Meetings: Not a Prioirty

To: Unit Manager

From: Wanderer, overworked charge nurse

Subject: Monday’s Meeting

I guess one of the included functions in the Managerion™ 2000 automated management toolset randomly creates meetings and requires our attendance.  This would explain relative randomness and recurring frequency of such meetings and their lack of cogent concept or agenda.  Having meetings just to have meetings about meetings is pointless and a waste of all of our time.

In the last 4 meetings we have decided absolutely nothing, but keep referring to later meetings to “work out the details”.  Would it be so hard to make a decision?  Yes, you have multiple units that these decisions will affect, but sometimes you need to throw caution to the wind and make a decision – call it an executive mandate.  There is something to that y’know?

This said, I won’t be coming to any more meetings.  I’m not going to spend an hour each way commuting in to work for a meeting that lasts 45-60minutes and decides nothing.  It is not as easy as some might think.  Whether I drive or not it is at least 45 minutes in rush hour traffic and if I use transit it is even longer.  Now if we were going to decide something or the  meeting was going to last 2 hours, things might be different.  Also if I didn’t have to come back to work the night shift at 1900 it might be different as well.  But the last 4 meetings have done nothing of the sort.

I realize that it is part of your annual review to see how many meetings you presided over, ran or otherwise were engaged in, and I know management is in agreement that meeting indices are not quite what they should be for this fiscal quarter, but please, enough already.

So unless the next meeting will actually accomplish something, or is held in a local pub during happy hour, I won’t even be phoning it in.  I am a nurse, I take care of patients.  I am not a paper-pusher, drone, meeting junkie or have any aspirations to management  so just let me do what I’m good at – no more meetings.


Wanderer, overworked charge nurse

Breakin’ Them In

I work in a teaching facility and thus hate July.  Why?  New Residents.  They come in with high expectations, flashing the white coat like a badge and think they will fix everyone, be loved by all the staff and generally kick ass.

The reality is a little different.

I know they mean well.  For too long they were cloistered in the halls of academia and they had some exposures to Real Medicine©, now it’s for real.  The nurses put up with the inane orders like “bladder ultrasound per nursing qshift, straight cath for >300ml” in a patient with no history or issues with urination, with a chuckle and a knowing glance.  We can tell when they get in-serviced on a new test/disease/condition/medication because all of a sudden they order it for every patient.  You can tell when they get the C.Diff lecture as all of a sudden everyone who has a trickle of diarrhea is a “rule-out C.Diff“, even when said diarrhea is caused by stacked doses of Miralax, colace, senna, milk of mag and a Theravac enema since they haven’t pooped in 5 days.  But it is when they come face-to-face with what nursing deals with 24-7 and their eyes go wide and they ask, “Really?  You guys do this?” it is almost priceless.  Case from last week is brilliant in it’s “Welcome to Medicine” slap-in-the-face reality check.

At midnight the patient was alert, oriented and cooperative and now at 4am they are claiming we’ve taken them from the hospital as they pissed all over the floor and nearly ripped out the IV line.  We can’t even talk to them as every time one of us walks in the room they yell “Get the Hell out of here!” and refuse any intervention or attempt at re-orientation.  Hard to re-adjust someone when they won’t even let you be in the room.  So we call the intern.  “I’ll be up to see them in a couple of minutes.”

When she goes in to talk with the patient, she pretty much gets the same treatment.  Maybe a little nicer and at least they are willing to answer her questions.  But pretty much it boils down to “get the Hell out!”

“I have to talk to my senior, but I think I’m going to give her something to calm her down.” she announces.

“I think that’s a great idea.” says the nurse.

After a conversation with her senior she says, “How fast can you get Haldol?

“It’s not on over-ride, but pharmacy is pretty good at getting it in for us, they know we don’t order it unless we need it.”  the nurse replies.

“So I’m going to give her 0.5mg…do you think IM or IV?”

“Y’know,” says the nurse, “I’m not sure I want to be around someone who doesn’t want me there with a sharps, not really into running the risk of getting stuck.’

“Oh yeah, I didn’t think of that.” says the resident.

As she fills in her senior who has just come up I look over at the nurse, “0.5?  Really? Maybe we should just wave the vial under her nose for all the good it will do, right?”

“I didn’t want to question her like that though,” said the nurse, “Don’t think she would really take it as the constructive criticism that it is…”  She then goes off to pull the Haldol from Pyxis.

The patient is staying in their room, but refusing everything and is sitting there with a slightly pissed off expression, but you get that gnawing feeling in the pit of your stomach looking at them, that at any moment they might explode and take a couple of us with.  It’s the calm before the storm feeling where you make sure there is nothing between you and the door.

So the nurse comes back with the Haldol and the resident asks, “So if she won’t let you even in the room, how are you going to give it to her?

“Unfortunately, we’re going to have to hold them so we can.”  the nurse replied.

“Like hold them down?”  slightly incredulous resident.

“Yeah, sometimes we have to do things patients don’t like for their own good.  It’s not the best thing, but sometimes we have to.”

“OK.  Can I come in with you, y’know, help?”  she says.

“Sure, the more the better.”

They head to the room, three of them, the senior and I stand just outside the room in case we’re needed.  “We have to give you some medication,” says the nurse  “Go ahead and hold the arm,” softly she says to the resident.  The resident lightly places her hands on the forearm.

“No, you’ll need to hold a little tighter, especially if she comes up swinging, I’ll dodge  but you might be so lucky.”

Arm down, the patient is screaming a blue streak at them, “Get the fuck out!  Leave me alone you fuckers!” but they get the med in and step out.

“Thanks,” the resident says, “I’ve never had to do that before…don’t always realize what you guys have to do.  Now we need to figure why they’re acting this way,” she finishes as they walk off the floor.

And the 0.5mg?  Didn’t do a damn thing.  At least the resident got a little eye-opener out of it.

Disclaimer…we don’t randomly go giving anti-psychotics to everyone, there’s a bunch of important relevant details left out, but you get the gist of it.

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!

Orient the Charge Nurse?

Three steps to ensure new charge nurses are successful « Nursing Notes.

No seriously, I’m not kidding, actually orient the charge nurse.  It’s not throw them to the wolves and let ‘er rip?  Odd way of thinking, right?  It’s not however and it’s something that is rarely done.

It’s funny, for an organization that tries to be pro-active with their staff, give them opportunities for education and growth and support their leaders, mine does a piss poor job.

Orientation was three days, the last of which I was on my own while my “preceptor” watched tele due to a sick call.  Mostly it was, “Here are the things you need to do. ”  There was no talk about responsibility, choices, what the other nurses were going to ask of me.  Nothing to truly prepare me for being a charge nurse.

And a preceptor past orientation?  That is about as funny as leadership development.  We talk a big talk.  Have had several conferences that were really not much more than expensive opportunities to talk a big talk but not have any sort of follow up.  Of ideas that were discussed in the last two events, not a single one has re-surfaced.  Not one.  Many were dismissed outright before we even left the conference.

In spite of the lack of support (mostly), I’ve learned.  Learned to juggle being a mentor/resource to newer nurses (and even some more experienced nurses), being a hard-ass when needed, leading from the front rather than sitting at a desk, taking my own patient load and still managing to do the things my manager expects us charge nurses to do like the minutiae of paperwork, flexing staff when not needed and balancing the load as able.

It might have been easier had I been supported and given a structured training, but with typical fatalism, I say, “It is what it is.”  I still get the feeling at times from my manager that I’m missing something, that there is something else I should be doing, but I can’t figure out what it is.  But I get validation in the best way:  from patients and my fellow nurses.  When a nurse is glad that you’re in charge versus another, it feels good and tells me that I’m doing something right after all.

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?

Naked Time!

Nothing dirty here, just a rumination of nakedness in the hospital.

You know it’s not going to be a good night when the first thing you do is forcibly re-direct a naked man out of the hallway and back to his bed.  Even though he was suffering from a nasty case of Versed-itis© (odd, sometimes insane behavior in normally sane and calm people as an adverse reaction to Versed), he was jumping out of bed post-angio and running into the halls naked, as we were trying to keep him safe.  It’s always fun when the doc is yelling for some help as she is being chased by the naked dude in his nude adventures.

It gets better when the IV nurses comes out of a room and says, “Yeah, thanks.  I just saw your patient’s penis.  Oh, and he tried to come on to me.”  That’s a surefire way to ensure no one bothers you the rest of the night.

Perhaps the best is when the naked chick is running around the unit doing laps, with a nurse or two chasing her with a gown and sheets.  It’s pretty damn hilarious.

What is it about the hospital that promotes nakedness?  Could it be the drugs?  Could it be the lowered inhibitions due to neurological decline?  Could it just be that they don’t care?

Lucky for me it’s been all three.  There was the psych patient in with syncope that the residents stopped all the anti-psychotics on thinking they were contributing to the syncope (turns out it was the the pauses he was having) but he ended up naked every night, roommate be damned.  There have been several cases of drug-induced nakedness, like angio boy.  And the neuro decline brings to mind the Huntington’s patient who slept naked and would jump out of bed to run to the bathroom, except sometimes he got lost heading there and ended up in the hallway.

99% of it has always been guys though.  It’s like we’re so enamored of our own bits that we need to show it off to the entire world, whether they want to see it or not.   If it’s in the rooms, I could care less.  Like the dementia patient who’s wife told us they had slept naked for years, it was comforting to him and once we got the clothes off, he slept like a baby.  It’s been pretty rare to have a female streaker.  I guess the societal mores are too deeply embedded in them (they just tell you about their need for a new vibrating friend…).  But when the lights go down at the hospital, too often the clothes come off.  And not in a Grey’s Anatomy-way.  Some will argue that this is just part of nursing.  It is.  A damn funny one!

I know however, that when I’m of the age and in the hospital, I’ll be the one running naked down the hall, freaking everyone out!

Falling Down

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Anyone who has read “The House of God” knows Fat Man’s Second Law:  Gomers Go to Ground.  It’s harshly worded and blunt beyond our politically correct society can accept, but it is true.  People, especially the elderly, fall.

And why not?  The elder with dementia that doesn’t understand their own limitations, the folks we pump full of beta blockers, diuretics, narcotics and anti-psychotics, and the TBIs and CHIs that can’t grasp their clumsiness are all part of the hospital (and in greater society) milieu.  They fall.  For multiple reasons.  If you do a quick search of the literature, I’m beyond positive that you will find hundreds, if not thousands of pieces of information of falls, causes, risks, sequelae, outcomes and the like.  And the chorus is the same:  falls are bad.  Falls that result in injury are bad.  Elder folks falling is bad.  Our friends of the Borg, er, The Joint (smoking) Commission have decreed that, Falls Shall Never Happen! Oh, and by the way, if they do pipes up CMS, we ain’t going to pay for the care costs related to the fall.  Go to ground and break your hip?  Hospital eats it as no one (even private insurers are starting to follow this trend), is going to pay for your care.

This fear of non-payment has created a flurry of activity.  Fall programs, rounding programs to ensure falls don’t happen by addressing all the things that cause folks to fall (pain, potty, position…), new special booties that both identify the wearer as a high fall risk and provide excellent grip and with all of this loads upon truck loads of new paperwork and charting.  So where does this leave us?  Stuck charting and paperworking instead of providing patient care.

OK, now what do we do about it?  Simple:  accept the fact that people fall.  Don’t point fingers in a blame game or penalize institutions when it happens, accept the simple fact that this will happen.  Then start operating under the assumption that everyone is a fall risk in the hospital.  Actually reduce the paperwork and charting so we can be present and available to prevent falls.  But always know that it will happen.

It’s not an easy fix as say preventing BSIs or CA-UTIs where checklists and proper technique will prevent many if not all infections.  Falls are too dynamic to be placed on a rigid checklist.  For example, a certain patient on my floor was incredibly unsteady, but was strong enough to be “mobile”.  Even though we rounded on them, they were close to the desk, minimized meds that could alter their mentation (worse than it was), they could have fallen in an instant.  Many times, even though they were mere feet away from my typical charting spot, they were up and in the bathroom before I could get to the room after the bed alarm sounded.  There was the patient that threw themselves over the bedrails opposite of their hemiparesis, of the one who suffered cardiac arrest while up walking.  These things happen.  We can never stop them all.

I know why we do all the excessive charting and paper trails besides the whole, “Look we’re doing something about it!”  It’s a way of (hopefully) reducing our liability in court.  So we can say, “Look at all the things we did.  We should be paid (or not have to pay)  Aren’t we good?  Forms in triplicate and fall assessments every 4 hours!  We did everything!”  If we had the assumption that people were going to fall and the rational expectations of this, none of that would be necessary.  But there is no such thing as rational expectations in health care anymore so we all suffer.

The best thing though is when asked where you were while the patient fell would be to reply, “I was charting their fall assessment!”