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’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.

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.

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?

First of a Thousand Words

I’m learning that there is only so much that you can write about on a daily/weekly/bi-weekly basis without getting into things like religion, money and politics – all subjects I learned long ago to steer clear from while at work and the dinner table.  Thees are things that I wish I could write intelligently about and eloquently enough to make a valid argument, but I have neither the time or the inclination to deal with the kooks that would stream from under the rocks if I did.  So instead, every time I get the urge to blather on about the inequities of tax policy, over-reach of global multinational, invasion of privacy, the corruption of our government and political process among other things, I will just post a picture.  It works for me.

Gratitude

Perusing my stats last night before heading to work I realized something:  I had broken the 100,000 visits mark someday Friday.  I know, big deal.  Yeah, there are blogs that do that in a day or even an hour, but they aren’t mine.  This little creation that started as a place to vent, educate and regale keeps growing.  And all thanks to you folks, my loyal readers, or at least the one that has visited 100,000 times.

Thanks for everything, y’all rock!

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.

Madness I Say

The air is cooler now, the last straggler leaves are hanging on in vain and the TV blares ads and Christmas jingles.  It must be Thanksgiving.  And what comes with Thanksgiving?

Black Friday!

Yes, that consumer smorgasbord of “deals” meant to strip us of hard-earned cash early in the season of giving.  Yes, long lines, maddening crowds, a little trampling here or there and stores opening the break of dawn (well, break of dawn in Europe maybe).  For weeks now we have been inundated with ads for “pre-Black Friday” and the real thing.  For some (I’m looking at you Target and Amazon) the first Black Friday sales were on the day after Halloween!  Pretty soon if this date creep continues the first Black Friday deals will be available on Boxing Day.

And what for?

Historically Black Friday marked the beginning of the Christmas shopping season.  As a child I can remember for Frederick and Nelson‘s, a department store in downtown Seattle would keep their windows covered up until that day.  When the blinds came down, we were greeted with magical vistas of Christmas gifts and scenes.  The stores themselves had not decorated until the night before.  There was no wreath hanging in the mall the first week of November.  It was that day that Santa took up residence in his corner at the store while hundreds of families braved the cold and wet weather for yearly pictures with him.   After that day it was OK to be Christmas.  As a kid it was that struggle to keep ourselves contained until the magical day now less than a month away.

As I got older it began to mean less and less.  When I worked for UPS, Black Friday was the start of “peak” season.  It meant more planes, more packages and more hours.  It also meant more stress on the workers.  Later on when I moved companies it meant more importers calling to see if their shipment was on the flight that just landed and when it would clear Customs.   While it was rare to see Christmas decorations before Thanksgiving, now it began earlier.  I cried when the first Christmas ad I heard was on the day after Halloween one year.

But what does it mean for industry?  Traditionally, the theory goes, it is the day that stores start showing a profit, or “being in the black”.  Thanks to creative accounting and reckless spending by the American public, nearly any day can do this now, but some still hold true.  But the sales data from Black Friday, and it’s cousin, Cyber Monday, are heralded with glee by news commentators as to the health of the spending public.  Moreso, it is a chance to offer slightly enticing deals to get shoppers into the stores. A $4 mixer?  Sure, I already have 2, but you never know when I’ll need another, plus it’s too good of a deal to pass up!  Brainless consumerism, buying stuff because it is a “good deal” is the sickness of the American consumer.

Not to say that I’m immune.  Each year I look at the ads and weight my options.  A couple of years ago, I was with my wife’s family in Northern Arizona for Thanksgiving.  Even in a small town, there was still Black Friday madness, I mean, there was JC Penny, and Fashion Bug and of course Walmart.  I had had my eye on a digital camera since my old one got lost on vacation earlier that year and Walmart had a deal.  I figured being a small town, things would no be so crazy.  Not.  I rolled down to the store early, like 5am early and the place was hopping.  Not trampling busy, but plenty of folks doing their thing.  Lucky for me I had the clarity of a mission.  Blinders firmly in place, I headed towards the Electronics section, skirting the scrum of people wrangling over $20 DVD players and wrestling over the last of the 3 cheap laptops in stock, I found my camera.  Grabbed it along with an extra battery and memory card and I was gone.  Through the check-out quickly thanks to cash and on my way.  Total time elapsed:  5 minutes.  Of course we went back later in the day for the late risers and it was crazier then than it had been at 5am.  And there was still a huge stack of the camera I bought earlier that morning.

This year, like the last 2 I will be on my way home when the shopping madness is in full swing having worked the night before.  My wife and our neighbor are going to brave the crowds for some stupid reason, but I’m staying at home this year.  So to all of you going out on Black Friday, good luck.  Be safe and be smart.

Head for the Polls

Tomorrow our great nation performs the ritual that makes it great:  voting.  We go to select leaders who we feel will best support our views, fulfill our needs and add to the prosperity of our nation.  It is a noble thing to serve one’s constituents, putting the needs of the many above the needs of the one.

I feel that in our country today, torn by negativity, bias, hateful rhetoric on both sides should have to take a day to step back, forget all of the nonsense, all of the bullshit, all of the false misleading ads, all of the things politicians say to get and stay elected and have a rational discussion of what is best for our country.  What is best for the whole?  How can we affect the greater good with our decisions?  This year we’re voting out of anger.  We place the blame and misfortune of years of mismanagement squarely on the heads of our current leaders forgetting that it took years to get us to this place…and it will take years to get us out.  You have to think about the issues rationally, try to sort through the bias that both sides spew to find the truth.  Realize the your decisions tomorrow can and will make a difference, good or bad, for the next several years.

So go to the polls tomorrow.  Don’t go angry, go with a clear head, a rational head and think what ramifications your vote might bring for the next 2, 4, or more years.  Choose the best candidate, not the one who has spent the most, slung the most mud, told the most half-truths and lies to win your vote.  Choose the ones that will benefit your district and your country.  Division will get us nowhere, rationality should win the day and unity will lead us on.

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!