I’m not dead, yet.

Truly, I’m not dead. I just feel dead.

In the week I moved I climbed thousands of stairs. Never, ever, living in a three story building again.

It took 2 days, well, actually 3 if you count the two hour jaunt the first day, to travel 1500 miles. The wife and I, along with our two cats in the front of a 24 foot Budget truck filled to the brim towing a vehicle.

Now comes the fun adventure of homeownership with all the little things. And finding a job. Yeah, still need work, but things are looking up.

Things are a’changing…and I couldn’t be happier!

Some True Words

And, as always, those that complain get their way, and those that are strong take the patients. And those who smile and chat up the manager the most get the kudos, all the recognition and the praise. Then the administration wonders why staff satisfaction is down.

This is from a comment an ex-coworker posted which I had to share because it’s true. Toxic workplace much?

Being unemployed has brought some true clarity to my career and it’s been good. I realize that I was (still am) pretty burned out and am taking steps to remedy that. Breathe. Meditate. Reflect. Exercise. Sleep. And while I’m stressed out about moving, finding a new job and starting over, I feel like I can go back to being the nurse I want to be (again). It will work out.

The Strong Suffer

~this was originally written the week before my last day

We are in the midst of the transition that prompted me to volunteer to quit my job and it sucks. Each day makes me realize what a good decision I made, but makes me worried for those left behind.

One of the biggest issues is that we’re combining two different units, one a typical med-surg/renal unit, the other a progressive care unit. Two very different staffs with different skill sets. The tele nurses are all ACLS and stroke certified, the others not. The tele unit started and built an observation unit and got used to and accepted the turn and burn mentality where you admit and discharge like there’s no tomorrow. The folks coming in rarely admitted in the levels we did and came from a more laid-back mentality.  SO yes, it’s a huge transition, especially for the new folks on our staff, huge changes in both practice and mentality. Add to that increased patient ratios and people are already starting to question the status quo.

The worst though is for the nurses perceived as “strong”. You know the ones that can take anything you throw at them, rarely bitch and just take their lumps, the ones with the advanced skills. They get the more difficult patients, the sicker patients, and more of them.

The other night was a perfect example of that for me. I started with 4, a decent mix of patients. (yes, I know, our ratios are low compared to some, but we have minimal support staff, it’s all about perspective too). Charge nurse comes to me with a proposition: drop one of my patients to take stroke admit. She figured it was easier for me to do this instead of giving the only other stroke nurse a 5th when she had never taken 5 patients before. This is a full on stroke, large MCA nastiness and there are a lot of things to do since we’re in the acute window. What choice do I have? I’m not gong to be a dick and say “no, let ’em suffer” am I? Not really. So I admit the stroke and considering now the CT looks, I lucked out. Then she comes back asking me to take a chest pain admit since the only other nurse just “can’t”. Whatever. They ask because they know I will only say no if I truly can’t. They ask because “you’re strong and can handle it, the others can’t.”

The last night I worked it happened again, I get the admit while the others don’t because “they haven’t done it.” And it’s not like I don’t want to work, I take my lumps but I believe it should be fair, at leadst to an extent. Give an equitable load, don’t dump on the strong nurses because you can. What comes out of that? Burnout. Demotivation. Animosity.

A good friend of mine who is staying mentioned all of this to me the week before we changed over.  He’s a guy who never complains, I mean NEVER.  And he was upset, worried and generally disaffected.  Did I mention he is a guy who always has a smile on his face, even when glove deep in poop?  To see him so upset truly shows me the folly of the madness being inflicted on us.  Here’s a nurse who smiles through everything, who gets every single LOL to love him, who’s clinical skills have grown immensely since hire to be a very competent, caring and effective nurse who will be put through the wringer because he’s “strong” and they run the risk of losing such an employee. But in the end “they” don’t care, it all comes down to money.

That is why I feel bad for my former colleagues.  It’s going to get worse before it gets any better, if it ever does.  The unit we spent years building was destroyed in one fell swoop and is reverting back to a mire of poor management, burned out nurses, massive regular turnover of nurse, disaffected staff and a manager who is crushed by those farther up the food chain.  Sadly it all lands on the patients and while there will be nurses who strive to keep the level of care the same, you can only fight the tide for so long.  Hopefully the worst of my prognostications doesn’t cone true.  One can only hope.

~disclaimer: I know there are places with far worse ratios and worse conditions, we’ve been incredibly lucky for a long time.  Leave it at that.

Seeing the Writing on the Wall

There are days where the obvious course of action is just that, obvious. But some backstory.

My facility is facing financial issues of an extreme variety. Between reduced reimbursement due to Congressional inaction, higher amounts of Medicaid and flat-out charity care we’re millions in the hole and it is necessitating drastic action. Layoffs are definitely in the picture. We thought that nursing itself would be spared, reduced to not replacing retirements and unloading PRN/part-time nurses. But no, the emergency reaches further than that. It won’t be calmed by those measures and there are only so many non-nursing auxiliary positions to cut. So it comes down to this: layoffs of bedside staff. This means increased ratios at the bedside, less staff on the floor and a general reduction in our ability to care for patients, while still being required to deliver the same care, check the same boxes and generally carry on, doing more with less.

This was not the facility I came to 5 years ago. It is not the same floor I came to 5 years ago. We’ve devolved, reduced to essentially a nursing home with telemetry capability. No longer being challenged except for the nightly herding of cats I knew it was well past time to move on. And I had been waiting for the right time to do so. When this unprecedented financial morass emerged I had a feeling that things would be changing. Being involved as a charge nurse, I knew the enormity of the changes and how it will effect the staff. And I wanted no part of it. Plus, I was scared for my own job.

So when the offer for a severance package for those willing to leave voluntarily came by email, I saw it as my sign. It took a bit to realize it was my sign, but in the end both my wife and I came to same conclusion: this was our impetus to move on into our next adventure.

So I took it.  So did quite a few other staff, which is telling to me in that folks would rather leave than endure the changes slated to happen.  There is a bright side, because so many opted to do so, no one had to be involuntarily laid off on the units I’m a part of.  We saved jobs and found a new path.

I didn’t want to write anything of this until it was for sure, but I signed my papers yesterday and have a firm end date.  It’s official.  When I signed the papers there was a rush of conflicting feelings, fear, excitement, sadness, peace all fighting for attention.  The last couple of days have been a huge upper as person after person comes up to me and tells me how much they’ve enjoyed working with me and will miss me when I’m gone, it validates the hard work I’ve done over the years.  Still it’s freaky.  It is a huge step into the unknown.  But there is a precedent.  When I went to nursing school, we did much the same thing, pulled up stakes, packed the truck and headed out into the world and things turned out OK.  While finding work could be a problem, I’m confident with my experience and knowledge it won’t be a problem for long, plus there is a little cushion thanks to severance.  I’m not leaving nursing, just finding a new place to practice it, new things to learn, new people to meet, a new start one that will hopefully help pull me out of the burnout ditch I’ve been stuck in for the last year or so.  And you all have a front row seat to it!

Don’t Call it a Comeback…

Like LL said,”Don’t call it a comeback, I’ve been here for years.” But really it is a comeback. Back to mine, back to my roots, back to what is important to me. I realized that even if it would mean a pay cut, somethings are more important than money. Call it karma when an offer came through for extended severance in light of looming lay-offs. I’ve been thinking about all of this quite a bit and while I haven’t arrived at a full decision, the beginnings of a plan has emerged. If things go like I hope, big things are transpiring in the next couple of months.

Every Now and Then, You Win

“Hey Wanderer, there’s a guy in 32 that wants to talk to you.”

Great, I think to myself. It’s a complaint, or a problem, or something unpleasant. Prejudicial? Probably, but the way things have been lately it’s the reality. Head up, smile plastered on I head over to 32.

As I walk in I see a familiar face. He had been with us for about 2 weeks, dealing with the effects of alcoholic cardiomyopathy and most of us only gave him even odds to stay sober and in good shape. I had spent a lot of time educating, reinforcing and generally trying to help him beat the odds so it was good to see him because he looked like it all had worked.

“Hey,” he said, ” I’ve been sober now for 73 days thanks to you guys.”

We talked for awhile as he related everything that had gone on since discharge and how he had really turned his life around. It was nice to hear for a change.

The Tale of the Good Samaritan

“He’s a 55 year old male found down by a bystander and brought in by EMS. He’s being admitted to you for altered mental status, ETOH withdrawal, hyponatremia and chest pain. Any questions?”

It’s a common story. Passerby sees guy slumped over on the sidewalk, sleeping soundly In a drunken stupor and calls EMS. EMS comes and determines the guy is drunk as a skunk but “altered” so per protocol they bring him to the local ED. A workup by Dr. Caresalot show the altered electrolytes and altered mental status of a chronic drunk, but instead of giving him a banana bag and letting him sleep off the drunk, they admit him.

On admit labs his alcohol level is 456 mg/dl or .456 on a breathalyzer, over 5 times the legal limit. A level this high shows dedication and a long history of this kind of abuse, which means he is more susceptible to withdrawal symptoms at a higher threshold than normal. Guys like this start to have withdrawal symptoms when they hit the 150 mg/dl level, so the shakes, the autonomic symptoms, the hallucinations and agitation are starting when he hits the floor.

Ativan is given in copious amounts over the next couple of hours to control the symptoms. Then while on the toilet he has a withdrawal seizure and bradys down earning a trip to the ICU for more intensive Ativan therapy. He can’t protect his airway and aspirates while on the vent and develops pneumonia. A delirium develops during his stay in the ICU and when stable enough for the floor he needs a sitter to deal with his agitation while the delirium clears.

Every chance he is asked about quitting alcohol he states adamantly “I’m never going to stop drinking.”. So he stays with us for two weeks, detoxing him, curing his pneumonia, clearing the delirium, repleting magnesium, getting him fed, all of the healing that being in the hospital provides. So after the two weeks, with help from social services he is discharged to housing, clean and sober, ready for a new life. He then walks into the convince store around the corner from the hospital and walks out with an 18 pack under his arm to start over. And the cycle continues over and over again.

I’ve lost track of how many times we’ve done this. More times than not, a good Samaritan calls it in. Instead of minding their own business, they take it upon themselves to “help” with no understanding of the events they place in motion. Instead of leaving the drunk sleep off the drunk, they call 911 to get help. EMS is obliged then to treat and transport starting the whole series over again. I’m not against helping, I just wish people would think before they acted and our ED docs would not admit everyone who shows up on the doorstep.

 

What a Difference

The other night I got called off. For 45 minutes. Yeah, talk about getting my hopes up. But I went in and floated to our sister unit. It was one of the best nights I’ve had in awhile. I got to thinking why that was and several things came to mind.

First, it was a single shift. Come in, do my work, go home.

Second, I wasn’t in charge. No politics, no managing disparate personalities, no calming the irate customer, er patient. Just me and my patients.

Third, there were no chronically. Lately we have had multiple long-term patients. You know the kind, multiple co-morbidities, unruly families with unrealistic expectations, tons of meds, sick – but not acutely ill, the chronically ill, with personalities to match. After days/weeks/months of the same people, it gets old. There was none of that. It was, refreshing.

Sometimes change is nice.

What Protocol?

5am. My patient on a Lasix drip has a potassium of 3.0 from the labs I drew an hour before. Shit, what to do?

Wake the doc up and get my ass chewed?

Or…

Consult the protocol and start giving potassium replacement per protocol?

For the sake of my bony ass, the second option really seems the best, but, alas there is no protocol ordered, nothing in the regs saying I can implement it on my own, I am stuck calling the doc to get an order for potassium replacement. It went better than expected thankfully.

But I never should have been in the position if the docs had been anticipating that this might be an issue and planned accordingly. I mean, let’s thing this through…CHF patient, being aggressively diuresed with a Lasix drip running at 20mg/hour with a pretty awesome urine output, odds are pretty good that all of that peeing is going to impact the level of potassium… So to stave off the inevitable call, when there is a protocol on the books, wouldn’t it be a smart idea to write, “Potassium replacement per protocol.”. Unfortunately though, it appears that our residents missed that day in class. So they get the call.

While I rarely agree with the dog/tractor/child-posting Asberger-esque Happy Hospitalist, in his post about Call Parameters…blah, blah, blah he lays out a plethora of standing orders that would basically end calls to him. Call it extreme protocoling. But it has the under-pinnings of a decent idea. Give the nurses the tools they need so they can treat the patient instead of spending time on getting orders. There are issues with that though.

First, there is the issue of control. Some physicians tend to be a little on the control-freakish side, liking to micromanage care, which I get. Letting protocols run free deprives them of the minute control some need. I turn to say that it frees them to be more efficient with their time and reduces the amount of time spent on hold waiting to talk to the nurse who paged them. Win-win, right?

Which brings up the second issue: lack of nurse follow-thru. This can be an issue if you have lazy nurses. Lack of this follow-thru is what dooms it on my floor. Many of our nurses don’t even draw off scheduled labs, like cardiac enzymes q6, when the patient has a central line. How are these nurses gong to have the follow-thru to manage an electrolyte replacement protocol? They’re not. Probably what would happen is the patient would get the first dose and redraw, but odds are good that anything further won’t happen. I know this as I’ve seen it happen, so it’s not pure cynicism on my part to doubt it would be done right. There are some nurses that are very cognizant and would do well with such a protocol, but they are way out-numbered by those that aren’t. So we end up with the myriad and endless game of phone tag.

There are places where this works, critical care comes to mind, but it could work on the floor. All that is needed is staff buy-in, but in my milieu, that’s dreaming. So, I’ll just be calling the docs and making all of our lives inconvenient. There’s a protocol for that too…

What’s Wrong with Health Care?

Image via Wikipedia

Customer service.

We’ve turned taking care of the sick and injured into fucking Burger King. Everyone wants it “their” way. Sorry folks, life isn’t like that especially in my house. When we turn patients into consumers, they begin to expect to treated like customers and hence have no skin in the game. This leads to unrealistic expectations and our administrative “leaders” play up that we are in the business of providing customer service instead of healing. That then becomes our problems on the floors and our “customers” think that “their” way is the only way.

Yes, I will be disturbing you at midnight to check your vitals and then doing it again at 4am.

Yes, you will have blood drawn, probably several times through the day and night.

No, you can’t have your hydrmorphodemerolepam every hour, even if that’s how you take it at home – which is probably what got you here in the first place.

No, burger and fries are not part of your heart healthy diet to help treat your congestive heart failure.

Yes, lasix makes you pee. And, yes, I will be giving you a dose tonight, as the doctor ordered, every 8 hours so that you can breath and not have a hugely swollen scrotum.

Yes, it would be nice for your family to come in to learn wound care techniques so they can care for you at home.

No, not all of them can stay the night with you in a double room.

No, you can’t go out to smoke, even just for a minute. And I’m definitely not giving you an oxygen tank and wheelchair to do it.

Yes, you are more than welcome to leave AMA because we’re all racist assholes who won’t give you IV narcotics every hour, please just sign this form.

No, you don’t get a cab voucher, discharge prescriptions or fresh clothes if you do leave AMA. Sorry.

Yes, Dr. First-Year Intern, they just left AMA after threatening the entire staff, but you might catch them by the ED if you hurry. I’d bring Security with you though.

I will be polite and respectful, but I will not fawn over ingrates, feed into those with unreasonable expectations or take the crap from the dis-respectful. I refuse to be turned into a cashier clerk at the local fast food joint or a Pez dispenser of Oxycontin. There is difference between customer service and letting the public run wild in our house.

It’s time to take it back.

To set expectations.

To educate our patients.

To let the world know that we are not there to be exploited, abused and disrespected.

It’s a long journey, but it starts with a single step, for nurses and other health-care providers to stand up and say, “NO MORE!” and start to expect our patients to be active and involved, to care about their health, to put some skin in the game and start behaving like responsible adults.

But that will never happen. Sad.