Progression of Manbaby, an anecdotal study

Within one 5 hour shift, I had the entire spectrum of Manbaby stages:   infantile, toddler, school age, adolescent and grown-ass adult.    It is interesting to observe the progression.

1.  The infant was 11 months old.  A third child with a "really high temp, and going up and up" in spite of basically a topical spritz of Tylenol at 99.5 degrees.  No other symptoms, yet the parent was beside herself, screaming on her phone about the catastrophic medical emergency for which she nearly called 911.  I had to tell her to put the phone away and tend to the already walking
child, who looked like a rose, as he attempted to climb up an IV pole.

2.  The toddler with a head bump, no loss of consciousness, no visible injury.  He screamed and screamed as the mother loudly explained every second of the terrifying vital signs I was doing.  She helpfully conveyed fear with every word instead of distracting with the phone, a song, or book.  She demanded a pediatric neurologist to be called immediately as she rocked the shrieking child, smoothed his hair and kissed him repeatedly.  Feed the frenzy.

3.  Young school age kid (on the cusp between toddler and school age) with a simple forehead laceration.  Parents demanded plastics in triage (they don't take call here, and don't answer our calls) and asked when they would see a pediatric neurologist (never.  What is with the pedi neurologist demands?  Some Dateline episode I missed?).  Insisted on over-explaining everything to the kid, offering information he didn't need to have, talking incessantly about needles.   I put topical  numbing medicine on, much wailing and gnashing of teeth from both parents, hand holding, repeating over and over "it's not going to hurt", (it probably will.  I don't lie to the kids.  It stings).  The kid was too absorbed in an iPad game to notice.  5 minutes later, I heard blood curdling screams, a harbinger of good times to come.  Dad had used hand sanitizer on the kid and he had a paper cut.

We had to wrap the kid in a, "Bat Man cape" (arms in pillow case then burritoed in a sheet) and 2 people to hold him down for sutures.  More blood curdling screams.  Dad repeatedly saying "I know it hurts, daddy's here", drowning out our usual successful diversionary banter, while mom sobbed and rocked in the corner, wailing "it's almost over".  No attempts at diversion.

3.  School age kid, (age 11) hopping on two feet, with a knee injury sustained about 3 minutes prior     to arrival.  Hopping.  Two feet.  Mom immediately commandeered a wheelchair, of course, and harangued the registrar until I finished with the tiresome chest pain patient.  Within 5 minutes asked for blankets, pillows, juice, "some kind of splint", ice, pain medication, and for the orthopedic to be standing by to care for her precious little guy because "nothing is too good for my son".  She, too, smoothed his hair and told him how it was all going to be ok, don't be afraid, mommy's here.

4.  Adolescent male.  Age 16.  He's been here before as evidenced by mom's chummy "we know our way around" banter and checklist of what makes her special lil' guy better with his cyclic vomiting.  A liter of fluid and some zofran, and could we please get started on that because I have another kid at home whose plans were cancelled because of the patient's visit to the ER, and younger bro is NOT happy.  Mommy made sure to let me know that baby boy doesn't like needles, and could we please use the smallest size, and this arm, and not to try unless I'm sure, and he has persnickety veins, and could we draw the blood at the same time so he doesn't get too anxious.  Although I found a vein immediately I spent a good 10 minutes pretending to find one while Mommy cooed and cuddled.  Gag.  The kid didn't vomit once in the ER. Demanded juice and crackers after about 20 minutes and wanted to go home soon after that so they could get on with their evening plans.  I didn't hurry as I had other things to attend to.  This was a textbook example of novice Manbaby.  I suspect many, many issues at home.

5.  The  55 year old came in with his mother for....oh, never mind.  It makes me want to vomit.  I've covered Manbaby, both the gloriously single and the married kind complete with Mommywife in the past.

This is really a recipe for creating steel reinforced apron strings.  I don't care if it's not politically correct

11 years

Hard to believe that this is the 11th anniversary of this blog.
That I'm still working at the bedside.  That I still have something to say.

That people still read anything I write.

Boggles the mind.  Or Bloggles.

Don't know how much more I have left to say, but sometimes inspiration strikes.

So many of the blogs I loved back in the day are no longer around.  Madness.  Nurse K.  GuitargirlRN, to name a few favorites.

I wonder what all of them are up to, if they are still working in the ER.

If you are out there still, stop by and say hi!  Miss you all!  

Lake-sword autocracy vs. autonomous collective

My ER did some remodeling and created a locked area  for dedicated psych hold beds.  Now, because the patients have a nice, warm, safe, cushy bed with a TV, they wait much longer for a commitment bed.  'Cause, you know, they are in a safe place.  I refuse to work there.  The days holding routinely number in double digits. Weeks.

Two of our old psych rooms were turned into medical rooms.  There was no increase in staff to reflect the increased acuity.  The assistants are routinely taken off the floor to watch the suicidals which are now in overflow hallway beds with the drunks, and the beds are always filled.  We have more psych patients than before.  Many.

Sometimes it gets loud there, in the hallway, what with people trying to walk, steer stretchers, move X-ray machines, stuff like that.  There are 10 computers at that end of the ER.  It is loud.  Phones are constantly ringing, alarms always dinging. There is no privacy for the patients, and no privacy for us.  People are always hanging on the desk asking for things.  You can barely hear yourself think.

Often, the patients talk to each other, complain to each other, and get each other all ramped up and agitated.

One night was particularly wretched.  The patients were heckling, actually heckling, security, nurses, docs, anyone who walked the gauntlet of hallway dwellers.

Security and the assistants were beside themselves trying to keep things calm, but they had a job of it.

After a couple of hours I went out to dwell in triage, happy to get away from the cacophony.

One of my zone mates had PTSD from the events of the remainder of the shift.  She was wild-eyed, her usually flawless bob sticking out all over from many frustrated passes.

"It was awful.  It was really hard trying to take care of actual sick people, they just wouldn't shut up, they kept at it and at it.  "Nurse! Nurse!  I need, water, I need food, this sucks, I want to see my lawyer".  They were all trying to outdo each other in the asshole department.  Then they started to organize themselves.  They had a list of demands!  They were there so long they established their own form of government and elected a representative.   Possibly a king!”

Happy I am closer to retirement with each passing day.

Supreme executive power derives from a mandate from the masses, not some farcical aquatic ceremony.

In which we are screaming, but nobody can hear us

Our admins were absolutely skewered on the latest round of employee satisfaction scores.  For added fun, this year we were also given an opportunity to evaluate our director.  Some of the comments were shared during a staff meeting.  Meetings are administrative crack.  If it's not working, by all means, have a meeting or 12. The bosses appeared shamefaced, bewildered, confused.  

"Absent"
"Drowning, send lifeboats"

"Administrative puppet"

"Not an advocate for nurses"

"We have a director??"
"In your opinion, is there anything we do RIGHT?"

That explains why the director has been out and about in the department, "visible" more in the last 2 days than at any time in the last 12 month 5 years.  She was not out of her rat hole office to help.   She was certainly not dressed for patient care, in her sharp little booties and lab coat.  Why do admins wear lab coats if they never do anything to get dirty, such as:

start an IV, surely you remember how.

answer some call lights.  

deliver a couple of meal trays, get some blankets, walk someone to the bathroom.

Instead, we have to take time away from our task to make inane conversation about HOW ANOTHER AWARD MADE UP BY ADMINS WOULD MAKE US FEEL MORE VALUED.  

SOO looking forward to next year's roast.  Doubt they will make this an annual event, though.  

So

There are days I love my job, some when I hate what being an ER nurse has become.  I would love it if I could still do nursing 1970's style.  20 uninterrupted minutes for each of my patients at a time, helping them understand all their meds, treatments, and an in-depth plan that we will work out together for the length of their stay, complete with meal times, snacks, back rubs, bed baths, etc.  It would be lovely to chat with them about their family,  jobs,  previous experience in hospitals, belief systems, hobbies, how they love to take long walks on moonlit beaches.  For the most part, though, it is a race against time, and I waste a good bit of  it apologizing for what isn't being done rapidly enough to suit them.  Priorities?  Constantly changing.  Minute to minute, actually.  A nurse's priorities are manipulated by everyone EXCEPT nurses.

Although I don't work in Massachusetts, several friends and family have asked my opinion on their proposed upcoming ballot question regarding  nurse:patient staffing  ratios.  Let me walk you through my thought process on that issue, and share this exhausted bedside nurse's perspective.

My tale begins shortly after receiving nurse to nurse report from the off-going day shift.  I was responsible for four patients in the critical care zone (strokes, heart attacks, trauma) one more than is prescribed, although there is no mandate here.  It is assumed that if one nurse is busy with something truly critical, the other will pick up the "slack".  I hit the ground running.

There are three providers, all of whom have promised patients that "the nurse will be right in".  As you can imagine, I can't be in four places at once.

(In real time, now) I am answering the call light of one of my patients who is demanding instantaneous service who has to go to the bathroom.  I can simply take off the cardiac monitor leads and disconnect the IV as he is ambulatory.

I return to my desk and computer, where I must log in and acknowledge all orders and do all of my charting.  At my work station,  I find the family members of 2 elderly patients standing at my desk.  One wants water and warm blankets for their father, the other has a mother who needs to go to the bathroom "right now".  Neither of those patients are mine.  I explain that I or their nurse will attend to them as soon as possible.  The emergent toileter relative argues that the need is immediate, so I have to take care of that patient (belonging to my zone partner who is busy with a combative suicidal overdose) before I even begin to attend to the needs of my own patients.  It is a weak, dizzy, and demented nursing home patient, and the relative is useless (as they usually are), so I hunt down another equally busy nurse to assist with transfer of the patient from the bed to the commode, which I also have to hunt down.  In addition, she is caked with stool that has to be cleaned before returning her to bed.  Naturally, the relative also wants water, warm blankets and a turkey sandwich which I ignore for now place low on the priority list of tasks.  My ambulatory patient, now back in bed,  is also now ringing for meds and to have the IV restarted.

It has been 25 minutes since three physicians have promised things to patients that I have yet to provide.

Back to my desk to print med orders for 3 of my patients.  This is a policy, also a safety issue.   I must take the printed sheets to the bedside for confirmation of identifiers and allergies.  Every med.  Every patient.  Every time.  Antibiotics and anti emetics for 2 of them.  IV fluids and pain meds for one.  Before I get the orders printed I am interrupted once again by emergent-toileter-relative-who-is-not-my-patient at my desk to demand the warm blankets and water.  I say shortly that I will send in her nurse.  I hate when people stand at my desk, it's just rude.    Unless your relative is coding, standing at the desk is like jumping the queue.  Use the fucking call light.

Here is a short list of what I must do now:
Wait behind 2 other nurses to get meds out of the Pyxis, one of which is an orientee and is being coached by her preceptor so even the commonly used meds take awhile to find.  After a couple of minutes it is my turn.  I must input my password, use my fingerprint ID, find the patient name, then pull saline, tubing, antibiotic, second tubing for the antibiotic, small admixture bag with adapter, and anti nausea meds for both patients which entails knowing what they are called in the Pyxis.  A one liter bag of saline I know is listed under "Sodium chloride", with a drop down list for how big a bag you want.  I have to hit the screen on average about 4-5 times for EVERY ITEM  I need after typing in some key letters, then wait for the door or drawer to open, then the individual lid containing only the desired medicine.  I pull out what was ordered, close the lid and drawer.  Fortunately the antibiotic and anti emetic is exactly the same for both patients and this ain't my first rodeo, so I have what I need relatively quickly.  I also get the pain med and more IV fluid for the ambulatory patient.  One of the newer nurses has a question about how to administer a medication that she has never used, so I instruct her on how it's done.  Remember that.  I am taking time out of patient care to provide information to a less seasoned nurse.  This will always be a priority for me, you cannot burn the newbs, lives literally depend on it.  I grab a couple of syringes and blunt needles to draw up the anti- emetics and drop one "set" of meds by my computer, taking my orders into the other patient's room.

35 minutes have elapsed.  Nobody has what was ordered yet.

The first patient complains about the wait, I apologize insincerely, eyeball the monitor and general condition of the patient, (note that he doesn't look that uncomfortable) while simultaneously  mixing the antibiotic.  I confirm identifiers (name, DOB) and allergies.  I hang the IV fluids.  I inject the anti emetic over 2 minutes, and during this time I assess the patient:  skin color, and temperature, vital signs, pain level, get a quick and dirty on the onset of illness.  I try to make eye contact and sound sincere but I'm pretty business-like.  There is already an IV pump in the room and I spike the antibiotic that I have already mixed, hang it, priming the tubing and feeding it through the pump.  I set the pump for one hour.  I make sure the patient has a call light and have one foot out the door to run to my next task.  The family wants to know how soon admission to comfy floor bed will happen (hours) and what time is dinner (you have abdominal pain.  Never).

47 minutes elapsed.  I repeat the procedures on the 2nd patient, but must find an available pump first which takes a few minutes. I have to retrieve a visitor from the waiting room, as all must be escorted in our ER (topic for another day).  Emergent-toileter-relative-who-is-not-my-patient glares at me from her helicoptering position at the door.  I am moving too fast to flag down.

I am back at my desk now about 57 minutes in and I haven't even laid eyes on the 4th patient.  I have done nothing but toilet a patient who isn't mine, clean up shit, give meds and fluids.  I have done nothing, really, to educate my patients or make them more comfortable, or even make them feel like I care about their problems.  Tasks, tasks, tasks.

 I discover that CT has called, along with ultrasound, for the shortness of breath and leg swelling which is patient number 4.  I explain that the doc wanted to wait on the lab test before sending for the CT.  I hunt down the physician to see if it's ok to send to to ultrasound.  First I check to see if the patient has a patent IV: yep.  Quick assessment, check the monitor and VS, then disconnect and transport the patient myself to ultrasound because there is never anyone available to transport since our last transporter, the 4th this year, quit after 2 months on the job.

I return to my desk once again.  One of the physicians wants to know if meds were given:  yes, not charted.  She thought so, was just wondering if there had been any response.  No idea.  Haven't been in the room, but haven't heard any puking and they asked about dinner, so all good from my perspective.

All of this has taken place in about 1 hour and 10 minutes into my shift.  I have charted nothing, my zone partner is nowhere to be found, and my boss wants to know if any of my patients have orders for admission to the floor and can be transported (nope) or discharged (hell no),  or can be moved out of a room for an ambulance arriving with chest pains.  That means that now any remaining  tasks care to be provided to any other patients will be put on hold while I take the next 20 minutes with this new patient.  Move family of patient in ultrasound to hallway amidst grumbles, move in new stretcher, accept ambulance report, then triage/assess/undress/EKG/place on monitor/start IV and draw labs on the chest pain patient who is from a nursing home.  This patient turns out to be an elderly 90 year old, non-verbal and demented, also combative, and therefore non-participatory in his care.  He has  2,000 meds and has never been at our facility, so they all have to be entered into the computer.  I say screw it, and merely attach the list to the chart with a sticky note to the provider that I will get to the meds when I can (our pharmacist who loves to do that shit).   It is Friday afternoon and nursing homes are well known for the tactic of sending their difficult patients to the ER at this time with vague complaints or  "chest pain".  My 20 minute intake takes about 45 minutes to an hour due to incontinence, possible fever and sepsis, while dodging swinging fists and verbal abuse.

I feel I have been a bad zone partner and not been able to help with the combative overdose, but fortunately the paramedic (bless him) has been in with her the whole time.  Her other 2 patients are fortunately awaiting admission, so need little in terms of assessment and treatment at this time (except for the soul-sucking emergent-toileter whose family member continues to glare and ask for stupid things like jello).  I carry on.  In the meantime, two of my patients are on the call bell "just" wanting updates on their admission progress (hours, you are stalled in the ER as there are no available beds on the floors), "just" some warm blankets, "just a quick question",  and at 4:15 in the afternoon to inquire if a sleeping pill will be ordered when they are admitted.  Dunno, and right now I don't care.  Not my job and not up to me, ask the hospitalist.

Less than 2 hours into my shift and I have had limited contact with my patients.  This doesn't feel good for any of us.  Its "adequate" at best.  To me it was crappy care.

Our administrative clip board commandos walked out at the end of the day knowing the department was about to implode, but leaving us with "adequate staffing".

"Adequate staffing" did not add additional personnel for the additional 12 patients in hallway beds.  There were two LNA's, one of whom was designated to sit and watch the suicidal patients in the overflow hallway beds.  The other was being ridden like a cheap pony.  There was one paramedic who was occupied.  The EKG department calls it a day at 4 PM and we have to do our own.  Just one less resource and an additional task.

If we had 4 extra nurses we would have been golden, even with non-stop ambulances and an overcrowded waiting room (5 hour wait).

With 3,  it would have meant a world of difference.

One or two even would have helped.  An extra paramedic.  A couple of LNA's.  Our secretaries were thoroughly in the weeds.

At this point I completely understood why Massachusetts nurses put this on the ballot, born of utter frustration.  More nurses, better care.

Hospital executives don't care and won't spend the money on nursing unless compelled to do so.

If I lived in Massachusetts I would vote yes.