A Happy Hospitalist: What Happened To The Nursing Profession?

A Happy Hospitalist: What Happened To The Nursing Profession?

….I was going to write a bitter polemic about this, but realized that it would just fuel Happy’s ego.  It’s bad enough that I’m linking to it, but I had to say something about it.  So here goes:

1.  More often than not as nurses, we’re not allowed to exercise our critical thinking and judgment thanks to rules, regulations and policies.  Even when we know that it is not necessary to call (thanks to our experience, training and critical thinking), we still have to call, or if nothing more, document why we didn’t.

2.  Some nurses are better/more experienced/better educated/have more common sense than others.  Same goes for doctors.  ‘Nuff said.

3.  We’re not always sure the doctors are aware of the situation (many times they aren’t…) so we call to inform them of it.

4.  Us night shift nurses really love nothing more than to call up a sleeping hospitalist at 3am to report a critical value (that really isn’t, see point #1).  It’s almost as much fun as having to call a cardiologist at that un-godly hour.

Just my view.


I just finished working 6 out of the last 7 nights.  It’s kicked my ass, but in the end was worth it.  One of the shifts was overtime, which never happens anymore so I had to take advantage of it.  I feel like I should be more tired, went to bed at 9am and woke up at  feeling fine.  I no longer understand my body’s sleep patterns, they’ve gotten too screwed up.  Now I just sleep when I feel like it and hope for the best.

Luckily I have a week off and in spite of having to take ACLS tomorrow (and the next day) it should be enjoyable.  But alas, it is Spring in Oregon and there is nothing but clouds and rain in the forecast.  We had one day of bright sunshine this week and it was wonderful.  I felt alive again, at least for awhile.  Considering the previous evening I was riding through downpours on the way to work it was a nice change.

Here’s a couple of funnies from the week:

Chief Complaint 1:  Suicidal Stomach
(actually suicidal, stomach pain, panic attack, but our system only shows the first 20 or so characters of the complaint.)

Chief Complaint 2:  Penis Lac
(in comments to the side “S.O. w/tongue piercing.)  That’s sexy…nothing like the feel of steel on your…uh, nevermind.


Of my demise, once again, have been greatly exaggerated.  Between Comcast, near-eviction, a psychotic landlord, 2 near Codes, a root canal, 2 weeks of antibiotics, a sick wife and a busted rear wheel, blogging has not been at the forefront of my mind.  I am still alive, kind of.

Taking the beak though, further crystallized for me why I write:  I like it.  It is one of my creative outlets that requires no more money than I already put out, which is a good thing!  I’m energized and happy to be back on the horse.  But of course I have to work.  OK, well maybe later this week….

Bill would make cyclists pay to use & maintain roads.

Bill would make cyclists pay to use & maintain roads | Local News | kgw.com

This pisses me off on so many levels that I’m seeing red just thining about it.  I can understand why the reps involved in this want to pick on a visible minority, hell, we’re not always the best of stewards (us cyclists).  But this is just an out and out attack.

I went through the commentson this article and the most common one is, “Good!  Make them pay for using the roads too!”  Nothing could be farther from the truth.  I pay property taxes, state and federal income taxes, I register all three of my cars (including the restoration project) and the family does drive nearly every day thereby consuming gas and adding to the gas tax fund.  Who’s telling me that I don’t pay me own way?

It’s just bullshit.  By bicycle commuting I take a car off the road, thereby reducing my carbon output and reducing congestion, plus I’m doing something healthy for myself that will reduce my draw on the health systems down the road.  Besides, the fee will not even pay for the administration of the program, much less contribute to actual upkeep of the roads.

You better believe that I’m going to involved in getting this bill killed!

medical-esque posting to resume shortly…

EKG of the Week #1

click for larger view

Pretty classic example of failure to sense and failure to capture.

As you can see, the pacer is firing but there is no response from the heart.  No P-waves, no QRS complexes, just lone pacer spikes hanging out.  This is classic failure to capture.  Possible causes of this can be a fractured or dislodged lead, battery failure or electrolyte abnormalities among others.  Luckily in this case the patient has an intrinsic rhythm that is probably perfusing them.

The second item shown is failure to sense.  Notable for this is the pacer spikes in the ST-segments.  Failure to sense is exactly what is says, the pacer is failing to sense the cardiac cycle and inappropriately pacing.  Again, luckily in this case the pacer is not capturing so the inappropriate pacing is not causing issues.  The biggest problem with this failure is inappropriate firing when the heart is not quite yet refractory possibly initiating ventricular arrhythmias.  Causes of failure to sense include lead issues (dislodgement, fracture or poor positioning) or sensitivity issues requires a change to sensitivity.

In this particular case, it appears the patient is in atrial fibrillation, which may be causing issues with both capture and sensitivity.  The erratic electrical signals emanating from the atria may be throwing off the pacer, but many times they are programmed with this in mind.  For nurses the important things to remember is to check on the patient when the pacer is acting up and ensure they are stable.  Past that, with permanent pacemakers, we need to get the cardiolosit involved.  If it the nurse who is running a temporary pacer at the bedside, adjustments to both output and sensitivity may be required to ensure adequate sensitivity and capture (but that’s a whole other ball-game!).

Here’s what a pacer strip should look like:


Each spike has a corresponding activity, just like it should.

When Your Hands Are Tied

“No, no Mr. Fisher.  You need to get back to your room!”

That’s what I hear as I round the corner with a fresh cup of coffee the other night.  I’m also greeted by an elderly man, droopy drawers and all, attempting to urinate on our new floor.  Yep, just another night.  But it isn’t.  I hear the voices start to rise, his more than the nurse and I can sense the frustration in her voice as she tries valiantly to both defuse the situation and return Mr. Fisher to his room, safely.  Normally, I’d be jumping in, but knowing Mr. Fisher, extra people running in to help only makes him ramp up more.  It riles him up something fierce.  I can see him though.  Slightly defensive posture, fists clenched, muttering gibberish and leaning back almost as if trying to figure out if he is going to strike.  Besides what we’re doing, there’s not a thing we can do.

You see, our hands have been tied by the family.  Instead of having medication available should Mr. Fisher get out of control, we have nothing.  Just us.  Luckily every time he ramps up, we’re able to bring him back down.  But it is getting worse.  On admit, the MDs prescribed some medications to help even his moods and reduce the paranoia and hallucinations,the psychosis of advanced dementia.  And you know what?  It was starting to work.  Now instead of walking down the hall with PT crapping his pants and being wildly inappropriate, he’s actually returning to regulated behaviors.  But no, the family decided they didn’t want that and of course the docs complied.  Gone is the Aricept, gone is the Seroquel, gone is the Zyprexa and Haldol for outbreaks of violent behavior.  In their place is an order to “call son if planning to give PRN meds”.  Gone is our ability to make decisions.  All we’re left with is our abilities to talk this gentleman down from the brink.

The very first night, he got crazy.  Between the nurse and I, we spent 2 hours trying to bring him back.  All for naught, until my friend Haldol.  Just a touch and he calmed down.  Evidently, the next day, the family threw a shit-fit over this.  And I’m left to wonder why.  It’s not like we had to call for a PRN order, the doc had written the Haldol as part of her admission orders.  It’s not like we hadn’t tried everything else at our disposal, believe me, we had.  In essence our hands were tied.  It pissed me off.  None of the family had any sort of medical background.  They didn’t want their dad “oversedated”.  I can understand that.  We have a tendency to chemically restrain folks for the sheer convince of it, but I’ve never been an advocate of that.  It is however a good thing to have available if the patient gets out of control.

As the days wore on, the therapeutic regimen of medications designed to temper some of the behaviors of dementia, like him taking a crap as he walked in the hall with PT, began to work.  He reverts back to the gentleman  we knew he probaly was.  Instaed of continuing, the family unilaterally decides that it isn’t the medication, but that he’s actually doing better.  So they insist the docs stop them.  All we have a touch of trazadone to help him sleep at night.  Thanks.

What really screwed us though, was that the off-going nurse actually said, “Oh yeah, he’s been an angel all day!”  That’s like saying “It’s awfully quiet!” at 2am.  Good things can never come of it.  And sure enough the worst began to happen.  He ramped up again and again.  The nurse would spend 2 hours talking him down and he would sleep for another couple of hours and then the process would start all over again.  In a moment of frustration I posit, “Maybe we should call the family.  Maybe they can get him to clean up.”  Yeah, right.  We were being used by the family as a respite from caring for him, but they were unwilling to give us the tools needed.  It’s like when you need to cut lumber and all you have is a plastic steak knife.

I know what the studies say about the use of atypical anti-psychotics and the geriatric population.  At times you have to balance the long and short-term goals.  Do we want our loved ones to be more lucid or more “natural’?  Is the risk worth the outcome?  The most frustrating part of this was that the family directed this, but they had no medical background at all.  Even though the physicians thoroughly explained why the medications should be used and for us to have in reserve they still wouldn’t let the professionals do their job.  I wonder what would have happened if we could not have gotten Mr. Fisher to calm down.  What would have they said if we had to restrain him?  What if he had gotten violent and hurt one of our nurses (an ex-lumberjack, he hadn’t lost his strength)?  Could the nurse have pressed charges against the family for denying them the tools to do their job right?  But lucky for us, we were able to soothe him and get him back to his room and bed.  What about next time?  When does it become the nurse’s, no the physician’s, responsibility to provide the neccessary tools to keep the patient and themselves safe?  And in this day and age of litigation, how much can/should the fmily direct care if it comes to a patient safety issue?

I don’t have any true answers to any of it.  I believe that we should have the tools needed, the gamut from interpersonal tools, to chemicals to restraints to use when needed to keep our patients and ourselves safe.  Maybe though, we should just sedate, intubate and paralyze every patient we get.  If I wanted that, I’d go to the ICU, but most days I like it when my patients can talk to me, even when they are acting out.