Night Shift Survival

I’ve worked nearly every shift in the world in the myriad jobs I have had the pleasure of toiling at.  Swing?  Early AM?  Graveyard?  Splits?  Late Evening + Early AM?  3 hours?  4 hours?  12?  8?  I feel like I’ve done them all.  I found though, that I really do like the full 12 hour graveyard  Why you ask?  First, less bullshit.  No management, PT, OT, social work or docs.  This of course has it’s disadvantages too, but you soon learn to deal.  Second, the mood is different.  Many of my night shift colleagues and I figure we have 12 hours to get everything done and the pace kind of reflects that.  Third, it starts with a bang, then usually calms by morning.  Though some nights you start with a bang and it never stops.  Did I mention lack of management in the house?

Thing is with nights is that it is completely opposite from the rest of the world and our natural circadian rhythm.  Nature did not mean for us to be up all night when we should be sleeping.  Guess that’s why night shift work is considered a carcinogen.  After 2 weeks of flip-flopping back and forth from nights to days made me realize that I may have what works for me to help me “survive” the night shift.  I’ve seen severl post around the blogosphere talking about this, so I figured to add my voice to the fray.

Wanderer’s Tips to Night Shift Survival, volume 1.

1  Pick a millieu.  Say what?  It’s simple:  decide if you are going to stay on nights or are going to flip back and forth.  I know that I function better when I’m more consistent.  I plan my schedule to cluster my days and work a 3 on, 2 off, 3 on, 6 off rotating schedule.  During those 2 days I stay a night owl and don’t flip back to days until the 6 day stretch.  But I don’t have a long stretch like that, you say.  Bribe your scheduler.  Seriously, having a block of time to be “normal” will make you feel better and more apt to stay fresh when you’re back on nights.

2.  Don’t rely on caffeine.  I know that’s heresy to say to night shifters, but too much caffeine only makes you shaky after awhile.  And you’re still tired.  I usually have some sort of caffeine at 2am or so but I’m not mainlining it all night long.

3.  Stay hydrated.  I know that leads to the need to pee which we never seem to have, but it will make you feel better.  Plus you have to counter the diuretic effect of all that caffeine.

4.  Eat small.  No big meals.  It will only make you slow and tired as you digest.

5.  Get some sun if you can.  I know during the winter it can be tough, but I swear getting some sun in my face makes me feel better.

6.  Exercise.  A little bit of something to raise the heart beat before bed can help you sleep better.  I ride a bike every day I can and on those days where I don’t I miss it.  Plus it helps me drown out the night prior.

7.  Black out curtains and a face mask.  Best money I have spent on things to help me sleep.

8.  Pharmaceuticl help.  I have an issue sleeping on my non-work days so I have turned to the occasional help of Ambien.  I maximize sleep when I can.  Things like Benadryl/Tyelonl PM/Unisom/Melatonin can leave you with a bit of a hangover effect, but they work.  Caveat emptor.

9.  Realize that you’re going to miss out on things and make peace with that.  Sleep is needed and you have to guard it jealously.  A favorite story of mine is a friend who worked nights and their mother kept calling at 1pm, when they were asleep.  She would say, “I thought you would be awake.” So my friend decided to turn it around and call their family at 2am…they should be up right? It only took one time for their mom to get the point.  Your family, friend, telemarketers etc. all need to know that you sleep in the day,just like they sleep in the night.  It’s hard if you have kids though…good luck.  So turn off the phone and crash out.

10.  Understand that you will get tired of nights at one point and decide to go to the “Light Side.”  Truly you are a sell-out, but the reality is that those who stay on nights are just jealous…

Hope this helps.  I swear by all of this and has kept me “sane” for nearly 3 years.  Granted that “sane” is a relative term…

Has H1N1 started to peak?

H1N1 cases fall in U.S. but could rise with Thanksgiving travel, gatherings – washingtonpost.com.

For the first time, this week showed a drop in case of H1N1 with only 43 states noting widespread H1N1 activity.  I was at a critical care conference this week and one of the speakers mentioned this very report.  He also raised concerns about a “second wave” problem related to holiday travel, that there will be a surge post-Thanksgiving due to family get-togethers and increased travel.  He also noted reports out of the Ukraine of mutated strains of the virus.  From the article:

The news came as scientists in Norway announced that they had detected a mutated form of the swine flu virus in two patients who died of the flu and in a third who was severely ill. It is the most recent report of mutations in the virus that is being watched closely for any change that could make it more dangerous.

In a statement, the Norwegian Institute of Public Health said the mutation “could possibly make the virus more prone to infect deeper in the airways and thus cause more severe disease,” such as pneumonia.

The institute said that there was no indication that the mutation would hinder the ability of the vaccine to protect people from becoming infected or impair the effectiveness of antiviral drugs in treating people who became infected…

The World Health Organization said viruses with a similar mutation had been detected in several other countries, including Brazil, China, Japan, Mexico, Ukraine and the United States. “No links between the small number of patients infected with the mutated virus have been found and the mutation does not appear to spread,” the WHO said in a statement.

With my apocalyptic thinking cap on I can see a “second wave” of the mutated resistant strain of H1N1 sweeping the world turning us all into zombies.  If only…

The only thing this really means is that there may be less ILI cases landing in our ED and thus onto our obs unit.  Which may or may not be a good thing.  Interesting stuff nonetheless.

 

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…

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:

A Happy Hospitalist: I Wonder If I Should Recommend A Divorce

A Happy Hospitalist: I Wonder If I Should Recommend A Divorce.

Perhaps this is one Happy quote I do totally agree with:

He said I was treating her like baby and told me not to come back.

Which is fine. Except that attitude is a major part of the problem. Perhaps adults who act like babies, adults fully incapable of making grown up decisions (like showing some initiative in their own disease management); Maybe they should be treated like children.

I don’t know what to do for someone who chooses not to help themselves. Free will is a powerful thing. But it works both ways. All I can do is make sure we do everything within our power to remove the barriers to patient’s care. And hope they make the right decisions for themselves and their family.

It’s funny we were just talking about patient responsibility this week at work and how that should play into the reforms slated to take place in health care.  I’m of the nature that says, “You can do whatever you want.  BUT.  You must be willing to take responsibility for your actions.”  And that is the problem with so many of our gomers.  They refuse to take care of themselves and end up back in our halls time and time again.

Take for example the twin renal patients who by all accounts have used up their money from the MNB (I didn’t know that was possible to do, so that assumption may be wrong).  They spend months at a time in-house, then get discharged.  And when they get sick again, because they live 200+ miles away, they get Lifeflighted back to our hospital – because that is where their docs practice and they refuse to live closer.

Or the young (under 50) gentleman who is already in ESRD due to uncontrolled diabetes.  Last A1C was something like 14.  As he’s sitting with a CBG (actually serum glucose beacuse the meter just read “HIGH”) of 520mg/dl, says, “So can I have 2 bowls of Cheerios to go with the sandwich I have in my bag?”  And these are just a few of our frequent flyers.

So many are just the same.  They decide that they don’t want to take their meds, or won’t go to the pharmacy to pick them up, or decide that 3 times a week dialysis cramps their busy social schedule too much and only go twice, think that movie theater popcorn and Wendy’s is an essential part of a low-salt diet or think nothing of just stopping their Lasix one day out of the blue.  They come in all saying, “I don’t know what happened!  I was doing everything I should!”  And we spend hours trying in vain to (re)educate them, hoping that they will not bounce back once we turn them loose.

Part of me says, “Fuck ‘em.  They’re not willing to take an active role in their health care, they shouldn’t get any more than the barest of minimums.”  Research has shown that the management of chronic diseases is the one that saps the most money out of our health care and while the specter of paying for outcomes instead of fee-for-service may be a valuable tool to prod docs (and nurses!) into more productive engagements with their patients, this too is a two-way street.  All the teaching, even if done in the most agreed upon, for sure to work approach, most interdisciplinary method possible will never work if the recipient of said information is not willing to put it to work and practice the concepts we teach.  Maybe those that refuse to do this should be excluded, be given a certain amount of chances, document the refusals, then at a certain point, begin to withhold all but the most basic of care.

The other part says that maybe if we keep doing what we’re doing, it will sooner or later sink in and the habits will start to change.  Plant a seed and all that crap.  The problem there is we cannot continue the status quo.  Something will break and it isn’t going to be the patients.

And as for our ideas about reforming health care, we all conceded one point:  the paradigm of health care must change but that entails a societal shift in values.  More prevention, less end-of-life heroics with the understanding that death is a part of life and the reduction (some argue by any means) of non-compliance with medical therapy.  It sounds harsh, but we are reaping what we’ve sown.  The American Entitlement attitude has led us to this point and it will only be by changing that attitude will we be able to fix the probelm we’re in.  And if that means treating adults like children when they are acting that way, so be it.

Who is the AMA?

OK, maybe not really, but somedays it sure does feel like it.

At any rate it’s just plain funny.  Best quote?  “If you’re not sick, we’re not doing our job.”

Dr. Wes: An Open Letter…

Dr. Wes: An Open Letter To Patients Regarding Health Reform.

“Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term “leper colony” mean anything to you?”

Classic.  With just the right amount of snark.

Sometimes All You Have Isn’t Enough

And yet still, IRS wants more from you.  And your business.

“The IRS believes that some percentage of the costs incurred by employees using company-provided wireless devices should count as a “fringe benefit” and thus be subject to taxation. Since workers inevitably end up taking personal calls or emails, the thinking goes, it’s only fair that they pay for the privilege. What’s next? Maybe a per-cup tax on office coffee, or targeting furtive visits to ESPN or Hulu on the office PC? As one wag put it on the Journal’s Web site, “It’s like charging for the use of the company washroom.”

I understand the need to have taxes to support the myriad programs of our government, but this is ridiculous.  And the thing that stings, is that it is happening from top to bottom.  It’s one thing if your federal taxes get jacked, but now many states, counties and cities are finding new and creative ways to wring every last penny out of you.  Fees for awnings, inspections and permits are all going up in my fine city.  If there is a way to slap a fee on it, our lovely city leaders have figured it out.  Not to mention the colossal waste of money that the new soccer stadium will turn out to be.  How is it that a city who’s roads are so behind in repairs intends to spend millions on a new soccer stadium, that may or may not bring in any new revenue to the city?

And so like our friends in Washington, who think that our use of office resources needs to be classified as a “fringe benefit”, it will not be long until the local folks try to figure out a way to do that as well.  Or in other words, “If it moves, tax it.”