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.

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.

Are we Evil?

“Why would you choose to do this job?  I know you’re killing people and hiding the bodies.”  such was the thought process of the paranoid post-op patient.  No matter what we said, what we did, the delusion was so real to them that while they got along fine with day shift, there was a lingering mistrust of the night shift because we were killing people.

Sometimes I do question the things we do, the horribly invasive things we do, breaking chests open, sticking needles in veins, catheters in any numbers of openings, slice, sew, defibrillate.

And heal.  That answers the question doesn’t it?

bonus…

It’s just too awesome not to include…

Under My Skin

It’s not often that I get riled up by things patients do thanks to a dedicated sense of Zen and a well-developed ability to shrug things off. So it’s a big deal to me when I let someone get to me.

Someone did the other night. I know rationally it’s not a big thing, in fact it happens fairly regularly. But deep in my psyche it stung and I’ve been perservating over it since. I got fired by a patient.

It’s happened before, it will happen again is what I keep telling myself, but it nevertheless unnerved me. Why? The reason? It was because I’m a man. Or as I crassly put it on Twitter, “I got fired because I have a penis.” It’s one of those things us men in nursing come up against and we have learned to take it in stride. There are ingrained social and societal mores, stereotypes and prejudices that cannot be erased in the first five minutes of you meeting me, the male nurse.

Rationally I get it. Emotionally/psychologically I don’t.

If you’re a 80-something year old lady, having a male nurse is probably a bit out of your comfort zone and no matter how professional the nurse is, it still isn’t comfortable. But I don’t understand totally. If you’re that age, odds are good, like 100%, that your Ob/Gyn was a man. You let them view and examine your holiest-of-holies, but when it comes to the nurse, the one who ensures you get the right medications, that the treatments we are doing is actually working,  it’s just too weird. I’m not asking to examine your bits, in fact I want nothing to do with them.  I even offered that if you were uncomfortable I could have our aide help you with your bathroom needs. Clueless I’m not. I can tell when things are not quite right and take preventative action, so I thought I had it covered.

Yeah, I was a little surprised when a family member came out to the nurses station and spoke to a co-worker about it. Not to mention I was sitting right there. My name was on the patient’s board and I was the only guy sitting there. They didn’t talk to me because they were ashamed, but here’s the thing: I wouldn’t have been so upset if they had asked me about it. In fact in I would have offered to swap assignments on the spot, no muss, no fuss, no dirt off my shoulder.

We swapped out assignments and solved the problem

Here’s the thing too, they commented to the nurse who replaced me that it wasn’t my ability, but merely my gender as the reason to swap.  I’ll take that.  More though, I was angry.  I was angry because it wasn’t my skills, my attitude or inter-personal skills, it was that I was a man.  It’s accepted because of this, but what if it had been because I was black, or gay, or Muslim?  I’m not truly making comparisons and saying I’m being oppressed, I’m trying to make a point.  Prejudice is still prejudice.

I will agree that there are some places men shouldn’t be nurses.  Hell, I’m guilty about it since I had a little bit of problem with my wife having a guy nurse in OB, but I never would have asked to change (and in that case only because he was incompetent.)

I had thought at this point in time the acceptance of men in nursing this was a non-issue.

I was wrong.

As I said above, it’s happened before and will happen again. But it still doesn’t make it right.

 

Addendum:  I’ve let this post simmer for awhile and while I’m not as pissed as I was, it still irks me.  But I tell myself, “get over it.”  And it works.  Most of the time.

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.

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.

Is Protecting Yourself a Joint Commission Violation? | WhiteCoat’s Call Room

When are you guys going to learn? When a patient is choking the life out of you, you HAVE to offer them milk and cookies then tell them to go to a secluded room before you try to defend yourself. Those are the rules. If they have their hands around your windpipe and you can’t breathe, then just point emphatically to the secluded area.

via Is Protecting Yourself a Joint Commission Violation? | WhiteCoat’s Call Room.

Yes.  Yes it is.

This is the inherent problem of large regulatory bodies like the Joint Commission:  they do not operate in reality.  They exist in a perfect fantasy land where falls never happen, infections are impossible and ED (and all patients) are well behaved.  They do NOT understand the complex and dangerous reality that is modern health care.  Like managers, they should be required to spend an amount, say a week a year, of time where they are the primary surveyors.  Your primary survey (management) area is ED?  You get to spend a week in the trenches.   The people who are writing the rules NEED to be intimately familiar with the true consequences of their actions.  Handing down edicts from on high isn’t as easy when you know what it means to the actual providers.

Of course that is just a fantasy because like most bureaucrats, they got into this line of work to avoid (or couldn’t hack it) just this sort of thing.  Actual patient contact?  Ewww.

Who Cares if I’m Gay or Not?

Can We Stop the I’m-a-Male-Nurse-Who-Isn’t-Gay-Contrary-to-the-Stereotype Routine? « Those Emergency Blues.

Awesome piece!

It’s what I tell my patients:  I am a nurse.  My gender/sexual orientation/going to be a doctor, all of that bullshit means nothing.  I am a nurse.  A professional, educated and capable.  I am a nurse.  Just so happens to be that I’m a man.

And it doesn’t matter.  I am a nurse.

Culture of Coddling vs Eating Young

Not all that long ago I was a fresh-faced new grad, eager to explore the great wide world of nursing.  School was done, externship was over and I had passed the dreaded NCLEX on the first try.  I was ready.

Yeah right.

My first year was brutal.  Trial by fire, eating of the young, stress migraines and an overwhelming urge to run screaming as fast as possible away from my job and go work at McDonalds, that encompassed the first 6-8 months.  Then as if by magic, I realized I wasn’t struggling, I wasn’t hating work, I didn’t get sick on the way to work and people were asking ME for answers instead of the other way around.  I couldn’t tell you when it happened, just that it did.  Having been through it I know that it made me a better nurse.  That hell I went through toughened me up, made me become organized as a survival technique, taught me how to juggle the needs of my patients with the duties I needed to perform whilst maintaining a sembalnce of sanity.  And it worked.  It was kind of like boot camp:  break you down to build you up.

Since then I’ve precepted new grads, been a mentor of sorts to them and tried to make their first year a little less harrowing, but still instilling the fire they need to survive.  I don’t practice eating of the young, it’s counter-productive and will drive promising new nurses right out of nursing, or at least off of your unit leaving you back where you started: short handed.  But I do believe a little bit of “tough love” is needed.  Our job is not easy and the sooner you accept that it isn’t all candy and rainbows the sooner we can build you into a competent nurse.  Not saying that you’re crying on the way home everyday, but not shielding from the rough days either.

Our system just bought into the Versant Residency Solution, which is a systematic residency program intended to rapidly prepare new nurses.   “After only 18 weeks, trained observers report that Versant RN Residency graduates achieve Nursing Skills Competency ratings that are slightly above new graduate comparison groups who have been in professional practice for nearly a year and a half (17.1 months).”  Sounds awesome.  Wish we had something like that when I was starting out.  That would have made my first year a little bit better.  Or is it just delaying the inevitable?

Our RN Resident is with us for 18 weeks.  18 weeks of being precepted before they are on their own.  2 days a week in classes, 2 days a week on the floor.  It’s a tough schedule, worse for those that drew a night shift slot.  But in our over-saturated market many new grads were willing to sign over their first and second born to get a nursing job.  For 50 something slots, over 500 newly graduated nurses applied.  It’s that desperate here.  Truly these are the cream of the crop.  But for 18 weeks they are coddled into nursing on the floor.  I had 12 shifts with a preceptor, and was told straight out that by shift 9 or so I would be taking a full load with the preceptor merely supplying help when needed.  Our poor resident is struggling still to take 2-3 patients a night and they are already past day 12 and those running the program have told the preceptors that the residents aren’t expected to take a full load until the final weeks of the residency, if even then.  For 18 weeks we expect less, are allowed to expect less and not to push as hard as we might have before.  We’re coddling.

Do I expect new nurses to go through the same shit I did?  It sounds like it.  But I truly believe that there comes a point where you can no longer hold their hands, no longer allow them to sit idly by, skimming along with help from their preceptor:  it’s time to fly!  The 18 weeks is doing a dis-service as it is not making them fly on their own.  What made me a competent and efficient nurse?  Stress.  Pain.  Being kicked out of the nest and having no choice but to fly.  Did it suck?  Yeah, but I know that I’m stronger for it.  This coddling aspect is so ingrained in our culture, from the “everyone wins” school of thought in sports, to getting a 4.3 GPA on a 4.0 scale,  to overprotective parents, that we can’t just let people go and see how they function on their own.

Since I started on my floor, it has changed drastically.  The old battle axe nurses have moved on, now you’re more likely to get help when you ask  rather than a dirty look or eye roll and generally it’s a better place.  Being let fly here is far less daunting than it was when I started, there is support whereas previously you really were on your own.  But, due to the rules of the program we can’t let our residents fly on their own.

I know that people will ask, “So, are you doing anything to help the resident?”  Yes, the preceptors (there are three of them) and a couple of the charge nurses have talked about ways to help them.  We don’t want them to fail, but we don’t want the end of the 18 weeks to be a huge issue either, where all of a sudden you’re flying free and haven’t developed the skills to keep aloft.  Who knows, maybe this idea is great and it will produce incredible results – that’s at least what the program developers say.  But I have one lingering question:  how can you be as good as a 18 month nurse at 18 weeks when you’re only spent 12 of those weeks actually caring for patients?  Book learning is great, but it means nothing until you get to use it.  It is the actual act of caring for the patients that brings the book knowledge into focus as Ricky Gervais said, “Without application, knowledge is pointless.”  We’ll see how it end in about 3 months.