Black Friday Shenanigans

And here it is, the “official” start of the Holiday shopping season.  It matters not that we have been deluged since Halloween with commercials, ads in the papers and every so often, Christmas music overhead.  Black Friday.  It’s when retailers supposedly go “into the black”, finally turning a profit for the year.  And do they ever suck you in.

Great deals inside! That’s what all the ads scream.  What is pretty much hidden is the “Limit 1 per customer.  Minimum 3 per store.”  I know it is the science of loss leader.  HP sells you the printer cheap to hook you for the ink cartrtidges which are more expensive than heroin (I don’t know this from personal research!).  Retailers do the same:  advertise great deals to get you in the store and when you find out the one item you really wanted is gone, you stick around and buy something else.

I’m a nightmare for this idea though.  They don’t have what I’m looking for, I’m gone.  With a few exceptions, like a fight outside of a Toys R Us, or several incidents with Wal-Marts (here and here), it was relatively calm.  Nothing says calm like hundreds of greed crazed bargain shoppers running into the stores foaming at the mouth for great deals to me though.

I chatted with my patients about the phenomenon last night at work.  They too agreed that it seemed both excessive and well, crazy.  Is it really that important to get those “doorbusters”?  I’m sitting there cleaning up poop and the the news in the background is displaying images of crowds swarming department stores at the butt-crack-of-dawn.  It just seems, yes, excessive.

But I will admit I  bought something on Black Friday:  a fifth of Jameson.  I really wanted the doorbuster 18 year old single malt, the they had already sold out of their allotment…so I settled.

UPDATE:  some awesome pics from The Frame.  Desperation, claustrophobia and exhaustion.  Like I said…excessive.

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…

Stupid Patient Tricks

I heard about this from a friend of mine.

Dood comes in to the ED with chest pain.  Prior history of cardiac issues including prior stenting.  And a raging drug habit.  Dood gets the million dollar workup showing he’s probably got some new issues with his coronary vasculature and ends up taking a trip to the cath lab.  Lone behold there’s a new blockage and he gets a shiny new stent to fix him up right good.  But here’s where the fun begins.

Claiming he’s having a “reaction” to the Versed he becomes a raging asshole and as soon as the nurse steps out of the room to get supplies he bolts.  With an arterial sheath still in place!

Many times the cath lab sends the patients out to the floor so the sheaths can be pulled on the floor thereby increasing throughput or something like that.  An arterial sheath is a large bore introducer that is used to gain access (in many cath lab cases) to the femoral artery so that diagnostic and interventional catheters can be passed up the femoral into the aorta and then the coronary arteries.

So dood is on the loose outside our facility with a 2-3mm hole in his femoral artery plugged with the introducer which really isn’t built for a whole lot of movement.  If that was to come out, there might be issues…  Security is called, who then call the local PD to find this guy.  They find him (I’m guessing it was at our local watering hole…) and bring him back to the ED where the sheath is pulled.  But the ED docs want him monitored for  any complications post-pull.  Y’know, like bleeding, hematoma, occlusion of the artery.  Minor things.  But dood is still a raging asshole and demands to leave.  And for once, the docs see that to keep him around will only cause issues, they cowboy up and let him roll.  You still have to shake your head and wonder what was so important to get up just after having a stent placed, with a large hole in your femoral artery to decide you wanted out.  Guess we’re adding Versed as an allergy for dood now!

Has H1N1 started to peak?

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

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.


A Good Place to Die?

Why This Wisconsin City Is The Best Place To Die : NPR.

The result of all this attention is that nearly all adults who die in La Crosse, 96 percent of them, die with a completed advance directive. That’s by far the highest rate in the country.

Note this doesn’t say that these folks died without care, it doesn’t even mention what those advanced directives are.  It doesn’t matter, it’s that these folks have had the opportunity to explore their desires and wishes about how to proceed at the end of their lives.  And it is done before the end is nigh, giving folks enough time to thoroughly think through what they truly want.  Plus it gives them a facilitator who can answer their questions, refer them to other resources in the community to understand what they are deciding.

That’s the whole idea behind the proposal within the health care bills about end-of-life counseling.  In the case here,

But it’s expensive to spend time with patients filling out living wills. Medicare doesn’t reimburse for the time the hospital’s nurses, chaplains and social workers do this. Bud Hammes, the medical ethicist who started the program, called Respecting Choices, says it costs the hospital system millions of dollars a year. “We just build it into the overhead of the organization. We believe it’s part of good patient care. We believe that our patients deserve to have an opportunity at least to have these conversations.”

It’s not about “death panels”, it’s not about deciding how much to do at the end of life, it is about choices and the opportunity to make informed decisions about their choices.  That’s what so many people who are vehemently against the idea don’t understand.

I think it is just a good idea.

The Least of Your Worries

If you have end-stage cancer, and it’s incurable with whole body involvement, you’re in pain and don’t realistically have much time left, one would think it is time to consider hospice, palliative care or using medications like opiates to help you live out the rest of your days in some semblance of comfort.  Declining medications to quell the pain as you are worried about addiction is, in the light of everything else, seems kind of silly.  Worrying about being addicted to opiates is really the least of your worries.

Your cancer is going to kill you before you become “hooked.”  Yes, addiction is a scary thought, but I would think living out what little time I had left in excruciating agony to be a far worse fate.

But that’s just me…

A Little Bit of Sunshine

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Every now and then I run into a patient that reminds me why I do this job.  It’s not the ones that we save, the ones we see over and over again, the ones who are generally pleasant, polite and just nice, but one who manages to touch that part of you that lives behind the wall that so many of us put up to stay detached and uninvolved.  That remove becomes so ingrained that it is a reflex.  So often we shy away from letting our patients too close for fear that something untoward might happen.  Maintaining our professional distance is a survival tactic in our increasingly chaotic work world.  Many times the ones that say, “Thank you.” and truly mean it are those that break the wall.

In our age of patient satisfaction scores, core measures, Joint Commission surveys, evidence-based practice and the overall stress of caring for the sick and dying it gets a bit dark, like the light on an overcast day.  It’s still light out, but the clouds filter it down to a dull gray glow.  But that simple act of saying “Thanks,” can make the sun come out.

My patient the other night was one such person.  As I introduce myself, I hear the words so many of us dread, “I remember you!”  Immediately my mind starts turning, rooting around in the dark recesses trying valiantly to match the name, the face and the situation of where I know him.  But I can’t.  It’s blank.

“That’s great,” I reply, “No offense I can’t seem to remember you though. ”  And it’s true, I’ve drawn a complete blank.  Usually I have a pretty great recall of the patients I have taken care of, but not tonight, not even now.  “I’m hoping I did OK.”  I finish.

“Oh yeah!”  he enthuses, “You were great.  You took care of me when I was here for 20-some odd days with my valve surgery.  It’s good to see you again!”  Slowly the details are starting to come back, but really nothing.  From there I go into the normal nursing things as we chat.

Through the night he tells everyone that will listen how awesome our floor is, how dedicated and talented our docs are and how great of a nurse I am.  I bring in a pair of my nurses to hear his mechanical valve and he says, “Y’know, Wanderer is really great!  A number 1 nurse!” as they listen to his clicking heart.  I wink at him and say, “OK, how much do I owe ya’ for that one?”

The next evening as I come on and get report, the off-going nurse says, “He is so glad you’re back.  I told him I wasn’t sure, but he said he sure hoped you were!”

Sure enough when I walk in, he’s got a huge grin that I’m back.

So through the night we continue to chat.  He tells me how he thinks that our team, the physicians and the nurses at our hospital are amazing, that he wouldn’t go anywhere else for his care.  Compared to so many of the folks we have taken care of lately, who pretty much hates us, it is a needed breath of fresh air.

Finally in the morning as I do my final rounds before heading out he says, “I just wanted to say it was a pleasure to have you as my nurse,  thank you for all you do.”

I grin, turn and say, “No, the pleasure was all mine.”  as  I walked off the unit with a bounce in my step, a small bit of faith in humanity restored.

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.