We Have Met the Enemy...and We Don't Like Him (Part 2)

Noun 1. bean counter - an accountant or bureaucrat who is believed to place undue emphasis on the control of expenditures

Usually, the last thing in the world the bean counters want is for the ER to go on diversion- it's a money thing, or course. It always is. They will micromanage the hell out of what is going on in the ER to the point of silliness. The latest silly thing is "the Huddle". What is the Huddle, you ask? Simply stated, it is a meeting of the minds--the ER doc, charge nurse, admission nurse (reluctantly), and a couple of useless bean counters to "look at the board", or as I like to call it the ER scoreboard. How many patients, how many admissions, how many potential admits/transfers/discharges, where in the process are the docs/hospitalists on dispo's. Instead of asking "what can we do to help you", we get "what are YOU doing to get these 40 people out of here so we don't have to divert. It's all pretty senseless, because it's all just math; too many patients + not enough beds = diversion, a monkey could do it.

On Fridays, when the bean counters and managers go home, there seems to be an assumption that nothing happens in the hospital, that life goes smoothly on, and it is a happy little utopia for patients, nurses, docs and everyone. I humbly say this is complete bullshit, and Friday was business as usual. I am trying to get these people out of the ER, I really am. I have beds for everyone, including the suicidal 1:1. I am finding the charts for the hospitalist. I am communicating my ass off to the ER docs, admitting, and at the same time addressing the 5PM direct admit requests (you couldn't do this at 2PM when the patient saw you? Yes, I know about that). But I am only one person. The ER charge nurse is panicked and won't be talked out of the tree. We are on a help alert (does no good if you don't have orders). I get a call from the medical director who grills me on what the hospitalist is doing, how many admits he has (um, 6), why hasn't he called for a backup hospitalist--I simply hand to phone to the hospitalist who happens to be the only one in the whole hospital, not good. The medical director calls me back to let me know that she is flabbergasted that he is all alone, and it will be addressed on Monday, "in the meantime, there is nothing I can do about it", NO SHIT. And for the record, I didn't ask. It's Friday, inexperienced ER charge nurse, no techs, no volunteers, no paramedics, no LNA'a. Guess what? We are on diversion. Monday morning there will be an Ambush Debriefing: a surprise meeting, complete with white board, QM, and whoever was working on Friday to figure out how it all could have gone so wrong. Since everyone else worsk 3-11 and the meeting will probably be at 8:30AM, looks like I will be the only one there; I worked 4 hours past time to leave to try to straighten things out, but they don't care about that. Want to know how it could have been fixed?

1. More than one hospitalist. The floors were ready, willing and able to take their admissions, they just won't do it without orders. Can't blame them, why should they hang their butts out on a line?

2. Full nursing staff--it still is NOT OK to leave at 3 PM if you are a manager, without appropriate staffing levels. Come on, people, the same thing happens every week!

3. How about a little support for the nursing staff? LNA's, techs or paramedics to assist us in getting patients out of the ER and into their cozy floor beds. It's a no brainer- if the nurse is doing an EKG and mixing critical drugs, do you think she is going to transport the patient? Ridiculous!

Want to know what doesn't help? Constantly talking about the same damn thing over and over!!! I guess I can look forward to a heaping helping of bullshit tomorrow. Maybe I'll just call in sick.

We Have Met the Enemy...and We Don't Like Him (Part 1)

It's been a looooong few weeks, having started school again (Comp/Lit, LOVE it, but it's a ton of work. Is there any call for an aging BSN with a minor in English?). I have also started a new job as an admissions coordinator. On the plus side, it is a lot more days, or at least until 8 PM some nights. No weekends or holidays. I have been orienting to this job for about a month now, and am getting the hang of it, at least the mechanics of where to put the admissions. For example, it has been 30 years since I have worked on a surgical floor. In those days, patients for an elective cholecystectomy were admitted the night before, had enemas until clear, were shaved from "nipples to knees", and stayed in the hospital for about a week. Now it's day surgery. Goes to show you what-all I don't know, but hey, I ask a lot of questions and generally trust that the floor nurses aren't going to 1).Make fun of me, 2)JAFE me on admissions (Just Another Fucking Excuse) 3). Throw me under the bus or 4). Try to lead me down the garden path. So far, everyone has been great, really helpful. And I'm reasonable; to use the SeaBee motto, "if it's difficult, we might do it; if it's impossible, fuck it".

It is also good to see how the other half lives. I am responsible, in part, for getting the ER admits out of the ER, in addition to floor to floor transfers and direct admissions. I have identified quite a few items which will impact my own practice when I work shifts in the ER. It puts a face on the nurses who get my faxed report. It puts more human in the interaction process, if you know what I mean. I have a better "global picture" of the hospital and it's workings, which is good since I've only been there for about a year. The only bad ("only" ha!) is the micromanageing bean counters and their Ambush Debriefings. Talk about being thrown under the bus. I will have to relate that tale in Part Two.

You Guys are Killing Me

I happened to be one of only 2 female nurses in the department this shift. The other 4 were guys, all the docs were guys, the medic was a guy. The other female was in triage which left me to chaperone all of the many pelvic exams, female rectal exams, and any other exam the docs thought they needed a chaperone for. This is a somewhat unusual situation, and escaped nobody's notice that I was becoming increasingly annoyed to become the "crotch nurse in the land of testosterone". Hmmph. Big Mick (he is Irish, and big, but this pseudonym is not meant as a slur, believe me) noted that it was going to be a long "boys night". I predicted that the testoterone would literally drip off the walls. Eamon thought the boys might surprise me by getting in touch with their femininie sides. I told him I really didn't want to work in Brokeback ER, to which he plaintively replied "I just can't quit you!" Eamon, I don't know which is more disturbing, the fact that you know the reference or the quote or both. Whoo hoo! Let's talk about huntin' and fishin'. Which they did. Interesting night, I never thought there was that much to learn about ice fishing, snowmobiling, and potato guns. Ah, well. After all, this is New Hampshire

Fear of Flight?

Well, this was an interesting bit of fun. Local EMS brings for our entertainment an "out of control" 16 year old male with a history of ADD, no Ritalin for 10 days, who has been on a two day Red Bull bender. Mom and Dad have been unable to do anything at all with him, his usual impulsivity and anger issues having been exacerbated by the caffeine and sugar.

Charge Queen: We need to get security down here, I put him and the mother in the family room but he's a flight risk.

Me: Flight risk? Is it because Red Bull gives you wiiiings?

Charge Queen: EDnurseasauras, that is bad! But funny.

Maxine Lives!

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 bilteral 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 cantakerous 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.