The Tale of the Good Samaritan

A drunk man in the streets of Pichilemu.

“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.

 

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Coincidence? I Don’t Believe in Coincidences

Gold service star

Image via Wikipedia

 

In a hypothetical hospital many years ago there was an ED. Small, cramped, poorly laid out, understaffed and trying valiantly to provide “Gold Star Service” to everyone that graced their doors. For years this little ED-that-could worked their hearts out and while maybe not providing “Gold Star Service” to them all, they did the best they could and the sick and dying were taken care of.

 

Now for those years the poor manager of the this little slice of Hell cried out in need for many things. More staff. More equipment (stuff that worked). A remodel to improve flow and room for treating sick folks. And while other floors got staffed and remodeled, the poor little ED sat alone in it’s squalor.

When the surveyors of the Joint (smoking) Commission arrived the higher-ups would pull other staff from across Mammoth Health Care Inc. tm to ensure the illusion of competence was complete. Then, as soon as the surveyors left, things went back to normal.

This isn’t to say the care was poor. They did well in a poor situation catching many dire diagnoses and saving many lives. Yeah, not everyone got “Gold Star Service” but the vast majority made it out alive and whole again – sometimes after a stay, but saved nonetheless.

Then one day the Master, CEO of Mammoth Health comes to visit dragging behind him architects, facilities engineers, nursing vice-presidents and the entire entourage that befits one of his rank and stature. Plans are shown that would vastly improve the poor little ED-that-could. A remodel, more equipment and more staffing. Mouths gaped, had all the prayers been answered? Yes, their time had come finally.

Smarter minds thought though, “Why after all this time choose now?”. Those minds began looking and trying to figure out why now. Thanks to scuttlebutt it became apparent: one of the Master’s family/entourage had been to the little ED-that-could and had not gotten the full “Gold Star Service”. All of a sudden, it made perfect sense. They could see it so clearly now.

Coincidence? Like I said, I don’t believe in them.

More readings… Very Influential People

What’s Wrong with Health Care?

A Burger King hamburger sesame seed bun, as se...

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.

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.

Banana Bags? I Got Them.

Crass-Pollination: An ER blog: Enough with the Banana Bags already.

Uh, yeah.  I’ll second that.

Unfortunately, our docs believe they can save every drunk and therefore, admit them all.  Of course all of them need telemetry monitoring because they are “tachycardic” forgetting that in tachycardia, you treat the underlying issue.  Y’know, like dehydration?  But no, these wonderful specimens of human existence get dumped on our floor for days, if not weeks while we dry them out.

A couple of weeks ago we had a nurse nearly knocked out by one of these assholes.  He got 4-point leathers and a ton of drugs.  The nurse got a concussion and no recourse but lost time and an injury.

Then there was the drunk who the doc didn’t want to send to the ICU and ended up needing more than 30mg of IV Ativan in a 12-hour shift, just to keep things to a dull roar.  Doc refused to send him even as he became more and more agitated and aggressive despite the Ativan, until the morning docs came to see him, where he promptly was sent to ICU for an Ativan drip in restraints.

My favorite of all times happened when I was an nurse extern.  We spent nearly 2 weeks drying this guy out.  Loads of Ativan, days upon days of sitters, thousands upon thousands of dollars worth of care.  The day he was discharged I saw him walking out of the convenience store 2 blocks from the hospital with a case of beer under his arm.  That was so worth it.

Our ED docs seem to have a major aversion to letting these guys (yes, they are 99% male) sober up a tad in the ED then kick them loose in time to get to detox to be admitted there – where they need to be.  We’re not going to save them.  If you have had 10 admits and 18 ED visits for ETOH in the last year, one more probably isn’t going to make a difference.

I am just so tired of it.

a caveat (there always is…)

I understand and know that delirium tremens can kill, that withdrawal seizures are just as dangerous and understand the pathophysiology behind chronic alcohol withdrawal, even the esoteric things like Wernicke’s  Encephalopathy, Wernicke-Korsakoff Syndrome and alcoholic cardiomyopthy and realize that admissions are justified in many cases, just not of the majority that I have encountered.  To me, ETOH is as good of an admitting diagnosis as “Incontinence”(not a neuro thing mind you) – in other words, full of crap.

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.