lawyer" when they don't get it.

Lots of patients become a strong  ADVOCATE for their pre-determined diagnosis and treatment plan, no matter how bad an idea it might be.  It has all been spelled out for them thanks to Dr. Google (note:  I am not talking about informed patients who have done some research.  Calm down.).  They simply need a provider to write for their desired antibiotics or a therapeutic X-ray.  Some sign in to the ER with the complaint,  "Need an MRI".  They do not get one.  Hilarity ensues.

ALIBI  is not a reason to come to the ER, but it happens a lot.  Roommate stole your Adderall?  Need a prescription refill?  Need documentation for missing a court date?  Too busy to wait for a PCP appointment for rash cream?  C'mon down.

Rarely, after using foul language and creating a hostile atmosphere which does not produce the desired outcome, there will come an APOLOGY for their bad behavior.  Not often.

Moving on, I present my top selections of the letters B-E.

Talking smack and BADMOUTHING about previous providers who did them wrong, be it in the community, another hospital,  may have fired them for being an A- hole, or not helping them just because they broke their pain contract.   Also they may refer to the last nurse who started an IV on their track-mark tattooed arms "that bitch that stuck me 11 times".  

CUSSING:  Uses the F bomb a lot.  Complains about "the wait is f*cking ridiculous, my f*cking pain is f*ing out of control, this place is bulls*it".  They don't "f*ing care if it's busy" or if people in the next room are trying to die.

DEMANDING, DILAUDID, DISRESPECTFUL, DRAMA:  The first two self explanatory.  Some examples of DRAMA?  Sighing loudly.  Moaning loudly.  Banging the sides of the bed.  Yelling out to the nurses every two minutes.  Throwing themselves around on the bed.  Whining, lots of that.

EXPLANATIONS, in which the patient is intent on convincing everyone that their particular problem is an original complaint, never before thought of in the history of scamming for narcotics.  The pain scale does not apply to them, and usually it is 11 or more.

FAKE CRYING: See DRAMA.  I need to see actual tears.  Sorry.

I could move on to the rest of the alphabet, but….nah.

…and then there were three.

Jobs.  I have 3 jobs.  I was hired back at Pseudo City, a job with plenty of action.  And help.  Lots of help.  I had forgotten what it was like to have transport techs, LNA's, and paramedics to work with.  Not to mention lab techs, EKG techs and, joy of joys, an actual pharmacist to do the med reconciliation on the admissions.  Bliss.  Busy, of course, being 3 times the size of BWOM Hospital and 6 times more beds than Scary Hospital's Bait Shoppe when it was an ER.

I was welcomed back by my old nemesis, Dr. Dewshe Bagghe.  He lifted an eyebrow and patted me on the shoulder.  "You're back?"he said wryly.

"I missed you terribly Dr. Bagghe" I said sweetly.

"Well, (he grumbled). Welcome back".

Of course, each new job requires an excruciating orientation.  Oh, the pain.

And because I am a glutton for punishment I was also hired back at the Bait Shoppe turned urgent care.  My severance ran out sometime in February or March, but my former co-worker who is wearing the boss hat  is now on-site supervisor and begged me to reapply so I could do some per-diem.  I really just wanted to tell them to stuff it and that was, in fact, my plan.  I figured they would low-ball me on the money but was shocked out of my clogs when my offer letter was for money than I was making, plus the raise I would have gotten had I remained another 25 days.  At $10 more an hour than BWOM I couldn't say no.  I did make it clear that I would not be working 12 hour shifts.  It's right around the corner from my house, easy money.

Except for the excruciating one day orientation even though I had only been gone for a few months.  I have had co-workers who were out on medical leave for longer than that.  So I had to spend a day sitting through useless shite.  The upside was that we were given a pass for the entire day to both the cafeteria and coffee shop to get whatever we wanted for our MANY breaks, as well as a $5 gift certificate to spend at the gift shop, which I rapidly used.  I did have to coach the poor little elderly volunteer how to make change as she seemed completely flustered.  Thankfully that is a skill I was taught by my father ("always count it back!") and I managed to make her feel confident for next time.

So, yeah, three jobs.  It's been awhile since I have had to juggle like that, but since I am not a tremendous fan of BWOM, I am doing very little there.  I probably will not last the summer, but feel kind of bad since they are in the process of a staffing crisis.  Clearly, where there is a staffing crisis, there exists unhappy staff.  Almost everyone there works at least 2 jobs, so maybe they should look into increasing the pay.  Just saying.

LOL's

The term "LOL",  before gaining widespread popularity as an acronym for responding to text messages and emails for which we are too lazy to write a proper response,  had another meaning   LOL= Little Old Lady.  At least in health care.  Of which there is an abundance at BWOM, a distinctly aged population, this hospital.  On any given shift the department will have a uniformly unhealthy selection of patients in their late 80's, 90's or even a scattered centenarian awaiting admission or transfer.  There are a lot of nursing homes and somewhat upscale assisted living joints.  There are lots of gravitationally challenged elders.  Lots.  Everyone sports yellow socks, yellow bracelets, and cute little yellow "falling stars" on the doors of the rooms for fall risk.  "Yellow socks for LOL's cause they will fall"

One LOL was brought by the usual contingent of  Entitled Concerned Family Members having become increasingly weak at home.   She had taken a fall several days earlier and evaluated at the ER (not ours) and sent home with family.  She did not do well.  She refused to eat or drink, take the pain medication, or participate in her care.  I don't know how the Entitled Concerned Family Members got her into the car, but it was necessary to lift her bodily out of the front seat by one of my heftier co-workers and was marked for admission within the first 3 seconds of her visit.  

As previously mentioned, the admission ritual is pointlessly lengthy.  There are also two issues that make the process just that much more difficult: the layout of the department and the happy bunny concierge service that management insists we must provide, even it if means that actual stuff we're supposed to do is not done in a  timely fashion, let alone properly documented.  I have many times stayed hours after my shift to document.  It's crap.  But I get paid overtime. Don't bother complain, Boss Lady.

It is often necessary to work around all the Entitled Concerned Family members who hang out in the room and think nothing of coming out to the desk and asking for everything they can think of under the sun.  The physical lay-out of the department is moronic.  Juice.  Crackers.  Pillows.  Warm blankets.  5 more warm blankets.  Reposition.  Toilet.  Toilet.  More juice.  Cardiac monitor beeping.  Concerns about BP.  Concerns about o2 Sats.  When will she go upstairs.  Can she have pain meds.  Can she have blood pressure meds.  Can she have tylenol. Will you recheck her temp.  It is a constant barrage; nothing gets done and woe if I have other patients to take care of with equally demanding Entitled Concerned Family.

The two nursing stations are placed back to back, but with the doc's dictation room and pyxis / med room in the middle.  You can't communicate well with the secretary.  The problem with the placement is the proximity to the doors of patient rooms which is less than 8 feet.  It looks like a bank, but with low counters and no bullet proof glass.  It is not possible to have a private conversation, speak on the phone, communicate with providers, or in any way follow any patient privacy policies.  Like all nurses,  I usually have a couple of  situations going at one time.  Consider juggling three bowling balls and a chain saw.  It is exhausting.  The desk placement makes the nurses sitting ducks for anyone with a questions or request;  ALL  the Entitled Concerned Family members  think nothing of coming over to the counter and asking for everything they can think of under the sun.

 It is NOT OKAY to interrupt constantly.

Herewith, my open letter to same.

Dear Entitled Concerned Family Members:

Let me just make a comment about why I am sitting ever so briefly at the desk.  It is not for your convenience.  It is not the check-out counter at the market.  It does not say INFORMATION in bold neon letters about my head, nor does it say HANG OUT HERE.

Please note that there is a computer, a centralized monitoring system, and a phone.  There are other personnel with whom I may be speaking about other patients; what she and I are speaking about is not only none of your damn business, but a violation of the privacy rights of other people.  We do not have the Cone of Silence.

What I want you to know is that while I would love to spend each and every moment of my evening with your loved one, you and your family members are rapidly sucking the life right out of me, as well as every ounce of empathy.  Your very nice but markedly demented grandma has been toileted 4 times in the last hour (3 of them needlessly because you keep asking her if she needs to go.  She's demented.  She says yes).  Turned her.  Given her water, juice, and a snack.  I have acceded to your requests for warm blankets and more pillows.  I have put all of the chairs into the room that are appropriate for the 2 allowed visitors even though there are 5-6 and I am stepping around them.  I have been into the room to address each and every variation of blood pressure or heart rate that has concerned you and reassured the lot of you that I am indeed keeping an eye on it and there has been nothing dangerous or even noteworthy about these variations.  I have relayed each of your requests, comments, concerns to the treating physician.  I would love to get her medication for pain but THAT ORDER IS IN THE COMPUTER AND I NEED TO SIT AT MY DESK IN ORDER TO ACCESS IT.  I also need some consideration for figuring her dosing and you keep distracting me.  It is dangerous.  I think she needs those packed cells more than another warm blanket.

I do not know when the floor will be ready to accept grandma.  Again, addressing that situation requires me to be away from the bedside for more than 30 seconds at a time while you dream up yet another inane request. Before I can consider giving report, I must call the pharmacy to get a complete list of her medications because you didn't bring one, assuming that "we have it in the computer".  We do not.

 I am sorry grandma is not feeling well and you have had to sit by her side for the last four hours, but really, I have this.  You guys apparently did a shitty job of taking care of her needs at home, why don't you all just go away now and let me have a crack at her.  You are so busy making sure that all the bases are covered that you are not letting her rest.  Now, beat it.

Yours Truly,
EdNurseasauras