Wasting Money at the End of Life?

Movin’ Meat: Are End-of-Life costs avoidable?.

Yes.  docs need to learn to say, “No.”

Case in point…a 90-something year old patient, recently had a pacemaker implanted for mild tachy-brady syndrome.  They had some occasional mild tachycardia and rare episodes of bradycardia which were non-symptomatic for a big reason: they were never out of bed or chair.  Yes, this lovely patient was completely dependent upon others for every aspect of their care, not to mention completely demented.  If your idea of quality of life is being 100% dependent on your family and having absolutely no meaningful interaction with them, then this is great.

I can understand doing procedures on folks with whom it will make a positive outcome – like the 80-something year old CABG mentioned in the above link.  It makes sense.  But to do these kinds of procedures on those with poor quality of life is just cruel.  It only delays the inevitable.

In this case, the family convinced the doc to do the procedure.  What makes my blood boil more though is that this same family had another member in and out of our facility spending nearly half of the last year of their life in the hospital in multiple lengthy admissions.  They would not accept that this family member was dying and insisted on all measures being done.  And now that there is a new one heading down this same road, it will probably be the same.

End of life costs are avoidable if we as society realize the death is a natural part of life and accept it.  Instead we claw and fight to eke out the last painful years many have, enduring lives of bed sores, PEG tubes, nursing homes and hospital admissions.  For what, a couple more years?  Years that can’t even be enjoyed because of the multitude of illnesses?  It doesn’t make any sense to me.

Banana Bags? I Got Them.

Crass-Pollination: An ER blog: Enough with the Banana Bags already.

Uh, yeah.  I’ll second that.

Unfortunately, our docs believe they can save every drunk and therefore, admit them all.  Of course all of them need telemetry monitoring because they are “tachycardic” forgetting that in tachycardia, you treat the underlying issue.  Y’know, like dehydration?  But no, these wonderful specimens of human existence get dumped on our floor for days, if not weeks while we dry them out.

A couple of weeks ago we had a nurse nearly knocked out by one of these assholes.  He got 4-point leathers and a ton of drugs.  The nurse got a concussion and no recourse but lost time and an injury.

Then there was the drunk who the doc didn’t want to send to the ICU and ended up needing more than 30mg of IV Ativan in a 12-hour shift, just to keep things to a dull roar.  Doc refused to send him even as he became more and more agitated and aggressive despite the Ativan, until the morning docs came to see him, where he promptly was sent to ICU for an Ativan drip in restraints.

My favorite of all times happened when I was an nurse extern.  We spent nearly 2 weeks drying this guy out.  Loads of Ativan, days upon days of sitters, thousands upon thousands of dollars worth of care.  The day he was discharged I saw him walking out of the convenience store 2 blocks from the hospital with a case of beer under his arm.  That was so worth it.

Our ED docs seem to have a major aversion to letting these guys (yes, they are 99% male) sober up a tad in the ED then kick them loose in time to get to detox to be admitted there – where they need to be.  We’re not going to save them.  If you have had 10 admits and 18 ED visits for ETOH in the last year, one more probably isn’t going to make a difference.

I am just so tired of it.

a caveat (there always is…)

I understand and know that delirium tremens can kill, that withdrawal seizures are just as dangerous and understand the pathophysiology behind chronic alcohol withdrawal, even the esoteric things like Wernicke’s  Encephalopathy, Wernicke-Korsakoff Syndrome and alcoholic cardiomyopthy and realize that admissions are justified in many cases, just not of the majority that I have encountered.  To me, ETOH is as good of an admitting diagnosis as “Incontinence”(not a neuro thing mind you) – in other words, full of crap.

Get the Defib?

Just a little VT.  It’s OK.

Nurses Commuting by Bike

I got this comment on my Scrubs are My Uniform post and thought it needed a full post to reply:

Hi!

I found your blog when I was searching for nurses who commute to work via bicycle. I am considering giving this a try. I live 2.5 miles from the hospital that I work at, but I am concerned about riding in my scrubs. (I guess this post is somewhat on topic of your blog entry). I don’t think it would be very smart to ride in scrubs seeing as how they are my professional attire and I don’t want to damage them. What would be best to ride in? I don’t want to show up at the hospital in tight spandex… but I need something that will help me sweat less.

Thanks for your help!
Elizabeth

I’ve never felt qualified to give advice on my blog, it’s an aversion to taking a stand maybe.  But on this topic I have more than a little experience.  I’ve been commuting by bike for the last 4 years.  While it hasn’t been full time for the last year, it’s been rather frequent.  A caveat here though:  I do not bike the entire ride to work.  I’m not going to ride 13+ miles then work a 12-hour shift on the floor, just not that fit.  Yet.  I ride anywhere from 1-3 miles (depending on weather, how I feel etc.) to catch a light rail train then a mile or so on the other end.  But I’ve done it in every kind of weather.  Rain, snow, howling winds, >100 degrees <10 degrees, have suffered through it all, and loved it.  Enough of my cred though…

Yes, riding in scrubs is a bad idea.  They are not built for athletic excursions and depending on weather conditions, not very versatile either.  This doesn’t mean you have to go full on spandex kit either.

Full kit and Hardcore.

There is nothing wrong with plain old shorts and a t-shirt.  During the summer months it’s what I ride in.  I do wear bike shorts underneath the regular shorts to alleviate chafing and add a little extra padding which is especially nice when I decide to go for a ride on the way home.  I stay cool enough in that and don’t end up looking like a superhero.  Winter/Fall commuting is a whole other can of worms which deserves a full post as well.

There are complications though.  First, sweat.  Starting the shift sweaty isn’t the best, in fact it really sucks.  In the depth of the Summer when it is 80+ I sweat heavily.  Let’s face it:  I’m a big sweaty guy.  There are wipes out there that some folks use, but I use water and paper towels in the restroom at work.  And I carry deodorant in my bag.  Second issues is hauling your stuff.  I started using a backpack, graduated to a messenger bag, back to a back pack and now use panniers.  Besides a sweat issue where the bag meets the back, the bags did a number on my back that went away when I started using a pannier.  I abused the Banjo Brothers Waterproof Pannier into submission and ended up replacing it with ones from Ortlieb.  There is enough room to carry my scrubs, wallet, keys, cell phone, afore-mentioned deodorant, lunch with room to spare.  I use the restroom to change on arrival, so I have to build in extra time for the commute to allow for this.  With clean scrubs, a quick towel off and a swipe of deodorant you will smell better than 99% of your patients and maybe some of your co-workers.

The benefits of commuting by bike outweigh the complications.  I get exercise.  I get some alone time before and after my shift.  Sure you get that in a car, but you’re dealing with traffic, right?  I have had absolutely heinous shifts where I’m ready to quit nursing and by the end of my ride home, I’m decompressed and OK with the world and my job again.  I highly recommend it.

Here are some other links about bicycle commuting:

Commute by Bike.  Great site, has a Commuting 101 series which is a great read for those starting out.

Bike Commuters.com.  Another site dedicated to those giving up the car commute.

Both of these sites have extensive sets of links for even more information and community building.

Yehuda Moon and the Kickstand Cyclery.  A funny webcomic to keep things light.

Lastly, just go for it.  Try it and see how it goes as that is the only surefire way to know.  Have fun!

Another Thousand Words.

All that remains?

We know trickle-down economics doesn’t work.  We know that health care is broken.  We know that a small group of fanatics nearly caused the wheels of government grind to halt.  We know that everything that tastes good, makes you feel good or somehow enhances our lives will probably contribute to our deaths.  And, by looking at the picture above you can see how the desks were laid out.  They really needed to clean the carpets more often.

Perhaps this is the crux of the problem:

Bill Maher: See, this is my problem, I’m trying – I mean, you’re – you’re a Senator. You are one of the very few people who are really running this country. It worries me that people are running my country who think – who believe in a talking snake. Um…
Mark Pryor: [Arkansas’ Democratic Senator] You don’t have to pass an IQ test to be in the Senate, though.
[chuckles]

via IMBD

~caveat emptor

Scrubs are My Uniform

Scrubs are pajamas. Initially a simple garment to be worn and left in the operating arena, the scrubs are now available in many a color and pattern to be worn by nurses, billing agents, medical assistants, doctors and anyone else in any way associated with physicians.

The fact that most people have no idea the difference between the girl who takes their copays and the nurse that evaluates them, most people assume they are all “nurses.”…

via The Pajama Brigade makes an Impression | The Happy Medic.

I get it all the time, “Well, you get to go to work in your pajamas.  How cool is that?”  I’ve worn many different uniforms in my work career from slacks, shirt and tie, to industrial workwear and just plain old jeans and a t-shirt and now I get to wear “pajamas” to work.  Sorry, that’s bullshit.  I am required to wear a uniform that happened to have been co-opted as pajamas.  To me, a uniform signifies that it is time to go to work, I call it “getting on my game face”.  Those “pajamas” tell me it is time to work, leave the world behind and focus on my job – my patients.

Now there are those that spoil this for those of us who take it seriously.  Since everyone and their uncle who works in health care  gets to wear scrubs, there are bound to be the one’s who abuse it.  I cringe when I’m out shopping and see people in scrubs, it sets the wrong idea, especially when those wearing them are misbehaving.  It is still bad behavior to break HIPAA whether you are wearing scrubs or not, it just makes it more conspicuous when you are in scrubs.

There are two issues here that get intertwined and blurred.  First there is professional behavior.  It doesn’t matter what you do for a living, you need to maintain a professional mien when representing that job/career/profession.  And yes, health care workers are held to a higher standard, get used to it.  It’s even more important when you are clearly identified by the public (by your wearing scrubs to the bar/lounge/grocery store/porno shop) to be a professional, because they associate scrubs with nurses/doctors.

Acting like an idiot in scrubs makes a bigger impression than it does in street clothes – people notice.  Second is the proliferation of scrubs into so many different fields.  Are they the doc/RT/PT/housekeeping/CNA/RN?  You can’t always tell.  Not to mention those outside of the hospital like vets, dental folks, office staff and the like where this has spread into.  Too many people wearing scrubs makes life confusing.  And due to this proliferation, clamping down and restricting use will be near impossible.  All that is left is some sort of uniform – like our friends in EMS/Fire/Police, or hospital color coding by job function.

As long as the color is not white, I can get behind this.  More so, I think that institutions need to require changing at work.  You get to work, change out of street clothes into hospital uniforms, then do the reverse when you leave.  If we are so worried about the spread of superbugs, why isn’t this a common sense idea?  I leave my work shoes at work and change clothes (partly because I usually commute by bike) on arriving and leaving.  It goes to the idea of getting my game face on.

The lesson here?  Scrubs are every bit a uniform, just like other professions.  Unfortunately there are those that wear my uniform that are unprofessional and act like idiots when in public.  Painting all of us with the same brush is just as bad.

Time to Laugh

Laughter.  Some days all you can do is laugh.  Some days that is all you need to do.  Here’s a double daily dose.

Enjoy!

h/t to @movinmeat

Work Ethic?

We all know an anomaly when we see one, and we all understand the importance of work ethic, personal responsibility, and manning the fuck up when you do something wrong.

Why is that so hard for some people to grasp?

via On Work Ethic, Personal Responsibility and Manning the F*ck Up | A Day In The Life Of An Ambulance Driver.

The tale is just a hook to get us in.  This is the true meat of the issue.  We’ve become so enamored of excuses, reasons for failure, placing the blame on others that the whole concept of personal responsibility no longer exists as a guiding force in our culture.  Why take responsibility for your actions when you can blame someone else?  Or make excuses?  Or whine your way out of it?

And people wonder why we’re in such a mess?