I know that it is silly of me, especially since I went into cardiac nursing; but I have a rule. None of my patients is allowed to code when I am their nurse. I know that it is stupid. And inevitable. And has arguably happened already- but we will get there. ...... This post is about reputations and the aura that you project when you work.
I know that I sound woo-woo when I say it, but we all know that person that shit always happens to. The person that no matter how hard you try to give them a good assignment their night turns to crap. The nurse whose patients always go d0wn the tubes. The person who is always working when the codes happen.
I am not saying that they are angels of death, that they are killing the patient; just that they are shit magnets. After a while if you see that you are on the schedule with them you just take a deep breath and think "here we go again....."
I have a colleague like that. He even acknowledges the bad luck. Calls himself "Black Cloud-Stinky Finger" I understand the Black Cloud part- never wanted to know about the second part. I think that after a while of being teased as the unit bad luck charm that he just decided to embrace the reputation and go with it.
He and I talked about his reputation several times, and I talked about my rule. Someday I will talk about my one "maybe' code since it is a freaky story..... Anyway, I said that I was going to try to embrace the opposite reputation- that I wanted to be the person that people thought of as the person that brought stability and calm shifts to the unit. I asked him and another friend on the unit to help me think of a name.
Everyone kept thinking of drug names- "The Ativan Kid" "Slow ride with Haldol". But that wasn't what I was looking for. I didn't want to be associated with the crazy patients, but the stable ones. I eventually decided to just go for the polar opposite of my friend's nickname
Rainbow Bright
Sunday, July 19, 2009
ER ridiculousness
I know that ridiculousness probably is not a word. It should be. Our census was horribly low this weekend. By the time I left tonight we had 9 patients. 9 on a floor that holds 22. We had 4 nurses today, which for a floor that does total care makes it a little difficult to find someone to help you when you need an extra set of hands for a boost. Most of the time ICU is begging us to send someone home so that we can take someone, but we are packed to the rafters.
So since we had nurses on standby in case of admissions we were praying for cardiac rain. Doing rain dances. Those of us who were scheduled in the next couple of days and didn't want to get cancelled were making bargains with children future or not.
And what shows up in the ER? Ingrown chin hair. Patient concerned about mole on leg. A bike vs skateboard accident. Undescribed male genital problem. Any chest pain you ask? Yep, 28 year old female. Did they admit? Of course not.
Like I said ridiculousness.
So since we had nurses on standby in case of admissions we were praying for cardiac rain. Doing rain dances. Those of us who were scheduled in the next couple of days and didn't want to get cancelled were making bargains with children future or not.
And what shows up in the ER? Ingrown chin hair. Patient concerned about mole on leg. A bike vs skateboard accident. Undescribed male genital problem. Any chest pain you ask? Yep, 28 year old female. Did they admit? Of course not.
Like I said ridiculousness.
Sunday, July 12, 2009
Where have all the PA's gone?
The big HMO across town has decided to open their own cardiac surgery program so that they don't have to keep paying other hospital systems to manage the care of their cardiac patients. As a result they need skilled staff to work on these units and to work with the surgeons that they have lured to run this program.
As a result they have agressively recruited the Physician's Assistants that work with our Cardiac Surgery group and have apparently made offers that are very hard to resist. Near impossible it seems as most of our PA's have jumped ship, leaving us with a measely 3 PA's.
You may not think that this would be a problem, but look at it this way. For every surgery there is a PA scrubbed in to assist. We have 3 Cardiac Surgeons, one of which has been known to do 3 cases a day. We have 2 cardiac OR's, so we are capable of doing simultaneous first case OHS. On any given day 2 of the surgeons will schedule cases, and the third will have office hours. A PA has to be available in the office for wound checks and suture removal, and another PA will round on patients in the ICU and on the floor, writing orders and taking pages from nursing staff. They will also round with the surgeon to address any current concerns.
Is it starting to sound as if the PA's are being spread a little thin? On top of that, about 6 months ago the physicans stopped taking their own overnight call for routine matters and started funneling calls through the PA's first. If the call was for an acute matter, the surgeon would then be notified, but the PA would be notified first. The PA's received no extra compensation for this new responsibility.
While I never understood why the physicians took all of their own call in the first place, I think that the call issue is the major reason that it was so easy for Major HMO XYZ to sweep in and recruit 4 of our 7 PA's. One of the PA's that just left said that any time that they spend working while on call is paid for at an hourly rate in addition to their salary. I have also heard that our physican group made no counter offer to keep the PA's that left.
I hope that they do something soon. The PA's that are left are visibly tired. They are taking overnight call every 2-3 days, in the OR almost every day plus trying to cover all of the patients in the hospital plus all of the clinic patients. This is a recipe for bad, bad things..... and I will be watching orders carefully
As a result they have agressively recruited the Physician's Assistants that work with our Cardiac Surgery group and have apparently made offers that are very hard to resist. Near impossible it seems as most of our PA's have jumped ship, leaving us with a measely 3 PA's.
You may not think that this would be a problem, but look at it this way. For every surgery there is a PA scrubbed in to assist. We have 3 Cardiac Surgeons, one of which has been known to do 3 cases a day. We have 2 cardiac OR's, so we are capable of doing simultaneous first case OHS. On any given day 2 of the surgeons will schedule cases, and the third will have office hours. A PA has to be available in the office for wound checks and suture removal, and another PA will round on patients in the ICU and on the floor, writing orders and taking pages from nursing staff. They will also round with the surgeon to address any current concerns.
Is it starting to sound as if the PA's are being spread a little thin? On top of that, about 6 months ago the physicans stopped taking their own overnight call for routine matters and started funneling calls through the PA's first. If the call was for an acute matter, the surgeon would then be notified, but the PA would be notified first. The PA's received no extra compensation for this new responsibility.
While I never understood why the physicians took all of their own call in the first place, I think that the call issue is the major reason that it was so easy for Major HMO XYZ to sweep in and recruit 4 of our 7 PA's. One of the PA's that just left said that any time that they spend working while on call is paid for at an hourly rate in addition to their salary. I have also heard that our physican group made no counter offer to keep the PA's that left.
I hope that they do something soon. The PA's that are left are visibly tired. They are taking overnight call every 2-3 days, in the OR almost every day plus trying to cover all of the patients in the hospital plus all of the clinic patients. This is a recipe for bad, bad things..... and I will be watching orders carefully
Saturday, July 11, 2009
Strokes- strokes everywhere
Surgeons are on vacation, and for some reason we seem to be having a sale on large Occipital and Cerebellar strokes this week. We sent two to hospice on Friday, and a third extended her stroke just before she was transferred to acute rehab at the end of the week. Luckily she seems to be coming back around in the last 24 hours. For the last couple of days she was really only arousable to painful stimuli, so I was pleasantly surprised when I took over and she woke up and started talking! A lot of word salad, the year is dirty sanchez, with some definite visual cuts and a right sided neglect- but much better than the near vegetative state that she had been in. There had been talk of sending her out to hospice too, and I am too used to the action of fixin' through surgery and the cath lab to have a hospice trifecta in 2 days.
Where oh where have our cardiac surgeons gone! I have not seen so many gerontologists and neurologists in the last year as I have in the last week. Strokes frustrate the hell out of me, give me a good MI any day- I know what to do with them!
Where oh where have our cardiac surgeons gone! I have not seen so many gerontologists and neurologists in the last year as I have in the last week. Strokes frustrate the hell out of me, give me a good MI any day- I know what to do with them!
Monday, July 6, 2009
Cooperative patient care
On the floors at my hospital we are told so often, and in so many different situations to never hold the Lantus, that it has become second nature to give that injection almost without thinking twice.
Over the last couple of days I had a patient that had been receiving tube feeds, which had been discontinued the day before with the exhibition of a normal swallow in this patient post intraoperative stroke. The orders had read to give a half dose of Lantus the previous day and resume the previous daily dose of 50 units in the am when I was to take over the care of the patient. There were two problems with this dose. The first was that the patient had no history of diabetes, and the previous need for insulin was almost completely due to tube feeds. The second problem was that the patient promptly decided that she had no appetite and that she was not going to eat.
Not half an hour after after I gave the dose the hospitalist on call for the weekend showed up, noticed the dose, and in a display of cooperation between disciplines that Happy could learn a lot from spent the next two days working with me to make sure that this lady's sugar never reached a critical low one time. With close monitoring of her blood sugar and intake I was able to inform the physician when the blood sugar dropped from 135-77 in the span of an hour. When half an hour after the administration of 1/2 amp of D50 the blood sugar had dropped to 72, I was able to receive additional orders even though the patient was not technically hypoglycemic.
With continued drops in blood sugars over the course of the afternoon and more D50 for a low of 54, the physician and I were able to work together to formulate orders for maintenance orders for D10 and hourly CBG's that would maintain adequate blood glucose overnight. This was actually a collaborative effort, as I was able to tell her what the nurses were liable to need overnight, and how they were likely to interpret wording of certain orders.
At the end of the day she thanked me for all of my hard work, and expressed gratitude when she heard that I was back the next day. "at least we won't be starting all over again"
The point of all of the care was that this patient, with a recent large stroke absolutely did not need to have further insult caused by repeated severe hypoglycemic events. In fact, due to her neurological status, she likely would have been very hypoglycemic before anyone noticed. I could have had a hospitalist like Happy who walked up to the desk and calmly stated "She is in isolation so I didn't go in the room, but Mrs Smith is awfully diaphoretic and seems to be having a seizure. What do you think that I should do? "The fact that I was working with a physician that was concerned and receptive made an extremely difficult job easier. The last thing that I or this patient needed was for me to have to fight the physicians for appropriate orders while gowning up in isolation gear for c-diff to check her blood sugars every hour. In this case I was allowed to intervene before the emergency and my knowledge was appreciated and sought out. I want to clone this doc!
Over the last couple of days I had a patient that had been receiving tube feeds, which had been discontinued the day before with the exhibition of a normal swallow in this patient post intraoperative stroke. The orders had read to give a half dose of Lantus the previous day and resume the previous daily dose of 50 units in the am when I was to take over the care of the patient. There were two problems with this dose. The first was that the patient had no history of diabetes, and the previous need for insulin was almost completely due to tube feeds. The second problem was that the patient promptly decided that she had no appetite and that she was not going to eat.
Not half an hour after after I gave the dose the hospitalist on call for the weekend showed up, noticed the dose, and in a display of cooperation between disciplines that Happy could learn a lot from spent the next two days working with me to make sure that this lady's sugar never reached a critical low one time. With close monitoring of her blood sugar and intake I was able to inform the physician when the blood sugar dropped from 135-77 in the span of an hour. When half an hour after the administration of 1/2 amp of D50 the blood sugar had dropped to 72, I was able to receive additional orders even though the patient was not technically hypoglycemic.
With continued drops in blood sugars over the course of the afternoon and more D50 for a low of 54, the physician and I were able to work together to formulate orders for maintenance orders for D10 and hourly CBG's that would maintain adequate blood glucose overnight. This was actually a collaborative effort, as I was able to tell her what the nurses were liable to need overnight, and how they were likely to interpret wording of certain orders.
At the end of the day she thanked me for all of my hard work, and expressed gratitude when she heard that I was back the next day. "at least we won't be starting all over again"
The point of all of the care was that this patient, with a recent large stroke absolutely did not need to have further insult caused by repeated severe hypoglycemic events. In fact, due to her neurological status, she likely would have been very hypoglycemic before anyone noticed. I could have had a hospitalist like Happy who walked up to the desk and calmly stated "She is in isolation so I didn't go in the room, but Mrs Smith is awfully diaphoretic and seems to be having a seizure. What do you think that I should do? "The fact that I was working with a physician that was concerned and receptive made an extremely difficult job easier. The last thing that I or this patient needed was for me to have to fight the physicians for appropriate orders while gowning up in isolation gear for c-diff to check her blood sugars every hour. In this case I was allowed to intervene before the emergency and my knowledge was appreciated and sought out. I want to clone this doc!
Breaking the cherry
I have been lurking on numerous blogs for a couple of years now, and have finally decided to take the plunge, join the insanity, drink the Kool-aid. If I keep this up I will have to make my theme mixed metaphors.
I am hoping to relieve some of the stress of the job by writing it out, as well as put it in perspective. If I am successful I will be able to entertain some of you as you have entertained me.
I am hoping to relieve some of the stress of the job by writing it out, as well as put it in perspective. If I am successful I will be able to entertain some of you as you have entertained me.
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