Um, You’re the Doctor, Right?

Back from a ID theft imposed digital holiday and stuck with a raging case of insomnia.  I mean, what did I do to sleep for 4 hours voluntarily?  I wanted to sleep, just couldn’t, so here I am.


Nothing puts experience in perspective like having a doc ask you for advice.  It’s humbling and kind of scary all at the same time.  Really?  You’re the doc.  Y’know, medical school?  At least 1 year as a full fledged doc, writing orders, telling us lowly peons what to do?  Any of this ring a bell?

The conversation went along these lines…

“So I have a patient I want on tele, but they’re bradycardic.  I mean, you do that right?”  Dr. Obvious.

“Um, yeah.  We have brady folks all the time.  Not really a big deal.”  says perplexed charge nurse (PCN).

“OK, can you guys do pacing on the floor or do I need to send them to ICU?”  Dr. Obvious.

“Uh, if you’re thinking they need to be paced odds are pretty good they need to be in the Unit.”  PCN.

“Right.”  Obvious is thinking here.  “They’ve been brady and slightly hypotensive.  You guys can handle that right?”

“Uh-huh.”  starting to look around for Peter Funt and a camera crew.  “I mean, brady is fine.  If he drops too low we’ll just drop into ACLS and do our thing.  How low is he anyway?”

“He’s been holding steady in the 40’s.  Last BP was 100s over 60s”

face palm… “Look as long as he’s not doing any kind of funny block, I’m cool with them in the 30s with a pressure that good.  He’ll be fine.  If you want, you can write orders for atropine prn and we’ll put pacer pads on…”

I’m trying not to laugh here.  Really 40-50s with  pressures in the 100s?  I thought it was a real issue, like they’re runnning 30-40’s in a Mobitz II block or something funky.  Really?  Sure, I appreciate being asked what our comfort level was, but you’re the doc.  You get the special white coat and all that to make these hard decisions.  You want tele, fine.  We’ll deal with the the issues, and if the fecal matter hits the air oscillator, we know what to do.

Had a patient the other week that ran consistently in the low 30’s post-Sotalol.  I’m OK with that.  BP of 86/40 in a CHFer who’s talking to me coherently and making urine?  I’m good.  Now the guy who we were getting pressures of 70/palp with a heart rate in the 120’s and was minimally responsive, that made my sphincter pucker a little.  But that’s why I love telemetry, we take relatively unstable patients (even those that probably need to be in ICU) monitor them and do interventions to fix them.  Part of me appreciates the call, but part of me views it as an insult, in the implication we can’t take care of the (not)unstable patient.  Make your decision, you’re the doctor, right?

It’s a Block, Kind Of

FTW - not for the win

My life has been one set of aggravations after another lately and I feel like the picture implies.  And it sounds trite and trivial to whine about them in a pubic forum, but sometimes we have to vent.  The problem is that I can’t spin them in ways to make it sound less trivial and less trite.  When I do write it out and go back over it the words sound like some teen who’s parents took the car away from. So it’s kind of like a block.  But I’m going to spit it out, get the vitriol, hate and anger out.  We’ll see what happens.

My doctor’s office.
They don’t seem to realize that I need answers sooner rather than later.  You see I had a result on a test which my doc wanted me to get further worked-up for.  They assured me that the office staff would get on it.  That was a week ago.  And today they don’t even return my phone call.  WTF?!  The results are life-altering and frankly I’m scared as hell about it.  I want, no I crave answers to what is going on.  That’s the fucked up thing as a nurse, you know enough to be totally freaked out, but not enough to be rational.  Reading Up to Date at work does not help the situation.

My Floor
I love my staff.  My co-workers are some of the most awesome nurses I have ever worked with and we’re one hell of a good team.  When shit goes south, I know they have my back and likewise for them.  But the patients, oh, our wonderful patients.  I’m slowly losing interest in little old demented ladies, the non-compliant trainwrecks that circle through every month or so, the stupid admissions and the psych cases that need “medical clearance” before going to in-patient psych.  It’s no longer a challenge.  Which is dangerous for me.  I get complacent.  I get bored.  I need to leave and find new adventures but the economy is still to fragile and based on item #1, I don’t want to be changing anything yet.  So I’m stuck.

The Floats
I’m tired of floaters to our floor.  I appreciate having them fill our holes and some days a body is better than nothing, but only barely.  What’s worse is when they get floated because our staff gets canceled (thanks to our convoluted staffing office’s system that no one understands and is about as transparent as mud), or they get floated to a sister unit as that unit can’t staff themselves.  Ever.  So I give up one of our floor nurses, trained in ACLS, stokes, rhythms etc., who can handle anything that gets admitted for someone who I have to carefully tailor the assignment for and hope they are there for the entire shift (one floor in the whole f-ing hospital has a special dispensation to have different hours 6-6 vs 7-7 and their nurses, even when floated keep that time, so we lose a nurse at 0630).  And if anything gets funky I pretty much end up taking over the patient(true story).

Our Aides
Who do as little as possible so it is like having no aide at all.  ‘Nuff said.

My Sister Unit
Them whose shit don’t stink, those that are better than us as they get “critical care differential”, those who take care of open heart patients and stent patients, those who can only take ACLS certified floats.  Yes, those bastards.  They tend to forget that I used to work with all of them before our units split apart.  So you have a post-open heart patient.  Big deal.  Been there, done that.  With four other patients.  Oooh, you had to pull a sheath.  And?  It wouldn’t be so bad if they weren’t so fucking condescending about it.  Yes, we’re the other tele unit, the dump unit, the one you turf the trainwrecks and pain in the ass patients too.  Even though you are an Intermediate Care Unit, the only true step-down type patients you take of are cardiac stuff, we get a ton of the nasty medical stuff that should probably go to you.  You stonewall any attempt to take any sort of non-cardiac patient all the time.  And I’m sorry that you had to take an admit the other night, we had 3 nurses and didn’t have the ability to take an admit at the time.  Yet in your busyness, you Ms. Charge Nurse-lifer still found the time to come up and chat with us for 45minutes.  You were really busy.  The classic line though was when one of you looked at our patients and said, “They have a chest tube!  Shouldn’t they be in the IMCU?  Can you handle it?”  No, we can’t.  I was wondering what that funny thing sticking out of their chest was, maybe I need to get them transferred!  No, the reason they are up here, I wanted to tell her, was because the surgeon wasn’t as picky as your typical guy is, because God forbid, his holiness, the cardio-thoracic surgeon would have to go a floor above yours and the ICU!  We can take care of a patient with chest tubes, it ain’t rocket science like you make it out to be.

Last, but not least, our Day Shift
I’m not starting a Days vs Nights war, this is not a general meditation of day shift, but my feelings towards our lovely day shift.  It can be summed up simply:  can you just get your shit done?  Ever?  Nursing is a 24-hour job, but that doesn’t mean you can dump everything on the night shift.  I am sick and tired of spending the first 3, 4, 5 or more hours of my shift cleaning up your messes.  I know I can’t say anything because all we do at night is sit around talking (yes, more than one has said this).  I mean we have to have something to do, right?  Nearly every night for the last 3 months has been  like walking into a war zone when I get to work.  Some days are better than others, but they are the exception.  It’s not a good sign when the nurse you get report from answers every question of “Did this get done yet?” with, “Oh, I didn’t see that.”  Not a good sign when the patient has been on the floor since 1600 and nothing is done and they’re lying in their own waste.  Having been around during the day for other things at work, I see the manic take hold until all of them are wandering around in circles looking like they are doing a lot but really doing nothing at all.  And if you really want to see frantic useless action, call a Code.  It’s like the proverbial chicken with their head off.  While it is nice to be welcomed by your patients, it’s never a good sign when they say, “I’m so glad you’re here!”  So yes, day shift, I’m not a fan.  Don’t you dare give my nurses shit when everything isn’t complete on a patient who arrived at 0630, because it never is when y’all do it.

At least I feel a little better now.

My GI doc appointment is actually scheduled now, my PCPs office called at 1900 last night to let me know.  Guess they heard my ranting.  Dude looks like a child though.  Could be interesting.

In the Trenches NYE

Once again I found myself ringing in the New Year with co-workers.  Not that they’re not fun to be around, but it’s not like I can dance and kiss them at midnight.

It’s funny though to watch the admissions though the night.  Until midnight, there was nothing.  The ED was dead.  Just a couple of the usual detritus of abdominal pain, nausea/vomiting and the requisite psych hold.  But after midnight it was all ETOH-related.  ETOH/Fall, knee injury, ETOH, fall with back pain and since I was in charge of the observation unit as well that night, I was getting the calls.

“Yeah, we need an obs bed for a “syncope” patient.”  said the house supervisor

“Syncope huh?  You mean falling down drunk, right?”

And the night continued like that.  Syncope chick tested positive for coke, ETOH, a UTI and Trich.  But denied that she drank, takes drugs or smokes (we didn’t go into the sleeping around part…)  I learned that you could test positive for coke just by  being around people smoking meth!  I never knew!

All in all it was much the same as every other night.  But for a New Year, with a full moon it could have been much worse.

The Non-Admit Nurse

As a charge nurse one of my responsibilities is to assign beds to patients coming in from the ED.  Somedays that gets sticky:  do they need to be close to the station?  isolation?  what nurse can I overload?  Others it’s real simple:  there’s one room and one nurse.

I’m looking at the locator (which shows what’s in the ED with notes if the patient is expected to be admitted) and see the following:  admit tele, k2.8, poss. seizure.  So I mark them on my cheat sheet and wait for the call from the nursing supervisor.  And like clockwork the phone rings.

I give the room away and tell the nurse.  Eons later the ED calls up with report, but the residents don’t want tele.  I mean, really?  A potassium of 2.8 with a seizure and no tele?  As I finish pounding my head against the desk, the nursing supervisor calls back.  “So they don’t want tele.  But I have a room on neuro and a chest painer who needs a room.”

“OK, let’s swap.  Neuro can have the low K and we’ll take the chest pain.”  I say.

“Hey J” I say to the nurse who was taking that patient, “Low K is going to Neuro, but we’ve got a chest pain for you.  Same room though.”

And we wait.  The morning is slipping away and we’re starting totake bets on whether this new chest pain will show up before shift change adn the phone rings.

“Hey is the room where chest pain is going an isolation room?” ask the supervisor.

“Yeah, it’s a private.” I say.

“But is it a negative pressure room?”

“No, what are you getting at?”

“They’re ruling them out for TB.  They have a nodule on the chest film and a positive PPD in their history.”

“Sorry, it’s just a private.  You’re out of luck.” as Isay as I hang up.

“Uh, J.” I finish, “they’re ruling out chest pain for TB so their not coming either.”

2 admits, not a single on to the floor.  I say to J, “Y’know, I should try to give you patients more often.  Guess they just don’t like you!” I joke.

As frustring as that may be, I love it when that happens.  One night I tried to give 3 patients from the ED to a nurse, all three ended up going somewhere else.  I guess the patients have heard about our reputation and just don’t want to come hang out!

Call Me Admit Guy

I don’t mind getting admits.  Being on the night crew we do far more admits than discharges, so it is something I know very well.  A couple of months ago, my wife was admitted for observation overnight for atypical chest pain.  I was following along in my head the screens for the admit history form and anticipating the questions as they came.  We do it that often.  It’s always tough though when you start the night off with an admit at shift change.

I’ve barely finished getting report from the say shift when  the unit secretary pages with, “ED with report on line 1.”  So I take report, but the patinet seems very familiar.  Somethings tickling in the back of head that I know this patient.  I ask the ED nurse to give me 15 minutes to at least pop my head in to see my other people and let them know that I’ll be back.  I get about 5.

With this admit the ED cleaned up.  The patient came up with admit history and med reconciliation already complete, so I guess it made up for the quick arrival.  Got them all tucked in and settled and went on my way.  It was perhaps the easiest admit I’ve had in awhile.  And the patient?  Sure enough, I remembered them, and they remembered me.  Seems I had done a good jub the last time they were in, so they were actually happy to see me.  What a change!

To top that off, I had a patient come back from surgery who at the sight of me nearly burst into tears saying, “I’m so glad you’re here tonight!” Twice in one night.  It was almost surreal.  Then I heard it was nearly a full moon.  Guess that explains that.

As admits, later in the night I get a call from charge who says we’ve got one coming up and it would either be me or A, and she would let us duke it out to see who takes them.  As my luck would have, A had conveniently disappeared right before ED called report.  So I took it.  The ED nurse said, “Didn’t I give you report already tonight?”   “Yep, I replied, I’m just the admit guy.”  Again I asked for 30 minutes as the admit didn’t have orders yet he said, “I’ll try.”  Sure enough though, they came through.  I asked for 30 and they gave me a hour and 15.  I got caught up, charted and ready to go.  Dialed in the admit, settled them in, put ’em to bed and finished the night.

It’s nice when it goes well, too bad it doesn’t happen all that often.  But I’ll take it when it does.