What’s Your Pain?

It’s something we ask all of our patients.  As nurses we want, no, need to know if our patient is in pain.  So we ask, “On a scale of 1-10, with 10 being the worst pain you have ever had, how would you rate your pain?”  Or we use the faces method, or whatever method of assessing pain is in vogue at the moment.

So very often with a straight face, the patient looks at you and says, “I’m in 9 out of 10 pain.”  Just like that.  Straight faced.  Vitals are completely normal.  Face calm, nearly serene, talking and laughing on the cell phone, with not a single outwardly visible sign of any discomfort.  Since we rely on out patients to report their pain to us, it is not something we can objectively monitor, you have to accept what they say it is.

Now I know people in chronic pain.  I know that you can learn to block, modulate, go into a Zen-like trance to mitigate your pain.  But I have never seen anyone in true 9/10 pain who is calm.  That would be impossible.  I always try to give a scenario with pain, so that the patient will understand what I mean.  I’ll say, “0 is no pain, 10 is being doused in gasoline and set on fire.” or for the ladies, “10 is giving birth.”  But still I get the odd answers.

The reason I bring all of this up is that we have had a preponderance of folks in “pain”.  These painieurs always report their pain is 9/10 and that the only thing that works for them is Dilaudid.  They watch the clock and call 5 minutes before they are due to “remind” us that their meds are due.

We actually had one come up to us who immediately complained about 9/10 chest pain.  The nurse, being thorough asked, “What do they give you normally?  Nitro?”  “No” she replies, “They just give me Dilaudid.”  Straight-faced, looking like she is in a café ordering a latté, yet still having 9/10 chest pain.  To me it is a total disconnect.

Partially the disconnect comes from the fact that we color the patients’ report with our own perceptions.  The other week I re-injured/aggravated an old ankle/foot injury.  It throbbed mercilessly and then it would spasm.  At times, the spasms were so painful that I felt like I would vomit from it.  Even my wife looked at me grimacing, sweaty and pale and asked if I was OK.  Sure I was being John Wayne-esque about it and stoic, but it hurt.  I popped a couple of Tylenol, grabbed the ice pack and put my foot up.  Even with me almost vomiting from the pain, I would only have rated the pain a 7, maybe a soft 8 of 10.  I can imagine what 9/10 pain feels like and I have no desire to feel that.  I know that if I was truly in 9/10 pain, I would not be calm.  That’s why it is so hard.  You wish you could tell the patient to “cowboy up” and deal with the pain, but you can’ – although I did overhear an orthopod tell his patient we was going to have to do just that.  We have created a culture where it is never OK to have some discomfort.  Just look at the rash of relatively healthy folks showing up to EDs complaining of the sniffles and low-grades temps thinking it is the flu.

So sometimes you don’t ask.  You observe from a distance and document.  Even when you’re assessing the patient, unless they bring it up, you stay away from it.  What I hate the most about the painieurs is that they color your assumptions of everyone else.  Where you normally would try to reduce the pain of your patients, you ask yourself, “Are they faking it?  Do they just want the buzz?”   And I hate they have done that to me.

I know there is no easy answer to this dilemma.  I try to take the road where unless they have proven themselves to be dodgy, I treat the pain full force.  But with some that you deal with time after time after time, you know that they are drug seeking and all they want is the rush.  But moreso I try not to let my own perceptions of pain color my view.  I may be able to deal with 7/10 pain better than others due to my nature, so I can’t let that get in the way of effective treatment.  And for the most part I don’t.  It is just those rare occasions where I question, but more often than not I give the meds and hope we’re not being taken advantage of.

And as for the patient who only wanted Dialudid?  The nurse called the doc who pretty much said they were a known drug seeker (which we knew already) and she would not provide their drug of choice.  The patient realizing they were not going to get Dilaudid promptly signed out AMA.

True Health Care Refrom – TBATM

The Blog that Ate Manhattan: TBTAM on Healthcare Reform.

Great read.  And far too true.  While I may not totally agree with Mad as Hell Docs (not sold on single-payer), they tie in with the whole idea of cutting out lobbyists and making this a discussion between the us and our docs.  To Hell with Big Insurance, Big Pharma and the lot.  My favorite quote:

Healthcare won’t get fixed as long as the stakeholders in health care with the biggest voice in its reform are the insurance and pharmaceutical industries, medical device makers, lawyers and others whose business thrives on the increasing health care expenditures of the American public.

Asking these folks to help us reform healthcare is like asking Master Card, Walmart, Verizon and Best Buy to help figure out your monthly budget.

Damn straight.

h/t once again to Dr. Wes!

The kids are dying!…

Shortage of shots as more kids die of swine flu – Swine flu- msnbc.com

What a way to sensationalize tragedy.

Yes, it is a tragedy when kids die.

Yes, it is unfortunate that we don’t have enough vaccine available.

Yes, some people believe that vaccines are bunk, especially the flu shot.

Yes, the hysteria is starting to rise.  It’s everywhere.  Makes one want to stay isolated inside the house and never leave, open the door with a N95 and turn the foyer into a positive-pressure space.  Makes me just turn off the news and news websites and pop a Xanax.

But why focus on kids?  Easy:  kids pull at our heart strings.  Kids are the easiest way to sway the public’s opinion.  Sad but true.

And I don’t need a special graphic to tell me that H1N1 is widespread in Oregon.  I just go to work.

Mad as Hell

Finally someone is stepping up to force the maniacs in Washington to slow down, think things through and include everyone in the debate over health care reform.  Enter:  Mad as Hell Doctors.

Yes, doctors, mad as hell that the majority of the country has been left out in the cold while the privileged few run our system beyond ruin in a vain attempt to fix it.  Single payer?  I’m not sold on that idea, but my love of this idea lies here:

Let’s restart the effort and take Health Care legislation off the table until the Spring session of Congress. In the meantime, let’s use HR 676 as a starting point for a new health care conversation and empower MAHD physician-citizens to seek out the best minds from America’s vast resource of inspired health care professionals. We will then assemble these individuals into a working team that does not include anyone from the private Health Insurance Industry, the Pharmaceutical Industry, or anyone currently holding public office. Their assignment will be to craft a thoughtful, actionable single payer health care model, uniquely tailored for America, that the entire country can comprehend.

Who knows, maybe this is the method to shore up our failing system.  But what I love the most the drive for honest and open debate.  No back room deals inside committees, no one involved who has received money from the very places we’re trying to reform, no “death panels” (dumb-asses…read the fucking literature), the interests for once are left out in the cold with the goal of bringing everyone in, and leaving no one out.  Is that such a bad thing?  Really? I didn’t think so.

Generation of Dummies?

Is Spell Check Creating a Generation of Dummies? – DivineCaroline.

Umm, yes.  That and Facebook, Twitter, SMS, email, MP3s, high-fructose corn syrup and video games.

It’s so easy to fool spell check too.  Example:  I was board with my roll at work.  Sure, it’s all spelled correctly, but the usage is definitely not.  My first degree involved a ton of reading and writing, banging out 10 page essays was child’s play, so I have an eye for errors and I see it all the time.  One job I worked at in nursing school had a typing portion where we were read a paragraph and had to type it without spell check.  We were then graded on how many mistakes we made, which played into the company’s decision to hire us.  From what I heard later on, it wasn’t pretty.

It’s not just with kids/teens, but it happens in the work place.  Even in our new EMR, there was a spelling mistake, using “course” instead of “coarse” for describing breath sounds.  Reliance upon technology makes us complacent, thinking that the red squiggly line will fix our writing errors, is like relying just upon the EKG to determine a patients’ diagnosis.

Being able to speak well and successfully convey ideas in a written format is essential to survive in our society.  As nurses we have to translate what we see/feel/hear into words and phrases to ensure others coming after us can understand what it was we were encountering.  Sometimes it works, “bibasilar coarse crackles heard”, others “rumbling sound heard” it doesn’t.  That’s why it’s important.  Having new nurses, or folks right out of school with the inability to do this beyond, “LOL” or  “OMG, ur so rite! ” becomes a concern, even moreso when you realize that even modern EMRs don’t come equipped with spell check…

No, we need it now.

Somedays our hospital staff just baffles me.  Somedays they are über-ready to get something done, like the CT tech who calls 30 seconds after you put the order for a CT in.  Other days you call phlebotomy and three hours later they show up to draw a “now” lab.  There’s no consistency.  And when you need something like blood, it’s usually not just something that you can be “meh” about.  Case in point happened a couple of weeks ago.

We had a patient who needed blood.  Badly.  Unfortunately due to their specific disease and numerous antibodies, they needed special blood.  The Red Cross had to fly it in.  Yes, fly it to us and we’re fairly good-sized city.  It’s not like we’re in the middle of podunk backwoods-land.  The blood bank calls us at 1am and says the blood has arrived and we figure we’ll be getting a call soon that it will be ready.  2am, nothing.  3am, nothing.  The house doc comes up asking if the blood has started, he wants it done now.

So we call blood bank.

“Calling about the blood for us up here on 5.  Is it ready yet?”  asks the nurse.

“No, we’re having a problem with the computer and can’t get it ready.” replies blood bank.

“No, we really need it soon.  It’s kind of important.”  replies the nurse.

“Well, you see there’s a probelm with the computer generated tag and I can’t do anything about it.  Only my supervisor can has the right access…”  says blood bank.

“And when are they coming?”  angrily asks the nurse.

“Uh, I haven’t called them yet.  Don’t really want to wake them up, it’s 3am.”  they say.

“Maybe you don’t get it.”  says the nurse.  “My patient’s H/H has dropped to 5.0/16.3 in the last 4 hours that you’ve been stalling on getting the blood to us.  You need to call them.”

“Let me make a call.”  they reply.

30 minutes go by.  The house doc comes by again, still wondering if we’ve started, which we haven’t.  And then comes the cool part.  He calls them.

“Look, I don’t care if the supervisor has to override this or that.  My patient needs blood.  If they haven’t arrived in 10 minutes, I’ll come down there and sign the blood out myself, to hell with your computers.”

Guess  what?  The blood was ready in 7 minutes.  Sometimes having an MD to throw their weight around is a good thing!

BikePortland.org » Blog Archive » National organization finds that bike-to-school bans are on the rise

BikePortland.org » Blog Archive » National organization finds that bike-to-school bans are on the rise.

Robert Ping, the State Network Coordinator for the Safe Routes to School National Partnership shared a startling bit of information during his presentation at the Safe Routes to School Conference today.

In communities throughout America, students are being told they are not allowed to bike to school.

“It’s pervasive throughout the country and we’re hearing about it more and more,” he said. The problem, according to Ping, is that many school principals and administrators feel that biking and walking to school is simply unsafe. They are concerned about being held liable for anything that happens during the trip to and/or from school.

Used to be I could sit in my paretn’s living room and watch a steady stream of kids walking to the school at the end of the block.  Not any more.  Instead it is a steady stream of cars lining up to drop children off at the school.  I go past a small private school on my way home from work in the morning and during the school year I play a frequent game of “dodge the soccer-mom minivans” as I run the gauntlet past the school.  And walking is unsafe?

An interesting side note is that while the schools are worried about walking and biking to school and the liability it “entails”, it says nothing about the over-active hormone machines known as high school students behind the wheel.

Me, I plan on living near the school where my kids will go so that they can walk or ride their bike to school.  It just makes sense, unless some dipshit decides there is “too much liability.”

Idiots in Charge

I’ve come to the conclusion that the people in charge of things like regulations and billing are some of the biggest morons in our industry.  Worse though, is that they just don’t get it.  They are so far removed from the bedside that they have no clue that adding an extra check box in itself spawns that many more things to click and chart under and then you multiply that by the number of patients you have and the number of times you have to do it. The single click quickly spirals into more than just one click.  That and the rules so often do not reflect the true nature of what we do.

Today while going over charge capture methodology for our Epic transition, one of the billing people said the following, “My clinical experienced is pretty limited, so let me see if I understand this correctly…”  So what’s wrong with that you ask?  She’s in charge of auditing charts for billing/regulatory compliance.  One would think that some degree of clinical expertise/understanding would be required to accurately understand the charts.

And the folks making the BIG rules, CMS, is suffering from such a case of rectal-crainio inversion it’s not even funny.  A perfect example we went over today was blood transfusion.  Simple right?  Drop a charge every time you enter a unit of blood into the computer.  But no, that would be too easy.  For CMS (and thusly everyone else) beleives that you should only get paid per instance.  In other words, per MD order, not number of units.  So if the order is for 1 or 6 units, we get the same thing, even though we do the exact same amount of nursing care for each unit.  Every time we have to double verify, take vitals, stay with the patient for the first 15…each time.  So if it is 6 units, you’re doing the same work 6 times, but really only getting reimbursed for the first.  Makes sense to me!

I still believe that every billing person, CMS regulator, TJC auditor and anyone who writes rules and regulations be required to spend at least a week a year, if not more in the trenches.  No cushy units, but units where they would have to work and be subject to the rules they have enacted.  Then they might not be so regulation happy.

One can dream can’t they?

Recession Ending Nursing Shortage? via Fox News

Recession Ending Nursing Shortage? « On The Scene « FOXNews.com.

Normally I’m loathe to have anything to do with Fox News, but this particular headline caught my eye.  And it’s complete bullshit.

The recession apparently has solved a problem in the healthcare industry, at least temporarily. A study out of Vanderbilt University shows that a decade-long nursing shortage has nearly disappeared in the past year. Researchers found that more nurses are delaying retirement or coming out of retirement because of demolished 401K’s and partners who have lost their job.

No, not totally.

Well, at least partially this is the case.  But usually the determinant of a shortage is am overabundance of open positions.  This means there are jobs that need to be filled, hence not enough nurses (or whatever) are filling those positions.  The problem here is this:  NO ONE IS HIRING.  Maybe I shouldn’t yell, but I am talking about Fox News…

OK, there are pockets of hope where folks are getting hired, but there are none in my city.  We have no, read that zero, positions open for nursing staff at my facility.  And it’s a story being told around our city, and across the country (some places worse than others).  The nursing shortage has been solved by the institutions not creating a shortage by having open positions.  Added to nurses staying put longer and voila’, no more shortage.

It’s going to suck when the economy does turn around and the boomers will finally retire.  It’s not going to be pretty.

Makes One’s Head Spin

The hue and cry throughout the land over health care reform usually ends with the same admonition:  read the bill.

Sorry.  Not going to happen.  Much like any other carefully crafted piece of legislation, this vaunted bill carries a ton of bureaucratic legalese that makes as much sense as Ancient Latin.  For example:

(a) Medicare-

(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended

(A) in subsection (s)(2)—

(i) by striking `and’ at the end of subparagraph (DD);

(ii) by adding `and’ at the end of subparagraph (EE); and

(iii) by adding at the end the following new subparagraph:`(FF) advance care planning consultation (as defined in subsection (hhh)(1));’; and (B) by adding at the end the following new subsection:  h/t Junkfood Science

Yes folks, this how it is written, full of additions, striking, subparagraphs, subsections and enough misdirection and confusion to employ a cadre of lawyers full-time for the next millennium (maybe that’s the point…).  My point being this:  it does no good to read something if it makes no sense.

I know that I’m probably oversimplifying things, but again, a quote:

(hhh)(1) Subject to paragraphs (3) and (4), the term `advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

`(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to./p>

`(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses./p>

`(C) An explanation by the practitioner of the role and responsibilities of a health care proxy./p> (JFS again)

Sure, this is a little clearer, unless defined by paragraph 2, subsection 2, which refers to chart 23a for those referred to in subparagraph 2, section 3.  Those in subparagraph 3, section 2a, please use chart 84-4b.

Sorry, got carried away for a second.  The pundits wonder why our representatives don’t read bills (remember, no one really read the Patriot Act either as it was full of the same crap, and there wasn’t “enough time” to do so.)  It’s simple, this is why.  Understanding biochemistry is easier than reading Congressional legislation.  It’s no longer as simple as “I’m Just A Bill” of Schoolhouse Rock fame.  The concept is the same, but the ideas contained therein are a little more complex.

The argument goes that to encompass such a wide swath of American life, it needs to be complex.  But it is the very complexity that makes it unwieldy and administratively top-heavy.  Like the tax code, this too will spawn, or at least encourage the cottage industry of interpretation due to the mostly vague nature of the act itself.  We can’t have our decisions made by committee or by the elite, especially when it comes to our health.  That is something between a doc and his patient.  If the doctor is not the Primary Provider, see Section 21a, paragraph 5, subsection 4.  But I think you get my point.

I have no answer to this problem.  Wish I did.  I don’t think socialized medicine is the answer, nor do I think our current system has any life left in it.  We obviously can’t continue on the same path we’re on.  And yes, there is going to be some pretty bitter pills to swallow in the coming months and years.  But I know one thing:  I don’t want the government running my health care.

And now for some levity: