Paging Doctor Obvious

I know that your residents have told you in great detail that you must be careful around the nurses. They must be led to the right decisions and when you are not available, be given adequate, concise and precise instructions for the successful administration of medications and interventions to heal you patient. But really? Did you really need to write this order?

Hold lorazepam for respiratory depression or oversedation.

It’s not like we’re going to say, "Hmmm…Mrs. Smith is only breathing 11 times a minute and won’t stay awake for more than a brief moment, but she seems anxious. Maybe I she just needs a little more lorazepam…" Maybe some might though. But the vast majority of us do have the common sense not to do something as boneheaded as that, we don’t need it spelled out for us.

And also, taking 4 hours to write admit orders is just not kosher. Learn to speed it up a bit buddy.

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!

Too True, Too Funny

Shoe expedition, part II « Cranky Epistles

I didn’t even know you could get Papagallos, Esquivals and Swarovski-encrusted Converse sneakers for kids. Moreover, why would you want to get crystal-encrusted-sneakers for your kid? What the fuck? What kid can go out and actually play in such ridiculousness?

*snerk* was the sound I made as I blew soda out my nose when I read that.  What?  You actually let kids go outside?  OK, I’m reporting to CPS…not.  Every summer day at 9am it was “go outside and do something, you’re not allowed back in until dinner.”

And the hipster shoe clerk?  We have a legion of those people in PDX, thankfully they confine themselves to dive bars, dive coffee houses, fixie bike meet-ups and indie rock shows.  They would not be working at *gasp* a mall…

We’ve decided that most people have more money than sense.

I hear ya’.  More money than brains.  Isn’t that the American way? » Blog Archive » National organization finds that bike-to-school bans are on the rise » 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 «

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.

Sleepy Head

One of the nephrologists is a  notoriously sound sleeper and wakes up very, very slowly.  So when he’s on-call you can pretty much ask for whatever you want and he’ll sleepily agree to it.  And when you’re having the conversation he requires constant stimulation to keep him awake.  There’ll be long silences puncuated by the nurse saying, “Dr. Nephro…you still with me?”  To which he’ll groggily assent that yes, he was still there, kind of.

A friend of mine had called him one night for a patient with out of control blood sugars figuring to start an insulin drip to get the patient better controlled.

As the nurse is on the phone “Uh, OK.” says Dr. Nephro, then  silence.

“Dr. Nephro?  Are you still there?”

“Huh?  Oh yeah.  Uhhh…let’s start a Vitamin K drip…” trails off as he falls back asleep.

“Dr. Nephro?  Don’t you mean insulin?”  asks the nurse.

“Uh yeah.  Sure.” he replies then proceeds to give relatively cogent orders for the insulin drip, with a little extra prodding from the nurse.

About 6am, we get a phone call at the nurses station.  It’s Dr. Nephro.

“Uh…” sheepishly he asks, “Did I order a Vitamin K drip on someone last night?  I seem to remember getting called, but I can’t recall if I actually ordered that.  Did I?”

Being the good charge nurse I replied, “Well, you started to…”

“Really?” he asked.

“Yeah, but the nurse re-clarified it with you and got the insulin drip the patient actually needed.”  I replied.

“Oh, OK.  Thanks for being on top of it.”  he said as he hung up.

I was talking to a nurse over on the renal floor and she said that they can pretty much get whateve they want out of him when he’s like that.  It does however, make for some interesting morning phone calls!

3 Years Ago

It was 3 years ago today that our beautiful baby daughter came into this world in a rush of chaos, shattered dreams and hope.

Three years ago today I sat alone in a back hallway unsure if either my wife or my daughter was alive.

Three years ago I felt pride swell up inside as I saw Mia for the very first time and knew I was a father.

Three years ago started the most unforgettable 8 days of my life that changed us forever.

Today would have been Mia’s third birthday.  In my mind’s eye I can see her as she would have been, but still remember her as she was.  She was with us for too short a time before returning to heaven, but it was a time I’ll cherish forever.

Happy birthday little one.  We still miss you.  Sleep well.

Mia's BLue Light