A construction worker comes in day before yesterday while I'm at lunch. They're all in Trauma II when I get back. Blood all over the floor, the stretcher, the clothes. Everybody's gowned up. Turns out the guy was cutting a board with a circular saw and somehow ended up severing his brachial artery. He was drifting off, every once in a while. The chopper was called to transport him to another facility and his wife was getting ready to head out on the 75 mile trip to the other hospital. I overheard another nurse giving her directions.
Me: "Don't hurry, now. Take your time. You don't want another accident today."
Spouse: "I won't. I'm fine."
Me: "You are taking someone with you, right?"
Spouse: "No, I'm okay to drive."
Me: "You need to at least take someone with you."
Spouse: "I'm really okay, I'll be okay."
Me: "I know you think you're okay and you probably feel okay but you need to take someone with you."
Spouse: (looking at the other nurse, now) "I'll be okay. The Lord will take care of me."
Pause
Me: "The Lord told me to tell you to take someone with you."
Saturday, October 13, 2012
Friday, October 12, 2012
We Are The Champions
It seems no matter what the problem is in the hospital, the solution is to have the ER nurses take on one more responsibility.
Electronic charting, for instance. The patient's vital signs, height and weight doesn't transfer from the triage note to the flow sheet (where everything after triage is charted). Solution? Have IT or a representative from the software provider tweak the issue? No. Better to require the ER nurse before triaging the bleeding, moaning, puking, smothering, screaming and/or dying patient, to first click on the flow sheet option, open a flow sheet, apply it, save it, close it and then open the triage sheet by clicking on the electronic forms tab, triage sheet tab and then the go to sheet tab.
A patient in a hospital in Chicago killed himself by drinking a cleaning substance which was left in a treatment room. The solution? Make sure noxious solutions are clearly marked as such? Acknowledge the fact that, unless a patient exhibits suicidal tendencies, common sense dictates that we're simply not responsible for every single irrational thing anyone, anywhere might decide to do at any given time in any given place? Realize some people are just too stupid to live? No. Better to declare cleaning agents can no longer be kept in the treatment rooms, thereby creating a need for the ER nurses to go all the way to the clean utility area to get a spray bottle of solution to clean the rooms after patients leave, then go all the way back to the clean utility room to replace the bottle. Hibiclens, alcohol, betadine, hydrogen peroxide? Same thing. Can't be kept in the rooms. How did we ever keep from killing patients back in the day when we kept glass thermometers soaking in alcohol-based antiseptic in stainless steel trays with lift off lids in each treatment room? How do we keep them from hanging themselves with the sheets on the beds, for instance? Where does the responsibility of ER nurses stop?
ER doctors (whose salaries exceed ER nurses in our facility by in the neighborhood of nearly 10 times and rightly so considering the level of education and licensure required of them) can't seem to manage to a) sign the patient discharge instruction sheet or b) sign and document a diagnosis on their T-sheets. The solution? Discuss with the physicians the reimbursement issues involved with incomplete physician documentation? Create a system whereby physicians are motivated to complete proper documentation such as not allowing them to work until said documentation is complete, as would be the case if a nurse were to do the same thing? No. Better to devise a new form for the ER nurses to be responsible to fill out at the discharge of every patient requiring her to go down a list, checking boxes indicating each form is accounted for and that the MD has signed his documents and written down a diagnosis. If anything is missing, it will be the nurse's evaluation that suffers and she may miss out on her 2% annual raise, if the hospital happens to even give raises that year, which they often do not.
Somebody in the hospital is getting paid minimum wage to scan all the ER documents into the computer but can't quite manage to scan them in the correct order or even right side up in all cases. The solution? Counsel the persons responsible for scanning, impressing upon them the importance of legible scanned documents? Explain to the entire hospital staff in an in-service if necessary that the upside down, scanned electronic documents can easily be turned right side up by clicking the rotate button on the pdf file viewer? No. Better to add to the ER nurses' responsibility that of ensuring each discharged patient's chart is placed in the correct scanning order and paper clipped, once before giving it to the ER doctor to sign and add his diagnosis to, and then a second time when received back from the doctor in a messy pile, paper clip missing.
Patients come to the hospital without a clue what medications they take, nor the dosages or frequencies. The solution? Public teaching regarding the necessity of the above data in order to provide safe care of the patient? Requiring a family member to go home to retrieve the patient's medication bottles? Refusing to render care in non-critical situations until somebody magically remembers or retrieves said data? No. Better to require the ER nurses to find out what pharmacy the patient uses and call them and waste their time looking up the medication lists of patients who don't care enough about their own health to notice what chemicals they put in their bodies. Or call the patient's primary care provider's office and waste time they could be using to tend to the needs of responsible patients who actually make appointments and seek medical care in an appropriate setting. Or, in the event the pharmacy and PCP's office are both closed or the patient orders medications from an insurance mail-order system, require the nurses to pull the information out of their asses. Incomplete medication forms are unacceptable.
Some of the ER physicians are having difficulty mastering the task of ordering ER medications electronically. The solution? More and extensive teaching regarding the electronic ordering of meds to be done by IT with ER physicians? Reworking the current system for the physician ordered medications? No. Better to require the ER nurses to learn to enter medication orders electronically (despite an aggressive taboo in the past regarding taking verbal med orders from physicians) which is to only be done in an emergency. We all know how that's going to play out, now don't we? After all, we do work in the emergency room. They're all emergencies, aren't they? I mean, in somebody's eyes.
Besides, the ER physicians are busy. They have every patient in the ER to see and there are several nurses to share the (growing list of) responsibilities assigned to them. However, with the exception of a code situation, the doctor spends approximately 7 minutes with each patient and has an average of 2-3 orders per patient to put in electronically. Otherwise, the medications need only be clicked "Continue" or "Discontinue" in the electronic medication list which was entered by the nurse while the patient was bleeding, moaning, puking, smothering, screaming or dying, incidentally (see the paragraph on electronic charting). Otherwise, he has one T-sheet to fill out. With a pen. On real paper and not on a goddamned computer. Like in the good, old days. Is it really that difficult?
Meanwhile, the ER nurse has an extensive triage form full of medical history that hasn't carried over from the previous admissions due to yet another IT glitch, a medication form (including meds, dosages, frequencies, routes, last dose and time, doctor who prescribed and pharmacy filling the medication), a flow sheet including everything anybody in the ER or elsewhere has done for or to the patient during his/her stay in the ER, a list of vital signs, a treatment sheet where things like blood cultures, etc are documented, transfer forms (okay, the MDs do 33% of this form, too), discharge education, a charge form and the new form where all the other forms are accounted for.
In the interest of time I'll stop here but know that this is an incomplete list.
Electronic charting, for instance. The patient's vital signs, height and weight doesn't transfer from the triage note to the flow sheet (where everything after triage is charted). Solution? Have IT or a representative from the software provider tweak the issue? No. Better to require the ER nurse before triaging the bleeding, moaning, puking, smothering, screaming and/or dying patient, to first click on the flow sheet option, open a flow sheet, apply it, save it, close it and then open the triage sheet by clicking on the electronic forms tab, triage sheet tab and then the go to sheet tab.
A patient in a hospital in Chicago killed himself by drinking a cleaning substance which was left in a treatment room. The solution? Make sure noxious solutions are clearly marked as such? Acknowledge the fact that, unless a patient exhibits suicidal tendencies, common sense dictates that we're simply not responsible for every single irrational thing anyone, anywhere might decide to do at any given time in any given place? Realize some people are just too stupid to live? No. Better to declare cleaning agents can no longer be kept in the treatment rooms, thereby creating a need for the ER nurses to go all the way to the clean utility area to get a spray bottle of solution to clean the rooms after patients leave, then go all the way back to the clean utility room to replace the bottle. Hibiclens, alcohol, betadine, hydrogen peroxide? Same thing. Can't be kept in the rooms. How did we ever keep from killing patients back in the day when we kept glass thermometers soaking in alcohol-based antiseptic in stainless steel trays with lift off lids in each treatment room? How do we keep them from hanging themselves with the sheets on the beds, for instance? Where does the responsibility of ER nurses stop?
ER doctors (whose salaries exceed ER nurses in our facility by in the neighborhood of nearly 10 times and rightly so considering the level of education and licensure required of them) can't seem to manage to a) sign the patient discharge instruction sheet or b) sign and document a diagnosis on their T-sheets. The solution? Discuss with the physicians the reimbursement issues involved with incomplete physician documentation? Create a system whereby physicians are motivated to complete proper documentation such as not allowing them to work until said documentation is complete, as would be the case if a nurse were to do the same thing? No. Better to devise a new form for the ER nurses to be responsible to fill out at the discharge of every patient requiring her to go down a list, checking boxes indicating each form is accounted for and that the MD has signed his documents and written down a diagnosis. If anything is missing, it will be the nurse's evaluation that suffers and she may miss out on her 2% annual raise, if the hospital happens to even give raises that year, which they often do not.
Somebody in the hospital is getting paid minimum wage to scan all the ER documents into the computer but can't quite manage to scan them in the correct order or even right side up in all cases. The solution? Counsel the persons responsible for scanning, impressing upon them the importance of legible scanned documents? Explain to the entire hospital staff in an in-service if necessary that the upside down, scanned electronic documents can easily be turned right side up by clicking the rotate button on the pdf file viewer? No. Better to add to the ER nurses' responsibility that of ensuring each discharged patient's chart is placed in the correct scanning order and paper clipped, once before giving it to the ER doctor to sign and add his diagnosis to, and then a second time when received back from the doctor in a messy pile, paper clip missing.
Patients come to the hospital without a clue what medications they take, nor the dosages or frequencies. The solution? Public teaching regarding the necessity of the above data in order to provide safe care of the patient? Requiring a family member to go home to retrieve the patient's medication bottles? Refusing to render care in non-critical situations until somebody magically remembers or retrieves said data? No. Better to require the ER nurses to find out what pharmacy the patient uses and call them and waste their time looking up the medication lists of patients who don't care enough about their own health to notice what chemicals they put in their bodies. Or call the patient's primary care provider's office and waste time they could be using to tend to the needs of responsible patients who actually make appointments and seek medical care in an appropriate setting. Or, in the event the pharmacy and PCP's office are both closed or the patient orders medications from an insurance mail-order system, require the nurses to pull the information out of their asses. Incomplete medication forms are unacceptable.
Some of the ER physicians are having difficulty mastering the task of ordering ER medications electronically. The solution? More and extensive teaching regarding the electronic ordering of meds to be done by IT with ER physicians? Reworking the current system for the physician ordered medications? No. Better to require the ER nurses to learn to enter medication orders electronically (despite an aggressive taboo in the past regarding taking verbal med orders from physicians) which is to only be done in an emergency. We all know how that's going to play out, now don't we? After all, we do work in the emergency room. They're all emergencies, aren't they? I mean, in somebody's eyes.
Besides, the ER physicians are busy. They have every patient in the ER to see and there are several nurses to share the (growing list of) responsibilities assigned to them. However, with the exception of a code situation, the doctor spends approximately 7 minutes with each patient and has an average of 2-3 orders per patient to put in electronically. Otherwise, the medications need only be clicked "Continue" or "Discontinue" in the electronic medication list which was entered by the nurse while the patient was bleeding, moaning, puking, smothering, screaming or dying, incidentally (see the paragraph on electronic charting). Otherwise, he has one T-sheet to fill out. With a pen. On real paper and not on a goddamned computer. Like in the good, old days. Is it really that difficult?
Meanwhile, the ER nurse has an extensive triage form full of medical history that hasn't carried over from the previous admissions due to yet another IT glitch, a medication form (including meds, dosages, frequencies, routes, last dose and time, doctor who prescribed and pharmacy filling the medication), a flow sheet including everything anybody in the ER or elsewhere has done for or to the patient during his/her stay in the ER, a list of vital signs, a treatment sheet where things like blood cultures, etc are documented, transfer forms (okay, the MDs do 33% of this form, too), discharge education, a charge form and the new form where all the other forms are accounted for.
In the interest of time I'll stop here but know that this is an incomplete list.
Friday, October 5, 2012
Overheard in ER
Nurse to Elderly Male Patient: "Do you still have your gallbladder and appendix?"
Elderly Male Patient: "No, I never had them. I never had no appendix or nothin' that'a way."
Elderly Male Patient: "No, I never had them. I never had no appendix or nothin' that'a way."
Thursday, October 4, 2012
This Bud's For You, Bud
I used to get automatic emails of the local obituaries but somehow when I got this new laptop in June, I quit receiving them and haven't yet gotten around to re-subscribing. In September I was out of town roughly 3 weeks, altogether, and because I long ago stopped buying a local paper on a regular basis, I've been out of the loop. Tonight while writing another post which I've since saved in draft form for another day, I did an online search to check a fact and ended up on the obituary page of the local funeral home. There I tarried for 30 minutes, or so, catching up on people I hadn't realized had passed. There were a few surprises but I was aware of about half of them before tonight.
I'm sort of a connoisseur of obituaries. I love them. I love everything about them, even when I'm sorry to see some of the names, like tonight. And I don't think I'm alone. Back in the 90's, my daughter took a sociology class at the local community college along with the daughter of one of my co-workers in the ER. The instructor, a male in his 30's, shared with the class one day that he used to date a nurse who always listened intently to the obituary segment of the local morning news on the radio which he considered a bit strange. Upon hearing the story, my daughter and my co-worker's child turned, open-mouthed toward each other whispering, simultaneously, "My Mom does that!"
In a small town, there are certain people you see all the time, people you don't even know but who, because you're around them for sometimes your entire life, as in the case of the natives, or at least for 33 years, in the case of me, you feel a closeness to without even realizing it. Then one day, something reminds you of them and you say, "Hey, whatever happened to that great big, fat guy who used to sit on the bench in the city park and wave at the cars going by?" or, "Remember that gal who used to walk up and down the highway picking up cans? Whatever became of her, I don't see her anymore?". It's complicated because you don't even know their names.
Lately though, the obituaries have begun to include pictures and that helps a great deal. Although, oftentimes, for some reason the family picks a picture from 28 years ago that nobody would recognize and that certainly complicates matters. It's easy to miss one and never realize it. The internet helps but I managed to miss a bunch in September, I found out tonight.
So tonight I was browsing, reading in depth each obituary, one at a time. I read the obituary for the boss I had at my favorite nursing job in my entire life. She died while I was out of town and unable to attend the funeral. That one hurt. And it was unexpected. But I'd already seen it in the free paper somebody had lying around at work one day. On the second page of the funeral home website, after a few of our ER regulars who came as a shock when I heard about them last week, I saw a familiar face.
He was a jovial guy. Used to come in with his wife. And daughter. They were all three sort of regulars but only periodically. The daughter had her own set of psychoses and, okay, I suppose his wife was probably crazy, too. But he was just a pleasure to see coming and never had anything seriously wrong with him, just wanted to be checked out to make sure a twinge in the chest or a little swelling in his feet or a cough weren't anything serious. No big deal. I didn't even remember his name, until I saw it and his face on the same page together. But when I realized he'd died it made me feel really, really sad. It sort of surprised me, the way it made me feel, and I even cried real tears for a while. And I still feel sad.
We get our balls busted so much of the time by people who just make our lives at work a living hell, that when someone is polite and acts like an adult and even makes us smile once in a while, we appreciate it. And I know I'm greatly callused, maybe even pathologically but I still love people, even though I'd probably be better off if I didn't, and in a quirky, philosophical way, I loved that guy. And now he's gone and never coming back.
You don't realize how many people you touch. I think Bud would be surprised to have seen me cry when I saw his picture online tonight.
I'm sort of a connoisseur of obituaries. I love them. I love everything about them, even when I'm sorry to see some of the names, like tonight. And I don't think I'm alone. Back in the 90's, my daughter took a sociology class at the local community college along with the daughter of one of my co-workers in the ER. The instructor, a male in his 30's, shared with the class one day that he used to date a nurse who always listened intently to the obituary segment of the local morning news on the radio which he considered a bit strange. Upon hearing the story, my daughter and my co-worker's child turned, open-mouthed toward each other whispering, simultaneously, "My Mom does that!"
In a small town, there are certain people you see all the time, people you don't even know but who, because you're around them for sometimes your entire life, as in the case of the natives, or at least for 33 years, in the case of me, you feel a closeness to without even realizing it. Then one day, something reminds you of them and you say, "Hey, whatever happened to that great big, fat guy who used to sit on the bench in the city park and wave at the cars going by?" or, "Remember that gal who used to walk up and down the highway picking up cans? Whatever became of her, I don't see her anymore?". It's complicated because you don't even know their names.
Lately though, the obituaries have begun to include pictures and that helps a great deal. Although, oftentimes, for some reason the family picks a picture from 28 years ago that nobody would recognize and that certainly complicates matters. It's easy to miss one and never realize it. The internet helps but I managed to miss a bunch in September, I found out tonight.
So tonight I was browsing, reading in depth each obituary, one at a time. I read the obituary for the boss I had at my favorite nursing job in my entire life. She died while I was out of town and unable to attend the funeral. That one hurt. And it was unexpected. But I'd already seen it in the free paper somebody had lying around at work one day. On the second page of the funeral home website, after a few of our ER regulars who came as a shock when I heard about them last week, I saw a familiar face.
He was a jovial guy. Used to come in with his wife. And daughter. They were all three sort of regulars but only periodically. The daughter had her own set of psychoses and, okay, I suppose his wife was probably crazy, too. But he was just a pleasure to see coming and never had anything seriously wrong with him, just wanted to be checked out to make sure a twinge in the chest or a little swelling in his feet or a cough weren't anything serious. No big deal. I didn't even remember his name, until I saw it and his face on the same page together. But when I realized he'd died it made me feel really, really sad. It sort of surprised me, the way it made me feel, and I even cried real tears for a while. And I still feel sad.
We get our balls busted so much of the time by people who just make our lives at work a living hell, that when someone is polite and acts like an adult and even makes us smile once in a while, we appreciate it. And I know I'm greatly callused, maybe even pathologically but I still love people, even though I'd probably be better off if I didn't, and in a quirky, philosophical way, I loved that guy. And now he's gone and never coming back.
You don't realize how many people you touch. I think Bud would be surprised to have seen me cry when I saw his picture online tonight.
Wednesday, July 4, 2012
Window to the Soul
Me: "Sir, on a scale of zero to ten, with zero being no pain and ten being the worse pain imaginable, where is your pain today?"
Elderly Black Gentleman: "It be in my eyes."
Elderly Black Gentleman: "It be in my eyes."
Monday, July 2, 2012
You Is Kind, You Is Smart, You Is Important
I just finished watching The Help for the second time. I saw it last year in Iowa and again tonight. I taped it on the DVR to watch with a friend who came to eat chili rellenos and homemade pico de gallo and relax in front of the television.
As we watched the beer-swigging Hilly swerving down the gravel road toward Skeeter's house after reading the book and revealing her secret, I jokingly told my friend, "That's how it's gonna be when my book comes out about the hospital". And we laughed.
Just now, after my friend went home I got out my notebook to journal a while and began to think about what I had said. I wondered what is it I really want to say. Here and in a book. And I decided this.
I want to tell our side. My side. What I and we are expected to smile through and not let common sense contaminate. Electronic charting and demanding patients in an ego-centered society and the crabs in a barrel syndrome with other nurses. All of it. I need to tell what kind of insanity exists in this profession, what I've seen that the rest of the world doesn't know, nor may believe exists. It's hard to believe. I know. I have trouble believing it, too. That's what I want to say. Because saying it makes me feel a little less insane.
But it's not just that, not just the hospital and the pressures and stressors of that. You and I know it's also about menopause and about having had enough water pass under the bridge to no longer be able to smile and nod and to even care a lot of the time. It's all of that, too.
I found an old pay stub the other day from 2009 that I'd stuck in a book to mark my place. I was working where I do now, in the very same department and as full-time status. I'm making exactly $0.16 more today than I was then. Three years ago.
My boss came out to the nurse's desk the other day and we were slow and we all started talking about something. There were three of us. And I said to him, and we weren't on the subject of salary, "Let me ask you something. I'm making sixteen cents an hour more than I was here 3 years ago. (He wasn't the supervisor then). Do you think there's something wrong with that?"
The answer is that there is something wrong with me, that's the answer. The answer is why am I not enrolled in truck driving school like I dream about all day long? And before the comments come telling me what a horrible life I'd have driving a truck, let me say that I know all of that. (Isn't it cute how I pretend there will be comments?) I've already been told. By everybody. But there is something about the prospect of turning in my notice and jumping in a truck and driving for 70 hours a week for a year that is somewhat of a siren song for me and others like me. I think of it as only a year because I really like to be home too much to do it for the rest of my life. But God knows I need a break from the ER.
Like Hilly, I'm tired. It's hard work eating shit pie for twelve hours a day, three days a week.
Monday, June 4, 2012
...and I quote
Possibly the best part of my job (if there is a best part) is the pre-triage form. When patients come to the ER, they fill out a form indicating their chief complaint which is then submitted to admissions and, subsequently, given to the triage nurse. These are some which have caught my eye (the quotation marks are mine, otherwise these are completely unedited regarding spelling, grammar, punctuation, sentence structure and capitalization):
"He has had a high Fever of 102.6 for the past 24hours coughin an cumplanin of his tummy heartin."
"High Fever, votmonting, sorl thoroght runy nosie"
"Colon burn Stomach hurts qallbladder"
"Right Lover Pain"
"Been Bound up in Gut For About A week"
"Fell on cement + with fist at heart area needs to find out if anything is badwrong"
"Face is Busted it woozy Need stitchly"
"Sour throught. Ears hurts runny noses."
"I have a shoulder that is on my right arm + down my arm + I have tingling in my Finger + it feels num"
"Herniated dick" (submitted by a female patient)
"I was diajnosed a year ago.In leavenworth KS My lungs hurt thats it I'm weezing!"
"Sunday yall said Go Sleep it off it Just a head ach made appomint to day she Been having headach nosia weak all this time No Legs are weak she has a concusion Dr SAID!!"
"My left foot is strained?"
"IM diying Bealse my arem is roting off."
"Cant really talk because half of mouth is swallowen abcest tooth, throat swalloen andchest pain"
I particularly like the ones with the exclamation points!!!
"He has had a high Fever of 102.6 for the past 24hours coughin an cumplanin of his tummy heartin."
"High Fever, votmonting, sorl thoroght runy nosie"
"Colon burn Stomach hurts qallbladder"
"Right Lover Pain"
"Been Bound up in Gut For About A week"
"Fell on cement + with fist at heart area needs to find out if anything is badwrong"
"Face is Busted it woozy Need stitchly"
"Sour throught. Ears hurts runny noses."
"I have a shoulder that is on my right arm + down my arm + I have tingling in my Finger + it feels num"
"Herniated dick" (submitted by a female patient)
"I was diajnosed a year ago.In leavenworth KS My lungs hurt thats it I'm weezing!"
"Sunday yall said Go Sleep it off it Just a head ach made appomint to day she Been having headach nosia weak all this time No Legs are weak she has a concusion Dr SAID!!"
"My left foot is strained?"
"IM diying Bealse my arem is roting off."
"Cant really talk because half of mouth is swallowen abcest tooth, throat swalloen andchest pain"
I particularly like the ones with the exclamation points!!!
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