I'm not 88 or 95 years old.  I don't know what its like to be at that age.  One thing I wonder about is why do  a lot of the very elderly put themselves through all of these complicated medical procedures?  Like being resuscitated and going through a hypothermia therapy. The risk of TPA.  Being on dialysis.  Taking a chance on a major operation.

Is it because their children want them to? Are they afraid to die? So many people are uneducated about health care.  They don't realize that they may survive the procedure but it is the recovery process that will kill them.  They will develop complications.  Just being in a hospital environment exposes them to so much risk. The chances of them making it are minimal.

I hope by the time I reach that age, we have started to deal with the fact that we can't continue to keep our very elderly alive with  medical care that will only make them suffer in the end.  I hope, but I doubt it will happen.  We want to live forever
 

This elderly confused man is picked up by medics on the street.  Here's the thing: He uses an electric wheelchair. Of course the medics can't take the wheelchair with them to the hospital....

So, what, you are asking will happen to the wheelchair?  It will be towed away like a car and
put in an impound lot.  Yeah, I'm not kidding.

I wonder if he will have to pay to get it out?  Chances are he doesn't have a van to cart his wheelchair home...now what?

Happy Nurse Week to all of my fellow nurses who are heroes 24/7.

One of my co workers dropped a pearl of wisdom on me this weekend.  This might surprise you, but this is what she said: "Coming here has become a lot easier since I have decided that I hate this place".

Probably sounds funny to say it was a pearl of wisdom...but it  got me to thinkin'...  The first inclination when someone says that is to say: Why do you work here if you hate it? You should move on, etc. blah blah blah.  Then I realized what she was saying:  I hate it here, I'm going  to hate it here, but I have to work here for whatever personal reason I have and I accept that it will not ever be anything different, so I accept that.

That might sound cynical and negative, but at least it is realistic. I work it in a terrible environment. It is outdated, shabby, too small, noisy.  It makes my job harder.  Every day there is a new change, from charting to equipment to any other idiotic change that comes down from above. These are going to happen and I have no control over it because basically those that make the changes don't really care what I think.  I can't make the ER over so the environment won't change anytime soon.

Now, lets talk about the patients.  A lot of them are shitheads. Even the nice people who are nice in the real word can be shitheads in the ER.  I deal with the dysfunctional, the addicted, the mentally ill, the ineffective copers, the stupid on a daily basis.  It is the reality of my job.  My job is thankless.

The point of all of this? Acceptance.  I work in a shitty, stressful environment.  A lot of the patients are shitheads. I have little control of change. I choose to keep working here. For years, I have wanted it to be different, stressed over the fact that it isn't different.  Stressed over the fact that it won't change.  Expected it to change. Accepting reality makes it so much easier.  Look around you.  This is it. This going to be it today, tomorrow, next week. You can leave or you can accept the reality that hits you in the face every day.  Then when something good happens it will be a pleasant surprise
.

In the middle of my weekend to work.  Because the weather here sucks,  apparently people have nothing else to do but come to the ER....

I actually ran at work yesterday. I mean move the legs full out run.

I don't run. I'm not a runner. At work.  I saunter.  I may walk fast once in a while.  Rarely. I'm not excitable.

This was one of those "Oh shit! That wasn't supposed to happen!" moments. But it did and I ran. It wasn't even our patient.  They were alive when they left the ER.

I started charge at 3 pm. Within a half an hour we had a  stroke come in.  Then a half hour after that the Oh shit! moment happened.  Then during that an MI came in.  Then here is news that there is a helicopter landing and guess what, the bed isn't ready.  Helicopter = critical patient.

Yes, folks, we got ourselves a GENUINE shitstorm happenin' here.

Six hours later I dragged my butt home.

My ER is shabby, old, falling apart, embarrassing really.  We are an inner city ER and last on the list for renovation because of that. Every other ER in the system has been redone, but then most are located in the suburbs where people have insurance and wouldn't come to a broken down ER.  Since the poor and elderly city folks don't have a choice, they still come to ours and don't expect a shiny new ER.  So the heads of the corporation don't really give a shit what our ER looks like.

So I have an idea.  We get Target to sponsor our ER.  We become the Target ER.  Target pays for the renovation.  We put a big bulls eye on the front of the ER.  The employees all dress in red scrub tops and tan pants with a target bulls eye on the pocket.  Everywhere you look there are signs that say: "This ER brought to you by Target".  Our patients are called guests...Target could advertise that they sponsor us at different events, on TV, the internet.  Its win-win for everybody.

In fact lets just extend this whole concept to all of medicine.  I mean health care has become a corporate, profit motivated environment anyway.  Lets go all the way.  Lets let corporations sponsor hospitals, clinics, every part of it.  It would save our system from economic collapse.  Companies would compete with each other to be sponsors of hospitals.

Becoming the Target ER is the only way I can think of that we will ever get a renovation.

I was reading a book recently and one of the main characters was a nurse.  She worked in pediatric
oncology.  It talked about her work periodically in the book.  There was one patient she had that she grew close to who was a teenager.  He was on the floor for a while.  He was hanging in there.  Then he got pneumonia and died.  This person she grew to really care for. This family too.  It brought tears to my eyes.

It was just a book, a fictional book,  but it got me to thinking about nurses. What we do.  How much I respect and admire all of us. The nurses who work with kids with cancer, knowing they are probably going to die.  The nurses who work with quadriplegics who are adjusting to a life in which they will never walk again.  The nurses who work with the teeny tiny premies for months hoping they will make it. The nurses who stay with families while their loved ones die.  The nurses who relieve the pain of the people who are suffering terribly.  All of the nurses, day in, day out who care for the sick and vulnerable among us.  Its a tough job, but they keep going back every day to do it anyway.    

Dear people who:

1) Want to  "guest blog" on the blog..

2) Want me to mention their group, product, cause...

3) Want me to review their product...

Answer: NO NO NO NO NO NO and lastly, NO.

If you have dollars in your pocket to give me, we'll talk..

I know, I'm a bitch like that.

Could it be that there is teeny tiny movement starting around the overprescribing  of pain medications that is an epidemic in this country?  In January Mayor Bloomberg (gotta love this guy) announced an initiative at the 11 public hospitals in NYC.  The VOLUNTARY initiative states that emergency departments "will not prescribe long-acting opioid painkillers, can only prescribe up to a three-day supply of opioids, and will not refill lost, stolen or destroyed prescriptions". What a concept....Read about it here.

In Washington state, a health care system has placed limits on how painkillers are prescribed.  Doctors are told " abide by the guidelines or face the consequences".  The states also now requires patients who are on high does of pain killers with little improvement to be referred to pain clinics.   Read the article by Kevin Pho MD here.

Here's the thing: This is really great.  Finally someone is paying attention and putting the responsibility for the epidemic where it lies: doctors.   The thing is, what politicians don't recognize is that health care has become a business, like any other business.  What is a business' goal?  Make money, stay afloat.  How do you do that? By making the customer/patient happy, so they will come back.   Lots of patients are made happy by getting that almighty narc script. Hospitals are even being paid more or less based on patient satisfaction, and therein lies the dilemma.  

Doctors fear patient complaints, poor satisfaction scores.   So what. The only people who will stop this epidemic will be doctors.  They are going to have to stand up as a group and say no.  They are going to have to stop whining about losing control of their practice, blah blah blah. 
They are going to have to put on thier big boy/girl pants and take responsibility for, change a culture, that they have created. 

OK its official.  I am going insane...

Every year we have to go through a "which frickin' waste basket do you put the moutain of waste we generate doing patient care?" education session.   Is it that red one, the pink polka dotted one, or the evil BLACK one? As of now, there are 8, count 'em 8, different plastic garbage containers with various names.  

I am sorry, perhaps I am a complete moron, but I can't keep track of what goes where. Its too much for my feeble little brain to comprehend...or maybe it is INSANITY to think we can remember.  Ya think?

Well, I'm doing the education online and actually reading it...not skipping to the end hoping to pass the test.  I come across a piece of information I had not known, may have skipped, subconsciously blocked out in an effort not to spontaneously combust:  The little chloraprep thingies we use to clean skin before IV insertion are considered HAZARDOUS WASTE.  OK...let me get this straight...the thing that I use 20 times a shift is hazardous waste.

Those little 1 1/2" x 1/2" cylinder thingies are hazardous waste...meaning they have to be put in a ziplock bag and into the EVIL BLACK plastic container that are only in certain areas of the ER?  You are kidding right? So I need to hold this EVIL cylinder, which by the way I have just applied to the patients skin, two feet in front of me as I go to search for a ziplock bag and then place it in the EVIL BLACK plastic container?

Now, take the amount of nurses who work in a day x amount of IVs they start and you will have many ziplocked EVIL cylinders to be disposed of.  We are gonna need a way bigger EVIL BLACK container.
In other words, it ain't gonna happen.

Here's the thing about all of this: The disposable system is very complex but its okay for us to waste narcotics galore down the sink, into the sewer, whose contents go to the water plant to be "purified" and straight into your kitchen...

What is the point of going on I ask you? What is really the ('sniff) point? All of the bloggers I started with or joined along the way have died a slow agonizing death...

RIP:

Emergiblog (the mother of all ER nurse blogs)
Nurse Ratcheds Place
Weird Nursing Tales
You Can't Fix Stupid
Etc Etc Etc

And now worst of all, Crass Pollination has died.  Is the world coming to an end? First she moves to Montana (why would anyone do that?), then the blog dies. What the hell happened in Montana?  Was it all the perverts who took over the forum? Who has Nurse K and what have they done with her?

Its hard to go on....I know how hard it is to keep the blog going.  Its a been there, done that, blah blah blah situation.  Whats the point? Who really cares?  Whats it all about (Alfie)?

The only thing keeping me going are

New Nurse in the Hood

White Coat

If they quit, I stick a knife in the blog....

Here is a word to the unwise:

If you have to have security escort you out because you refuse to leave, you probably aren't going
to get a free cab ride home from us, so don't ask...Duh

If you are discharged and refuse to leave the lobby, security comes, and you comment: "This happens every time, I have to be escorted out by security", maybe its a sign you should try another hospital...Duh

If you didn't get it at the other hospital, you ain't gettin' it here....Duh

It has been a long and stressful week in lots of different ways.  Time to look at some man candy

made by the Cleveland Clinic

As a nurse in the ER, you don't think much about cost.  That is, how much what we do costs.  It is only when you or your family go to the ER for something and get the bill, that you realize just how riduculously expensive it all is.

Case in point:  My friend developed a bad cellulitis.  So they went to the ER.  Even though, the cellulitis was already bad, they chose to give here antibiotics and send her home.  Of course, it got worse.  Way worse.  So back she went to the ER.  Mind you, she had called her doctor, but they said they didn't handle something like that is in the office.

She was seen by a NP.  She ended up having and I and D (incision and drainage).  She got an an IV antibiotic. Probably should have got all this on the first visit, but whatever....

So here's the point of all this: The I and D cost over 1,000 dollars.  Now mind you, here is what happens in an I and D:

1) Area is numbed up.
2) An incision is made by a scalpel and pus is squeezed out.
3) Iodoform guaze is put in hole that is left.
4) Dressing is applied.

Time this takes: about 5 minutes.

So a five minute procedure that uses a bottle of numbing med, a syringe and needle, and I and D tray, sterile gloves, idoform gauze, a dressing costs 1,000 dollars.  Okay......

Next time, I'll do it for her and I'll only charge her 50 dollars.  I mean seriously folks, this is not rocket science.  You could train a ten year old to do this.  Numbing up an area is simple, similar to injecting for a dog bite where there is concern about rabies.  I've done that a few times. I think I could make an incision and squeeze.  I also think I could put gauze in a hole, having done so back in my med surg days.  Honestly, can someone tell me why this costs 1,000 dollars?

Oh by the way....that 1,000 dollars is only part of the bill - it is called a "minor surgical procedure".  Then they are the other charges adding up to a few thousand dollars.  Then we wonder why medical care costs so much...

I've been neglecting the blog, I know.  Its the weather. Its still winter here and I can't stand it anymore.

Anyway...
There is a horrible prescription pain med problem in this country.  One we don't want to face. Its an epidemic. Its an epidemic doctors in particular, don't want to face. Their part in it is shameful.

I'll give you an example of how completely out of control this problem has become.  There was a man who
 came in who had someone managed to get over 800 tablets of pain meds  (two different kinds) in 2 months. 800 tablets! Thats insane.

Thats just one person. Imagine the millions of pills people get each month in this country. Why does this keep going on? Because doctors are a bunch of fucking wimps who can't say no. Its easier to say yes and pass it along to the next person.  I don't know how they sleep at night.

I can hear all the doctors say:  Patients expect his. We'll get complaints. Blah blah blah. Doctors have created this epidemic and they are responsible for stopping it.

Good luck to hospitals in the almighty patient satisfaction sweepstakes. They are approaching it all wrong.  They are approaching it from the top down, instead of the bottom up.

I am currently on a committee addressing this.  I sat for an hour and a half at the last meeting listening to a "performance improvement specialist" talk about what we say to patients.  What do we say to them when they present at the window?  Do we say: Can I help you? What can I help you with? How do we acknowledge them?  I mean seriously....

It seems the triage area is a place where people don't "feel welcome".  Could that be because the staff appears stressed out? THEY ARE STRESSED OUT.  Here is a list of what the two nurses at the triage desk deal with:

1) Answer phones:
     - from ambulances coming in, place those ambulances in the ER (if there is a bed available)
     -from idiot doctors offices, nursing homes, therapists, etc. who call to tell us their patients are coming in.
WE DON'T CARE.  We will deal with them when they get here.
     -calls from information desk about patients they can't find
     -random other calls

2) Let people in the door to main ER a thousand times a day. Deal with frantic relatives.

3) Give directions to people to inpatient rooms,  the cafeteria, coffee shop, pop machine, admitting, etc. etc. etc.

4)  Deal with people who have to be transferred to labor and delivery.

5)  Go outside to help people out of cars.

6)  Check people in.

7) Triage people.  WOW, yes we actually have to do this in the middle of everything else.

8) Take people to rooms.

All of this is really great, especially when there are 10 people at the window, 20 people in the lobby.

In the middle of all this we are expected to smile like a frickin' idiot.  Let me ask you, could you smile like a frickin' idiot in the middle of all this?  I don't think so.

Here is what will help patient satisfaction in triage:

WE NEED HELP!!  

No doctor office, etc. calls

Security handles traffic in and out.

Charge nurse gets ambulance calls.

Come up with the money to have someone at the desk which allows nurses to actually TRIAGE (what a concept).

If you take some of the  stressors in triage away, staff will be happier, less stressed and they will be able to welcome patients as they should.  Patient satisfaction improves. This ain't rocket science folks.

Here's a clue: Maybe you could ask the staff who works in triage what they see could help the situation.  What a radical idea.

Good luck to hospitals in the almighty patient satisfaction sweepstakes. They are approaching it all wrong.  They are approaching it from the top down, instead of the bottom up.

I am currently on a committee addressing this.  I sat for an hour and a half at the last meeting listening to a "performance improvement specialist" talk about what we say to patients.  What do we say to them when they present at the window?  Do we say: Can I help you? What can I help you with? How do we acknowledge them?  I mean seriously....

It seems the triage area is a place where people don't "feel welcome".  Could that be because the staff appears stressed out? THEY ARE STRESSED OUT.  Here is a list of what the two nurses at the triage desk deal with:

1) Answer phones:
     - from ambulances coming in, place those ambulances in the ER (if there is a bed available)
     -from idiot doctors offices, nursing homes, therapists, etc. who call to tell us their patients are coming in.
WE DON'T CARE.  We will deal with them when they get here.
     -calls from information desk about patients they can't find
     -random other calls

2) Let people in the door to main ER a thousand times a day. Deal with frantic relatives.

3) Give directions to people to inpatient rooms,  the cafeteria, coffee shop, pop machine, admitting, etc. etc. etc.

4)  Deal with people who have to be transferred to labor and delivery.

5)  Go outside to help people out of cars.

6)  Check people in.

7) Triage people.  WOW, yes we actually have to do this in the middle of everything else.

8) Take people to rooms.

All of this is really great, especially when there are 10 people at the window, 20 people in the lobby.

In the middle of all this we are expected to smile like a frickin' idiot.  Let me ask you, could you smile like a frickin' idiot in the middle of all this?  I don't think so.

Here is what will help patient satisfaction in triage:

WE NEED HELP!!  

No doctor office, etc. calls

Security handles traffic in and out.

Charge nurse gets ambulance calls.

Come up with the money to have someone at the desk which allows nurses to actually TRIAGE (what a concept).

If you take some of the  stressors in triage away, staff will be happier, less stressed and they will be able to welcome patients as they should.  Patient satisfaction improves. This ain't rocket science folks.

Here's a clue: Maybe you could ask the staff who works in triage what they see could help the situation.  What a radical idea.

Can I just say that it has gotten to the point of ridiculousness with test ordering in the ER?  I mean seriously,  MRIs have become the norm.  When did that happen? It used to be MRIs were considered an exotic test that was never ordered in the ER.  Now there are at least a few a day.

Yesterday I had a patient who had not one, but two, MRIs ordered.  And you are not going to believe this, but they were both NEGATIVE.  Wow what a shock.

I have an idea: Lets just have a standard order set for EVERYBODY that comes into the ER.  Everybody gets CBC, Panel 8, belly panel, troponin, UA, a complete body MRI. Damn it, if there is anything off in your body we will be able to diagnose it, whether you like it or not.  Just think, if we find something a little off, we can order even more tests and charge your insurance company even more money!  What fun!

This way, the hospital gets to use those expensive MRI machines, the doctors can jack up their acuity level and everybody will be happy.....

Here I am doing a dress  rehearsal for the big day tomorrow.

I'm probably the biggest union advocate you could find.  I grew up with a mom who worked in factories all her life and was the sole support of my brother and I.  She was a fierce union advocate and she passed that on to me.

Without unions, nurses wouldn't have what we have today: somewhat decent wages, benefits.  Nurses worked hard to get to this point, they sacrificed.  However, I am beginning to wonder whether our unions need to change in order to deal with a changing health care environment, otherwise they might cease to exist.

I think a lot about what is the future of nursing in health care.  I see the health care system painfully changing to adapt to less reimbursement, patient satisfaction, obamacare.  Hospitals are quickly changing to adapt.  I see our doctor group adapting.  Then there are nurses.  As usual, we sit back and let it all pass us by.  We resist change for the most part. We aren't proactive, but reactive.

These days our unions settle contracts that try to keep what we have, forget about getting anything more. Unions have rigid contract provisions, necessarily so.  They have to be clear cut.  The thing is, how does that fit in with a changing health care environment?  How does nursing adapt and change and prosper within this rigidity? It doesn't.

If we don't change, adapt, we will be left by the wayside, replaced by cheaper workers.  An example of this: there is a new program in my city that is called community paramedics.  It is just starting. The goal of this, bottom line, is to keep people out of the hospital.  They will do followup, do preventative care, anything they can to maintain peoples health. This fits right in with obamacare, medicare changes.  In other words, they are doing a lot of what home health care nurses are already doing.  The thing is they can be paid half of what nurses do.  This is an example of things to come as health care systems look for ways to decrease costs.

Can our unions become more flexible or will they cease to exist? Are unions outdated?  Will nurses care enough about our profession to wake up and take control of our future?  Only time will tell. Any thoughts?

       

The thing about working in the ER a certain amount of time is you could walk in with two heads and I would say: okay...what can I for you? Just when you thought you seen it all, in walks somethin' you ain't never seen before.

So I'm sitting at the triage desk and you walk in. To say that you are "different" is to understate it. Shall we say that your fashion presentation is a little out there on the edge? The edge where no one else has been and won't go.  Lets put it this way:  You are a combination of lady gaga and cindy lauper with a dash of street hooker thrown in.

You are, shall we say, UPSET?!!!!  Only your upset is different than other peoples upset.
Your upset is theater.  The angst is off the charts.  Your arms flail, your face contorts. You tell me your problem which is equally bizarre.

You are eventually discharged after being evaluated mentally and physically.   I love people like you .  Variety is the spice of an ER nurses life.

As a nurse, you don't think much about what you are witness to on regular basis.  Birth, death, trauma...life changing events.

One of the things we see as nurses that most people don't, is death.  A lot of the time it isn't pretty.  A lot of the time its not like in the movies where someone just goes and its over quick. Sometimes it takes a while.  Sometimes a family sits waiting for death, watching their loved one gasp. Sometimes that goes on for a while.  Its difficult to witness.  To see you mother or father seem to struggle for breath for a while.

As a nurse, to be honest, you just want it to be over.  For them.  Those are the times you pray for the end to come.  So they won't have to remember an awful end.

Nurses stay with families as death nears.  Its part of what we do.  We don't want them to be alone. Its too hard for them to be alone. So we stand there while they talk about mom or dad or grandma. You learn a lot about the person at times like that.  

Its hard to watch people cry.  Its doesn't matter how old the person is, they are still mom or dad.

One thing you have to learn as an ER nurse is humility. I see some young nurses with say a year under their belt, overconfident.  Its like they say to themselves: I've done this a year, I know it all.  Here's the thing: That kind of attitude will eventually bite you.

There's nothing wrong with confidence.  Its a good thing.   I have a lot of confidence. The thing is I have been doing this a long time.  But there is one thing I know: I don't know everything and I never will.  On a regular basis, I ask my co-workers for help.  I depend on them. If I've never done something, I know one of them will help me do it.  If I need help, I ask for it.

The longer you work in ER, the more humble you become.  The more you see, the more you realize you will  never see it all.  Overconfidence leads to mistakes.