Coincidence? I Don’t Believe in Coincidences

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In a hypothetical hospital many years ago there was an ED. Small, cramped, poorly laid out, understaffed and trying valiantly to provide “Gold Star Service” to everyone that graced their doors. For years this little ED-that-could worked their hearts out and while maybe not providing “Gold Star Service” to them all, they did the best they could and the sick and dying were taken care of.

 

Now for those years the poor manager of the this little slice of Hell cried out in need for many things. More staff. More equipment (stuff that worked). A remodel to improve flow and room for treating sick folks. And while other floors got staffed and remodeled, the poor little ED sat alone in it’s squalor.

When the surveyors of the Joint (smoking) Commission arrived the higher-ups would pull other staff from across Mammoth Health Care Inc. tm to ensure the illusion of competence was complete. Then, as soon as the surveyors left, things went back to normal.

This isn’t to say the care was poor. They did well in a poor situation catching many dire diagnoses and saving many lives. Yeah, not everyone got “Gold Star Service” but the vast majority made it out alive and whole again – sometimes after a stay, but saved nonetheless.

Then one day the Master, CEO of Mammoth Health comes to visit dragging behind him architects, facilities engineers, nursing vice-presidents and the entire entourage that befits one of his rank and stature. Plans are shown that would vastly improve the poor little ED-that-could. A remodel, more equipment and more staffing. Mouths gaped, had all the prayers been answered? Yes, their time had come finally.

Smarter minds thought though, “Why after all this time choose now?”. Those minds began looking and trying to figure out why now. Thanks to scuttlebutt it became apparent: one of the Master’s family/entourage had been to the little ED-that-could and had not gotten the full “Gold Star Service”. All of a sudden, it made perfect sense. They could see it so clearly now.

Coincidence? Like I said, I don’t believe in them.

More readings… Very Influential People

Whatever, Just Put Them on the Monitor

 

I wonder why new residents love to torment tele nurses?

 

Are we that easy of a target?

Or is it that they’re too intimidated by our drive? (True story, it was relayed to my manager that many of the 1st years were afraid of one particular charge nurse, mostly due to her breadth and depth of knowledge, but also that she was doing cardiac nursing before they were conceived.)

Whatever it is,they seem to think that the only true indication for telemetry monitoring is having a heart. Yes, true. But really does every single patient you admit truly need it?

I’ve heard some truly egregious statements with regard to this. One example is the 20-something year old with pneumonia who was tachycardic. Not SVT, not atrial tach or WPW, just straight up sinus tach with a rate in the 110’s. Gee, you think maybe that they were, A.) dry or B.) febrile? Or maybe a combination of both. A couple of days later, one of the attendings realized this and took off the tele, but the poor patient got charged the higher rate for the 3 days they were monitored when they really didn’t need to be.

Or the time there was a stroke patient on our neuro floor, probably the best place in the hospital for them, remote monitored on tele as well. “But the heartbeat was irregular.” complained the nurse to the doctor, “Shouldn’t they be on the tele floor?” Of course the young impressionable intern agreed, forgetting the patient suffered from chronic atrial fib…and had a pacemaker. The patient had been on all their normal home meds until admit and heart rate was well controlled, blood pressure was acceptable and all they were dealing with was the stroke sequelea. But out of the nice private room on neuro into a shared room on tele. Family was pissed. That was a fun one trying to smooth over.

Of course there is always the bleeders, usually GI in origin that HAVE to be on tele. I’m not talking the folks having gushing blood from mouth or rectum, but the LOL admitted with tarry stools and a slightly low H&H, or the post-surgical bleeder. The relatively stable ones. And on multiple times I hear the same refrain: we want them on tele so you can see if something happens. OK, maybe you forgot basic A&P, but really by the time we see something on the monitor, the damage has been done and they’re slip-sliding back to the ICU. Like the one last month who the nurse was helping get up to use the commode who syncopeed out and shit black stool all over the bed (luckily missing her)…guess what? Nothing on the monitor, beautiful sinus rhythm with nary a bump in rate from before. Off to the Unit they went.

It seems like everyone gets tele ordered. We’ve had a couple of new hires lately, all experienced nurses, one asked me, “So, patients get taken off tele and moved to med-surg, right?” I tried not to laugh too hard. “Nope, they stay here until they leave…”. It becomes a rote thing, just a part of the routine, not actually deciding if it benefits the patient.

On the other side are the times when you go, “What, they’re not on tele? Are you kidding me?”. Unfortunately due to the over-reliance on tele, I can’t remember a recent example of this! But it’s what comes with the territory. We take the ones that need to be on tele and theses that really don’t all the same. Because I really want the DNR comfort care patient on tele, (true story). I just wish I knew why.

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.