It’s a Block, Kind Of

FTW - not for the win

My life has been one set of aggravations after another lately and I feel like the picture implies.  And it sounds trite and trivial to whine about them in a pubic forum, but sometimes we have to vent.  The problem is that I can’t spin them in ways to make it sound less trivial and less trite.  When I do write it out and go back over it the words sound like some teen who’s parents took the car away from. So it’s kind of like a block.  But I’m going to spit it out, get the vitriol, hate and anger out.  We’ll see what happens.

My doctor’s office.
They don’t seem to realize that I need answers sooner rather than later.  You see I had a result on a test which my doc wanted me to get further worked-up for.  They assured me that the office staff would get on it.  That was a week ago.  And today they don’t even return my phone call.  WTF?!  The results are life-altering and frankly I’m scared as hell about it.  I want, no I crave answers to what is going on.  That’s the fucked up thing as a nurse, you know enough to be totally freaked out, but not enough to be rational.  Reading Up to Date at work does not help the situation.

My Floor
I love my staff.  My co-workers are some of the most awesome nurses I have ever worked with and we’re one hell of a good team.  When shit goes south, I know they have my back and likewise for them.  But the patients, oh, our wonderful patients.  I’m slowly losing interest in little old demented ladies, the non-compliant trainwrecks that circle through every month or so, the stupid admissions and the psych cases that need “medical clearance” before going to in-patient psych.  It’s no longer a challenge.  Which is dangerous for me.  I get complacent.  I get bored.  I need to leave and find new adventures but the economy is still to fragile and based on item #1, I don’t want to be changing anything yet.  So I’m stuck.

The Floats
I’m tired of floaters to our floor.  I appreciate having them fill our holes and some days a body is better than nothing, but only barely.  What’s worse is when they get floated because our staff gets canceled (thanks to our convoluted staffing office’s system that no one understands and is about as transparent as mud), or they get floated to a sister unit as that unit can’t staff themselves.  Ever.  So I give up one of our floor nurses, trained in ACLS, stokes, rhythms etc., who can handle anything that gets admitted for someone who I have to carefully tailor the assignment for and hope they are there for the entire shift (one floor in the whole f-ing hospital has a special dispensation to have different hours 6-6 vs 7-7 and their nurses, even when floated keep that time, so we lose a nurse at 0630).  And if anything gets funky I pretty much end up taking over the patient(true story).

Our Aides
Who do as little as possible so it is like having no aide at all.  ‘Nuff said.

My Sister Unit
Them whose shit don’t stink, those that are better than us as they get “critical care differential”, those who take care of open heart patients and stent patients, those who can only take ACLS certified floats.  Yes, those bastards.  They tend to forget that I used to work with all of them before our units split apart.  So you have a post-open heart patient.  Big deal.  Been there, done that.  With four other patients.  Oooh, you had to pull a sheath.  And?  It wouldn’t be so bad if they weren’t so fucking condescending about it.  Yes, we’re the other tele unit, the dump unit, the one you turf the trainwrecks and pain in the ass patients too.  Even though you are an Intermediate Care Unit, the only true step-down type patients you take of are cardiac stuff, we get a ton of the nasty medical stuff that should probably go to you.  You stonewall any attempt to take any sort of non-cardiac patient all the time.  And I’m sorry that you had to take an admit the other night, we had 3 nurses and didn’t have the ability to take an admit at the time.  Yet in your busyness, you Ms. Charge Nurse-lifer still found the time to come up and chat with us for 45minutes.  You were really busy.  The classic line though was when one of you looked at our patients and said, “They have a chest tube!  Shouldn’t they be in the IMCU?  Can you handle it?”  No, we can’t.  I was wondering what that funny thing sticking out of their chest was, maybe I need to get them transferred!  No, the reason they are up here, I wanted to tell her, was because the surgeon wasn’t as picky as your typical guy is, because God forbid, his holiness, the cardio-thoracic surgeon would have to go a floor above yours and the ICU!  We can take care of a patient with chest tubes, it ain’t rocket science like you make it out to be.

Last, but not least, our Day Shift
I’m not starting a Days vs Nights war, this is not a general meditation of day shift, but my feelings towards our lovely day shift.  It can be summed up simply:  can you just get your shit done?  Ever?  Nursing is a 24-hour job, but that doesn’t mean you can dump everything on the night shift.  I am sick and tired of spending the first 3, 4, 5 or more hours of my shift cleaning up your messes.  I know I can’t say anything because all we do at night is sit around talking (yes, more than one has said this).  I mean we have to have something to do, right?  Nearly every night for the last 3 months has been  like walking into a war zone when I get to work.  Some days are better than others, but they are the exception.  It’s not a good sign when the nurse you get report from answers every question of “Did this get done yet?” with, “Oh, I didn’t see that.”  Not a good sign when the patient has been on the floor since 1600 and nothing is done and they’re lying in their own waste.  Having been around during the day for other things at work, I see the manic take hold until all of them are wandering around in circles looking like they are doing a lot but really doing nothing at all.  And if you really want to see frantic useless action, call a Code.  It’s like the proverbial chicken with their head off.  While it is nice to be welcomed by your patients, it’s never a good sign when they say, “I’m so glad you’re here!”  So yes, day shift, I’m not a fan.  Don’t you dare give my nurses shit when everything isn’t complete on a patient who arrived at 0630, because it never is when y’all do it.

At least I feel a little better now.

My GI doc appointment is actually scheduled now, my PCPs office called at 1900 last night to let me know.  Guess they heard my ranting.  Dude looks like a child though.  Could be interesting.

Friday 12-Lead

Patient was a 30-something year old white female admitted for pancreatitis.  History of alcohol and  illegal drug abuse and yes, pancreatitis.  Currently undergoing fluid resuscitation with normal saline infusing at 250ml/hr.

Medications of note include a dilaudid (hydromorphone) PCA device with dosing of 0.2mg/dose with time lock out of 10minutes and verapamil 80mg PO twice daily.

Telemetry tracing shows normal sinus rhythm in the 70’s with a prolonged QT around 620ms (calcuated QTc of 650ms).  QT had increased since start of shift from around 360ms to current.

The following 12-lead is captured:

QT/QTc is measured at 622/671ms by the machine.  Quick manual calculation confirms this.

Patient is still asymptomatic and vital signs are stable.  She is just pissed you woke her up.

What is the probable diagnosis?  What needs to be done?  Should we call cardiology?  Call and wake up the EP doc?  Pacer pads?  Let her sleep?  Do nothing and pray she doesn’t have a R-on-T PVC?

Answers and discussion to follow in a day or two…

Cheap vs. Inexpensive

Do cheaper doctors provide inferior care? – By Brian Palmer – Slate Magazine.

To most patients it really doesn’t matter.  They’re not choosing a doctor because they are cheap, they are choosing them because they have to.  Constrained by the limits of their insurance plans they go for the doc who can get the in the office or sees them in the ED.  It’s not like they go out calling around to get quotes like they are buying a car.  But here’s the kicker, in spite of all the work we do to improve our outcomes, reams of data available to help patients choose their hospital it comes down to this more often than not:

Studies have shown that patients’ hospital preferences are more responsive to improvements in amenities like wireless Internet and on-demand video than the likelihood that the hospital will help them get well.

Who cares if the hospital will cure your nasty case of I’ve-abused-myself-for-too-long, because if they don’t have cable, gourmet food and staff fawning over you they’re not going.  To the average public it’s all about fluff.  There are exceptions to this.  There are those who seek out the very best doctors to help cure the rare childhood cancers, referral centers for LVAD therapies and transplant, exceptions do exist, but they better have wireless and food on-call!

The Couch That Nearly Killed Me

Look at it.  So comfortable.  It’s just sitting there beckoning you into its well worn cushions.  “Come, sit with me.  Be a lazy bum.”

Well that’s what I did.  I listened to it.  I plopped my ever-expanding ass right on it.  Remote control or game controller in hand I spent more time here than just about anywhere in the last 7 months.  Sure, I went to work, did household chores and lived life, but always ended up back here.  I knew that it wasn’t the best choice, but it was the easiest.

We get our post-open heart patients up and moving about on post-op day 1 and many times they are dangling at the bedside 18 hours post-surgery.  We get total hips up in the same manner.  Why?  It has been shown that muscles lose mass within 7 days in a hospital setting.  And we all know that the typical sedentary lifestyle of the American public causes obesity, fecal incontinence, diabetes, heart disease, loss of value on one’s house, cancer, impotence, heart attacks and all sorts of other bad things.

Prior to January of this year, I commuted by bike and train everyday.  It wasn’t a lot of riding, but enough to help me feel better and lose some weight.  I had been doing it for almost three years and was feeling better than I had felt in years.  Then I got sick with a nasty winter cold and worse, got a new car.

I felt like crap and I could drive to work.  How was this a bad thing?  And at the worst part of the year.  No riding in pouring cold windy weather.  Getting home and being in bed by when I used to only get home.  This was a good thing.  I dismissed the idea that this might not be best for me physically, that the riding had kept me somewhat fit.  And as the scale rose with each successive doctor visit, I played it off as something else.  It was the steroids, or the anti-depressants, or the buffet I had gone to the night before not realizing the lack of true physical activity as I drove  everyday.

Today I threw a leg over the old steed to take back a movie.  It was a short easy ride, something I would have done before without any stress.  Not today.  Legs and arms were burning, short of breath, side-ache and plain old miserable.  I could hardly walk upstairs to the main floor when I got back.  And it’s not like I was riding balls-out trying to set records.  I was way out of shape.  Call it an eye-opening moment of realization, self-awareness.

Now I know I need to get back on the bike.  Continuing to live like this will turn me into my father (who looks like Santa) and in the long run, kill me.  I can’t let that happen.  I’m not going to let the couch win this time.

Good-Bye Golden Arches

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McDonalds, what happened to you?

I know that the various critics have brought you down.  We’re told that fries are bad for you – too much sodium and far too much fat.  And beef?  Yeah that stuff will kill you.

And secret sauce?  Sure, it really is just thousand-island dressing, but it held a mystique until a plethora of websites let the recipe out of the bag.

Ronald is being held up as an icon of “everything that is wrong with our children,” and he is the smiling face that draws them into the stores to gorge on unhealthy food.   The critics say that McDonalds must be punished for serving the food they do, but no mention that the parents are willing partners in that…

I can remember as a child a trip to McD’s was almost as good as Disneyland.   I drank the proverbial Kool-Aid, knowing now that the food was just a diversion to play on the awesome playground.  I didn’t care about Chicken McNuggets.  I was there to play.

And there are millions just like me.  We’re trying to reconcile our deep ingrained love for the Golden Arches with the fact that their food is truly not good for us.  Saturated fat?  Bad.  Salty fries?  Bad.  Milkshakes?  Not even milk here folks.  And soda?  Diabetes waiting to happen, right?  And I would be hard pressed to point to the part of the chicken that is the “nugget”.

But many are still loyal.  It’s a guilty pleasure.  Truly I’m a sucker for their fries.  Yeah, they’re not the best fries I’ve ever had, but there is something near magical about the first bite of hot, crispy, salty fresh-from-the-fryer fries.  But how are we faithful few repaid?  Worsening food, poor attempts to branch out and a general dilution of the great thing that Ray Kroc built.

So what brings this on Wanderer, you ask?

My lunch today.  It was the most pathetic attempt at a Big Mac and fries that I have ever had.  Wilted limp lettuce, thin little patties, slathered with luke-cold “secret-sauce”, plastic cheese tossed in a bag by a mindless reprobate.  I ate it, hoping it would get better but knowing that it was impossible.

In a blind rush for profit the quality of ingredients suffer, not to mention the amount of product they must keep on hand for their sprawling menu.  Cut corners enough and people notice.  I cut them some slack.  But I can’t anymore.

Sorry Ronald, even your heroin-laced fries can’t bring me back.  There are joints that use quality ingredients, keep prices reasonable and have employees that like to work there.  Maybe at Hamburger University (it’s a real place folks…) you can look at those places, or maybe take a good hard look at the original playbook and change.  But as for me, I’m gone.  And while it’s probably better for me health-wise, I’ll miss it a bit.

Thanks for the memories though.

Addendum… I still support Ronald McDonald House Charities as they gave me a place to stay and take care of myself during one of the hardest periods in my life and for that I’m eternally grateful.