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.

Get the Defib?

Just a little VT.  It’s OK.

Nursing Shortage? Not in Some Eyes.

I know this rant has been making the rounds on Twitter.  It is full of rage, a touch of woe is me and the grim reality of the situation we place so many new grads in.  A quote (shield your eyes if easily offended…)

Image via Wikipedia: They got jobs.

Well, after a year of getting rejected I have finally decided to give nursing the bird. FUCK YOU NURSING FIELD! Too bad the schools and media are still insisting that people go to RN school. Believe me THERE IS NO FUCKING SHORTAGE! New grads are considered garbage. On top of that, the degree serves no purpose in any other setting. BSN is a complete waste of time and money.   …And it is not just the economy. Hospitals turning huge profits stopped new grad programs and hire foreigners.

Wow.  The rest continues on in a rant that she (assuming a she) will never get a job, never put her degree to use and that she wasted 6 years of her life.

First gut reaction:  she’s right.  It sucks to be told there is a ready market of jobs just waiting for new grads.  Read too many job requirements of  “at least 2 years experience” and raged at the screen saying, “How am I supposed to get experience if I can’t get a job?  WTF?!”  I know many, many grads who have cycled through our unit for practicum who have yet to find jobs.  We have nurses on our unit who jumped at the first offer (methadone clinic anyone?) but persevered and got the jobs they wanted.  In fact that was me.  I got lucky.  I can empathize.  The betrayal of it all is painful, kind of like when you realized Santa was not real, or your girlfriend was banging your best friend.

Second reaction:  buh-bye.  Maybe we’re (as a profession) better off not having this person in our ranks.  Nursing is not easy…what happens the first time they get a difficult assignment?  Or have “one of those days”?  Run out?  Quit?  Nothing in this profession is given to you, one has to work for it.  Take for example NurseXY, who landed his dream job in a world-class CVICU.  Seriously, go read his stuff, he worked his ass off for it.  Nothing was easy.  No one ever promised (at least anymore) that a job would be waiting right when you passed NCLEX – and if they did you should make sure they aren’t selling a pile of hooey.  Just because there is a nursing shortage does nothing to guarantee you a job just because you passed the boards.  Anyone who degrades their education to this degree and doesn’t realize that sometimes sacrifice is a needed part of our job has no place being a nurse.

Final reaction:  no seriously, buh-bye.  If you want to work as a nurse enough to devote 6 years and thousand of dollars to do so, giving up isn’t an option.  She never says that she looked out of state for jobs, into different avenues than the traditional hospital based nurse or for other ways to be a nurse.  Our system interviewed over 500 grads for spots in our residency program and they came from all over the Northwest.  They tried to make it work.  There is nothing to say she did this, just a whiny, “why isn’t it given to me!” rant.  We have too many toxic personalities in nursing and truly don’t need anymore.

I know this is harsh.  Maybe this person is a amazing nurse, top notch clinical skills with empathy to boot, is driven far beyond belief and tried EVERY avenue to make things work, but based on what I’m reading, what they posted onto the internet for everyone to read, I doubt it.  And with this rant, I doubt any but the most desperate, worst, idiot recruiter would ever even consider asking for a resume.  I know it sucks, but maybe it’s for the better.

It’s Never This Clean

Image via Wikipedia

A code last week reminded me that the biggest problem with classroom ACLS is that it is too clean, too managed, too un-chaotic.  Here’s a couple of recommendations to the AHA for inclusion in the next set of guidelines for ACLS curricula.

1.  More people, smaller rooms.  Codes almost never happen in big rooms, so you end up with 20-30 people cramming into a 10×10 (or smaller).  I swear besides the code team, everyone else tends to show up.  Housekeeping, dietary, looky-loo nursing staff with nothing better to do, extra docs not involved in the case, maybe a couple of pharmacists and an administrator.  To best simulate that feeling of claustrophobia and having to work under such conditions, the schools hosting the classes should hire extras to crowd around you so there is barely enough room to work.

2.  Auditory competition.  It’s usually a cacophony of noise as people are barking orders, shouting back values, yelling at each other and general noise in a code.  ACLS mock codes are just too quiet, like a quaint afternoon tea in the country.  They’re full of thoughtful contemplation, “Hmmm…we gave Epi, CPR is in progress, let’s see what the next step should be.”  Where usually it is, “What!!!  Did you give EPi yet?!!!” and “GET ON THE CHEST!!!!”  To solve this, using the extras mentioned above, have them loudly carry-on conversations to provide a sort of white noise effect and teach students to think with 10 different voices giving you information all at once.

3. Smell-o-vision.  Think it through.

Image via Wikipedia

4.  Realistic dummies that either poop, pee or vomit during the code.  Ever done CPR while trying to keep your scrubs out of vomit?  Yeah, it’s difficult, the hands slip off of their position as the gloves slide over the vomit on the chest so it’s kind of like hitting a moving target.  Also, the training should incorporate  identification of emesis into the H’s & T’s differential diagnosis.  Maybe call it T-H-Es?  We’re trying to look for a causative reason, ID’ing dinner might be a good start, it’s usually easily viewed.  One of the extras could smear chocolate pudding on the dummy with each rhythm check to add that extra layer of realism.  To make it better, the manufactures of the dummies could add an optional module that uses the force of the compressions and triggered by breaths to spew liquid material out of the dummy’s mouth.

5.  Re-organize the algorithms by using a drunken dart toss for each step, say every 2 minutes.  Many times the actions are just so random it is like that.  This way by using the toss method, random changes to the procedure would be accounted for and awaited thus allowing practioners to think ahead.  Besides, wouldn’t playing darts in ACLS be awesome?

Finally,

6.  Teach clean-up as part of post-recusitation care.  We’ve all seen rooms after a code.  Wrappers everywhere, boxes from meds strewn about, random pieces of detrisius tossed to the side of the bed, pieces for the intubation tray lodged in the computer keyboard, sharps hiding under piles of plastic and the puddles of body fluid.  What should be taught is that everyone goes on break, leaving one person to clean up the mess.  That job should be assigned with as much if not more importance than the compressors to ensure the rest of the team gets to take a break post-code.

If the AHA would consider incorporating these elements into ACLS training, it would make the providers so much more capable in handling the realities of the true in-hospital codes.  Just sayin’.

 

editors note:  your results may vary, data is compiled from triple-blinded, beer-goggled, non-placebo, peer un-reviewed observation of events on medical/telemetry/geri-psych nursing floors over a 5 year period of time.

Gettin’ Ran

It was night three, about 3am.  I had just gone down to the cafeteria to get something fried and salty to satisfy the ravenous beast in my gut.  I had about 5 of the fries while still warm as I walked into near pandemonium.  It was like someone turned the crazy on the minute I left the floor.

Compared to the previous two nights, this one hadn’t been too bad.  While earlier in the week it had been “grab your ankles and hold on!” tonight was a little better controlled chaos.  Instead of a rapid response we calmly sent the patient with a pH of 7.19 and a pCO2 of 95 to ICU for BiPAP.  Instead of getting hit with a CVA admit with no orders at shift change, the only patient we admitted came with orders and hours after shift change.  It was better.  Kind of.

While technically we weren’t short, we were.  We had two floats filling in for the one we were short and the one we floated away to step-down, but strong they were not.  They had the easiest patients on the floor, but were barely keeping head above water.   In essence we were short as they couldn’t help the rest of us.  And the scheduled aide?  Yeah, stuck in close observation with the paranoid, impulsive, delirious ICU transfer out.

I don’t remember a whole lot after 3am, it’s just a blur as we ran putting out one fire after another.  Your previously calm patient is now fucking nuts?  Hey isn’t that your patient trying to escape out the fire door?  Hey, my patient sounds like a stridorous 3 year old and has that “oh shit” look in her eyes as she uses every muscle in her body to breathe.  Bed alarms to my left, call lights to my right and I’m stuck in the middle with you all.

Our only saving grace was the 3 of us left from our core staff formed a tight team, picking up where each left off, answering call lights and bed alarms without the petty stuff that gets in the way.  What, you need meds on 97?  Got it.  Can you tuck 93 back into bed?  No problem.  Tight teamwork saved the night and got us through until 0705.

No falls, no restraints and chaos reigned in by the time day shift rolled in the door.  It’s how we do it.  It’s how we did it.

You want what?

“Hi, Dr. Heart, I’m calling you about Mr. I’ve-gone-crazy who your partner did a pacer generator change on today.  He’s become very agitated and combative since the start of our shift.  I need something now to calm him down as nothing else has worked.  Would something like Depakote sprinkles or Zyprexa, maybe even Haldol be OK with you?  said the nurse into the phone.

Seriously, the guy was freaking out.  Every non-pharmacological method we have in the arsenal had been thrown at him.  He was confused and rightfully so.  It’s not nice to put folks with dementia through surgery, it leads to some very funky things.  He went from perseverating over his pants to perseverating over his wheel chair, then he wanted to be in bed, now in the chair and wherever you put him he wanted out of it.  Did I mention he could not stand and bear his own weight?

The other nurses looked at me imploringly to help his nurse out.  “You’ve got to do something!” they said to me.

“She’s his nurse, and yes, we’re doing all of her work for her, but I cannot call the doc for her.  I don’t know the details, I don’t know enough about his history to state my case for what I think is needed.  But I will talk with her.” I said.

The nurse came up to me minutes later and asked what to do.  I reeled off the things that might help, meds that we have used time and time again in these situations.  She agreed and went to call the doc.  Above is how I pictured the conversation (she likes to hide in the med room or pharmacy office to call).

I can surmise how the rest of the above conversation went.  “You want what?  I have no idea about any of those meds.  He’s agitated?  Um, not really used to dealing with this, is he covered by Medicine?  No?  Really?  I don’t even know what the doses would be for those meds in this situation.  Uhhh…how about some Ativan?”

To which the nurse readily agreed.  Really we would have taken anything at that point.  This is not to say that our cardiologists don’t know what they are doing, they’re just not as adept at helping us handle the agitated and combative elder as say our medicine interns or geriatrics service.  It’s a level of comfort.  Our geri docs would readily agree to something like Depakote far faster than Ativan, but it’s their milieu.  Would not want one of them dropping a stent in my patient.  It’s what you know.

And the Ativan?  It worked for a while but he ended up with a sitter by daybreak, still confused and combative, but staying safely in bed.  Lesson?  Avoid general anesthesia and things like Versed and Fentanyl on demented elders:  it makes them worse.

(Am not saying to not do procedures on folks of advanced age, make sure you give us the tools to manage them and ensure their safety post-operatively when you do!)

Unorganized Thoughts

This last week beat the snot out of me.  I really want to write a resounding “Fuck yeah!” and a post related to some great nursing writing by Not Nurse Ratched and  Those Emergency Blues, but I don’t have it.  I’m running on empty from a worse week than normal.  If we weren’t getting screwed by the patients, the ED, docs and our fellow nurses there was a general feeling of being under a bad moon.  I feel like I saw the future of my floor this week:  it wasn’t pretty.  I want to say more, but can’t formulate coherent logical thoughts.  Believe me, I’ve been trying.  Nothing seems to flow right.  I have some snippets put down, but can’t seem to make them go anywhere.

Go read these posts.  They’re beyond good and in many ways capture what I’m thinking better than I can.

Dark Times by Not Nurse Ratched

Response to Dark Times by Not Nurse Ratched

Nursing Malaise by Those Emergency Blues.

I have this feeling of impending doom regarding my unit.  What they write about is evolving on my unit and I am scared to death about it.  I feel that even though my manager wants our input, doing so would make me (and every other charge nurse) complicit in the same destructive behavior described above.  I don’t want any of it.

Don’t worry I’ll find my flow again.

 

The Wonderful World of Versed

Just after shift change…

“Can someone give me a hand in here?!” came the frantic cry.  I looked up to see Dr. Flighty in full isolation regalia trying to keep a very naked guy from running into the hall.  As I got closer I saw the wild look in hie eyes, the look of fear, of the flight-or-flight reflex on overdrive.

“Hey, Mr. Smith…calm down there.”  I said interposing myself between him and the hall as three other colleagues ran to our aid.

“”I.  Have to.  Get out of here…”  said Mr. Smith looking around bewildered at the ruckus and chaos around him.

He was wiry dude.  Not tall, but strong – not in a bulging physique way, but the wiry lean cable-like strength of a life-long manual worker.  And I was having a hard time controlling him.  It was a battle between him running and him falling.

“Let go of me!  Leave me be!”  he said.  I could see the animal fear in his eyes.  “I’m not staying in that bed.  I’m not staying in this room.  I’m going home!”

“Look Bob,” I said, my tone calm, even, looking him in square in the face.  “I know you’re freaked out.  You’re scared, I can tell.  You don’t know what the heck is going on.  Am I right?”

He nodded his head so I continued, “You’re here because of the nosebleed, remember?  They gave you some medicine to calm you down so they could fix the nosebleed and now it’s making you feel very strange.”

The fear subsided a bit, but it was still there, a lingering caged animal lurking just below the surface.  “Now we’re just trying to keep you safe.  I know you’re scared, that you don’t know where you are, or that no one knows you’re here.  That’s my job, to keep you safe, OK?  Your job right now is to stay in bed, OK?”

He was still straining in our grip, so I eased up.  “Can you do that for me Bob?”  I finished.

Bob started to shuffle back towards the bed.  “This stuff will wear off, I promise you.  But you’re too unsteady to be up moving around by yourself, that’s why I need you to stay in the bed.”

Slowly Bob got into his bed.  We fixed his gown, re-hooked the telemetry leads, all the time reassuring him that this is what he needed to do.  It wasn’t complete capitulation on his part though, it was grudging at best, his glowering eyes told me that.  But he stayed in bed and slowly drifted off to sleep.

“He’s going to be a little embarrassed in the morning,” I said to no one in particular.  “And we’re going to add Versed to his allergies!”

“What did he have done?” asked Dr. Flighty, clearly shaken from having been chased out of the room by a naked guy.  “Had a raging nosebleed that wouldn’t stop, even around the balloons, so he went to cath lab for a coil embolization, think he had a little bit of reaction to the Versed or Fentanyl.”  I replied with a smile.

Skip ahead to the next morning.

“Hey Wanderer, Mr. Smith wants to see you.”  said another of my colleagues.

I walked into the room.  He was sitting there in blue paper scrubs with a sheepish look on his face.  He reached for my hand and said, “I’m so sorry if I caused any trouble last night.” he said, visibly shaken.

“You’re welcome,” I said, shaking his outstretched hand.  “Not really trouble.  You just kept on us on our toes for awhile.”

“I don’t remember much, but I do remember your voice.  Thank you for helping me out.”  he said.

“It happens from time to time.  We’re kind of used to it.  I don’t hold it against you at all, just glad you’re feeling better.” I replied and walked out of the room with a grin on my face.

If he only knew the extent of his behavior he would have been mortified as he seemed like one of those straight-laced types.  But we’re professionals and left him to his own memories because I know deep inside he knows and it would only shame him if we brought it up.  Best to leave it alone I figured.  Best thing though?  In the midst of all the commotion, neither his arterial site or nose bled!

Time For a New Hobby?

Middle-aged guy comes in complaining of chest pain.

He had been sitting down to a nice recuperative meal after running a leg in a relay race.  ED work-up reveals elevated troponin and some signs of mild dehydration and thus is admitted for monitoring overnight.

When he gets to the floor he tells us that he actually started to have chest pain while he was running, but at the end of his leg, it went away.  Usual suspects:  male, age in 50’s, ex-smoker, overweight – check to all of them.  Then he drops the bomb:  he’s had a stent before.  After he had “mild” heart attack 5 years ago across the country.  And what was he doing then?  Running a half-marathon!

Having flash-backs to Jim Fixx as we’re hanging Integrillin and heparin.  He goes to the cath lab and we go home.

I just wish I could have shared a word of advice:  maybe running isn’t your thing!

Rapid Response Teams: Excuse or Tool?

I know this has been discussed ad nauseam already, but I had to weigh in.

Thanks to an article out on Medpage Today, Rapid Response Teams Sign of Poor Bed Management, the whole idea of Rapid Response Teams has been brought into the spotlight.  The article’s premise is that poor bed management is the cause for Rapid Responses to be called.  Bullshit. 

Code Blog sums it up nicely by saying,

I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care.  I think they are called because stable patients just stop being stable sometimes.

Are there times where over-crowding and poor bed management are the cause?  Yeah, if it is crazy busy, the nurse might miss subtle signs or the patient is sent to a floor of lesser acuity, but these are the exception rather than the rule.  I can count on my hand the number of times I’ve called an RRT, of course now I’ve now jinxed myself, but each time it was from a rapid change in patient condition.  There have been times where I could have called an RRT, but managed it with judicious use of critical thinking and calls to the doc.  I think that some nurses use them as a crutch instead of critically thinking a situation through, but not because a patient was wrongly placed.  Like I noted above, there are times when the patient is placed wrong.  When our observation unit opened we had several times where they went from Obs to the Unit in a very short amount of time.  But again, these we patients who rapidly de-compensated – and a couple that never should have gone there, but those are the exception.

Have the authors forgotten that a hospital is an acute setting?  It’s not like these folks are healthy!  And thanks to the rise of observation (outpatient in the hospital) those who are admitted in-patient are the sick of the sick.  Having a resource to get help quickly is a godsend.  Sometimes all you need is some stat meds, or imaging and labs , or just someone to look and say, “Yeah, they’re sick!”  And sometimes you just need to have the ability to transfer to a higher level of care without jumping through hoops.

Even if we have the best patient flow possible, appropriate bed placement each and every time and proper resource management, there still would be a need to the Team.  Patients crump.  The article never addresses that simple fact.  It’s far easier to point out structural issues than the reality – of course structural issues are somewhat easier to fix.  Schedule better to make better use of the nurses you’re already overworking.  Staffing plays an important role in this as well.  A nurse that is stretched too thin can’t take the needed time to adequately assess their patients.  When you 5, 6, 7 or more patients at a time, you’re running and even the most perceptive, mind-reading nurse can catch a patient decline if they’re stuck cleaning and doing a massive dressing change because the wound is saturated in stool of a 400lb quad with the 3 other nurses on the floor because it takes at least 4 to move the patient safely.  That’s when the easy things to fix fall through the cracks, hence why we need a team to “rescue” the nurses.

It’s a complex multi-layered issue to which there are no simple and easy answers.  It impacts staffing, scheduling, patient flow and the vagaries of the human condition.  But would I choose to work somewhere without the back up of a RRT?  Not easily.