I Can Post If I Wanna

I can leave this world behind

Gone Too Long

OMG I KNOW! Please, before you light into me for not posting as often as I should.. or, well, ok... for like 3 years... understand that I actually started working in the real world of nursing. Things just started looking the same... day after day the scene didn't change much and although the stories of interesting first psychotic breaks, manic moods, and overindulgence in various mind-altering substances did begin to pile up, I got LAZY.

ENA Responds to President's Comments

The following is a statement from ENA President Donna Mason, RN, MS, CEN in response to comments made by President George W. Bush during a speech in Cleveland, Ohio, July 10, 2007.

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On July 10, a primary barrier to health care reform in the United States was illustrated perfectly by President George W. Bush during a speech in Cleveland, Ohio. Unfortunately, the President didn’t offer insight into a solution; instead he demonstrated a complete lack of understanding as to how health care is delivered today and how near the breaking point our health care system has become.

In talking about the challenges facing health care in the United States, the president said:

“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”

The issues facing health care in America are complex, but it is clear by this statement that the President isn’t even aware nor understands the fundamentals of the crisis.

Emergency departments are required by law under the Emergency Medical Treatment and Active Labor Act to accept, examine and stabilize patients with emergent conditions. But with wait times growing, the severe shortage of nurses, violence in emergency departments rising, and the ranks of the un- and under-insured so high, treating the emergency room like a primary care clinic, mental health clinic and an emergency room all at the same time is a recipe for disaster.

While emergency departments are committed to providing quality care for all patients, they are intended to treat emergencies, not to provide primary care services. Patients with diabetes, heart conditions, high blood pressure, mental illness and other chronic conditions need the care of primary care doctors and specialists to manage their conditions. They need to be treated before their conditions become life threatening. By suggesting that patients in America have access to health care because they can always go to the emergency department, President Bush not only over simplifies the problem, he ignores the true nature of the problems facing patients and hospitals alike.

A Centers for Disease Control and Prevention report this year showed a 20 percent increase in emergency department patient visits while the total number of EDs in the United States declined by 9 percent. At the same time, the average emergency department wait times are as long as six hours in some states with some patients waiting as long as 24 hours to be seen. When you combine this with the growing number of elderly patients, the ever present shortage of nurses, the nearly 200,000 fewer hospital beds and the tens of billions of dollars of unrecovered treatment costs every year, it is clearly a false and dangerous assumption that all Americans have access to health care because there are emergency rooms.

As president of the Emergency Nurses Association, I know that a solution to the current health care crisis will not be easy. We must build an infrastructure capable of treating a growing and aging population. We have to find a way to train the individuals representing the more than 147,000 qualified nursing school applicants that were turned away during the 2004-2005 academic year primarily because of the lack of nurse faculty to teach them. But most of all, we must admit the failure of the current market-based health insurance system and find a way to truly provide patients with access to care, access that actually prevents illness and injury before they become emergencies.

Nursing Student Sues School for F

June 24, 2007 -- Columbia University gave him an "F," but he deserves an "A" for audacity.

Nicholas Perrino was kicked out of the Ivy League institution's School of Nursing for missing an exam, and now he is suing to get back in.

"I should have went to Yale," moaned Perrino, who is representing himself in the case.

The 27-year-old Illinois native said he was working toward two master's degrees last summer, when his grandparents became gravely ill, forcing him to take a few days off.

He told his instructors he would be absent for a skills exam and tried to arrange a makeup, Perrino claims in documents filed June 15 in Manhattan Supreme Court.

Instead, he says, the school failed him in the course - part of a fast-track master's program.

Without the test, the school wouldn't let him continue his nursing coursework.

Filing academic grievances and appealing to the Columbia provost got him nowhere, he said, and he was withdrawn from the School of Nursing.

"It's insane," Perrino said. "It's not like I killed someone."

Perrino, who says he spent $65,000 on tuition, did complete a master's degree in public policy. He says he had a nearly spotless academic record at the School of Nursing.

A Columbia spokesman said he could only confirm Perrino had been a nursing student, and cited privacy rules preventing him from discussing the case.

Perrino is asking a judge to remove the "F" from his transcript, reinstate him at the school and reimburse tuition costs for classes he has already taken.

Found in the NY Post: http://www.nypost.com/seven/06242007/news/regionalnews/f_student_sues_columbia_nurse_school_regionalnews_kathianne_boniello.htm

Paging Doctor Borderline...

Finally! A day off to catch up on things.

Work has been sort of stressful - the new charge nurse flits around the unit going 12 ways at once and pretty much accomplishing nothing. When I work with her I don't feel we're a team. Although I try to remind her of things she has to do it feels like there's no back-up for me (there are only two floor RNs, one med-nurse and about 6 mental health specialists for each floor).

To top that off, we've got several psychiatrists here and one of them is just losing it all the time. He's had to apologise to the whole day shift staff once, and to me personally about 3 times. It's like he gets a difficult patient and gets upset with them or doesn't pay as much attention to them as another doc might, and they don't get good care. He gets stressed out about anything and takes it out on nurses, saying rude things and raising his voice.

I came in the other morning and there was a new patient on this doc's team who was admitted at 7pm the evening prior. He was actually the doc on call for the whole hospital that evening anyway, so he made the initial orders over the phone. He knew he would be doing an admit in the morning. The patient was living in a group home and according to staff there had been med compliant. The doc didn't order any meds for her except PRN Ativan and Ambien. I called him on his cell phone at about 10:45 in the morning, asking if we could get this patient started on her normal meds because she had basically missed the noon (while she was being detained and medically cleared), pm, hs, and am doses and it was approaching noon again. He went off on me that he doesn't give phone orders, and I responded with "Well, its 10:45 now and the pt's been here since 7pm - when can we expect you in to assess her?" he went on to say that I didn't have the experience to know that in most facilities they never made phone orders and "when you've been doing this for longer" and other crap like that (all of our good docs get right on new admits first thing in the morning).

He did come in about 11am but wanted to play some sort of power struggle game and didn't assess her even though she was running down the hallway screaming and cussing out other patients and making a big scene (well, yeah, now she's off all her meds...). We could only give her Ativan, which sedates a person and does nothing for the psychosis. I don't know about anyone else, but in my opinion being unwilling to order her own meds for her was about the same as ordering "hold all meds" - and this counted for the psych AND medical meds. I don't mind that so much, sometimes they want the pt off meds for a bit, but this was without assessing her! It is so frustrating to work with someone who has to prove a point at the cost of care of the patient. I mean, if she got in a fight or had to be restrained for safety because she was out of control, this would have bearing on her court case and she might be there longer or worse yet, she could be injured. I spoke to my nurse manager, and she told me to inform the medical director, who was ALSO wondering about this patient who is so out of control. He speaks with Dr. Attitude and nothing happens. At 15:30 when our shift is leaving she still has no orders. I'm in the back office with the medical director (aka PsychDoc from my previous posts) and a discharge planner and Dr. Attitude comes in and says "I want to talk to you" and I say "I was supposed to be off at 15:30, I'm 15 minutes overtime" and he just starts talking anyway: "You don't want this to turn into one of those things where people talk shit about each other behind their back and try and hurt each other - you don't need to go over my head, you can call me if you need something!". OMG oh well whatever now I know you're messed up. I only asked when we could get some meds for this pt.

Anyway, after I leave I guess he has a chance to think about how it's not nice to threaten your nurse - and he tells PsychDoc he wants to call me at home to say he's sorry! I'm glad he didn't because I would have told him to .... well, I'm just glad he didn't. Maybe I should call him Dr. Borderline. The next day we worked together, he tried to say he was sorry and I told him I didn't need his "sorry" and that if he could control his own behavior he wouldn't have to keep apologising to me. At lunch he bought pizza for the staff.

Yeah, you're a swell guy.

Thank god the rest of the people I work with are so cool.

WAKE UP!

Alright, that's it!

I'm going to start writing again.

I had a bit of a tough time finding time to blog as we bought the house, moved, tore out the kitchen, and remodeled, but now that's pretty much done (I say pretty much, because I still can't find my other black slingback mule... still some unpacked boxes in the basement!)

I'm still working at the Psych Hospital. I get along well with most of the people there, and have some good friends now. We have fun, and keep it interesting. We work well as a team, and you've got to have that when safety can be a concern. Work is always challenging and it's a new experience every day.

The full-time charge nurse position opened and I applied for it, but they hired someone from the outside. Up to this point I was only a fill-in charge nurse along with one other nurse and would rotate days. She has something like 25 years of nursing experience, but I'm not really seeing a difference from what was going on before. I made my own choice and decided that if I was going to wait around for a promotion I might be old and gray before it happened -SO- I started school again!!

I'm taking care of 15cr of prerequisites and hope to be able to start in the fall at The University. I say hope, because I'm applying pretty late. I expect to get in, but if that doesn't work I'll get in in Jan. I need 10cr of foreign language and I'm taking Spanish (yea!!) and I also needed Statistics, which I can take online (hmmm...). I'm super-duper-awesome-happy about going back to school even though the idea of now working full time and going to school in the evenings is a bit scary.

So what else is going on? My sister is coming from Florida to visit in September, and in August my family is going to Texas to meet my husband's family. I'll get to meet his mom and sisters finally after being with him for almost 7 years!

The house is improving a bit at a time, and we've made great strides in the yard, which was overgrown and hadn't been pruned back in at least 10 years. There are about 30 rhododendrons and tons of other trees, many I can't name. It was an amazing yard back in the day, but it sort of went wild and scrubby. Things look MUCH better - I'll probably post pics.

Anyway, I'm going to go barbecue some burgers now and take advantage of the beautiful weather. I'll write more soon about work and school and anything else I can think of that might be interesting.

Let me know if you're still reading....

-HK

Too much of a good thing

Ok, here's the deal. I like having a child's parents at the bedside. It's fantastic. It's the way things should be, with the parents providing care, reassurance, and valuable "insider information" on my patient.

Sometimes, though, you just need the room to yourself. (The following is heavily paraphrased.)

"So, what's that you're giving her now?"

"Nothing new, the dopamine infusion is about to run out so I'm swapping in a new one. You'll see her blood pressure go up for a bit, but it'll soon settle."

"Oh, right. Has she had a suction at all?"

"Not on my shift."

"Did she hoik?"

"I'm sorry?"

"Hoik, you know, like cough? Or was it all in the tube?"

(Struggling to keep up) "Uh, her last suction was before my shift, so I really couldn't say."

"Ah, ok." Brief pause. "What's that she's getting now?"

"This is one of her antibiotics." I check the clock. 0120 hrs. Please, please, go to sleep. Your child is sedated. She won't wake up unless... you start... to rub her feet and talk to her in a loud voice...

"So that's one of the ones to put her to sleep?"

"Yes, we don't really want her to wake up just yet, she needs to be relaxed."

Parent gets out own thermometer to check temperature. "Do you use these? These are good."

"Uh, we have some other kind." I am willing you to go to sleep. You are getting sleeepy. Sleeeeeepy...

Pointing to the monitor, where the respiratory rate has fallen slightly. "Where do you want the respiratory, boss?"

Boss? "Don't worry too much about the numbers on the screen. It's normal to pause a bit when you breathe, especially when you're in a deep sleep. You and I probably do too. If she stops for too long, the ventilator will kick in."

"Right, right. So what's that she's getting now?"

Poison. I'm giving her poison, IV stat. "This is another antibiotic. I'm just adding it into the line in a different place."

"Why's that?"

And on, and on. Don't get me wrong, I'll answer questions with the best of 'em. However, some parents feel obliged to do the heroic guardian bit and stay up all night, completely exhausting themselves and adding to their family's already significant stress levels.

Plus, on night shift the bedside nurse's patience is less abundant.

Why Not?

Mistakes

Let's start here: I've never killed anybody. Yes! Score one for the big guy. To the best of my knowledge I've never caused serious harm either. Here are some of the mistakes I've managed to make in the course of my career so far:

• Informed a patient's parents that we would call them when their child was off the heart bypass machine and back in the intensive care unit. That went down like a lead balloon as the child was in fact having spinal surgery. Oops.


• Gave a medication IV when it had been switched to oral.


• Gave a larger than usual initial dose of adenosine due to making an assumption about its concentration which turned out to be incorrect.


• Gave a medication that recently passed its expiry date.


• Missed giving a charted medication due to rushing and not checking the chart carefully enough.

The reason I know I made those mistakes is that, where I didn't discover the problem myself, I was notified by the constant checking and cross-checking and reviewing of my colleagues. It's a given that humans are fallible, and that in an increasingly complex hospital world, we will screw up from time to time. The trick is to minimise how often that happens, not to make the really big mistakes, and to put measures into place that reduce the risk of them happening again.

I've caught any number of mistakes from both nurses and doctors. Some examples follow. In each case I can see exactly how the mistake was made, and I can imagine doing that myself given similar circumstances.

• A ventilator's pressure release valve screwed in all the way, which would not allow excessive pressure to be vented to atmosphere.


• A bag of IV fluids made up correctly for the unit's standard orders, but incorrectly for the particular patient who had other requirements.


• A 'ten times the dose' charting error made by a tired registrar.


• A ventilator set up 'backwards', with the expiratory limb plugged into the inspiratory flow outlet. Patient was ventilating fine but it confused the hell out of the humidifier.


• An unnecessary medication prescribed by a consultant who made an assumption about the patient that turned out to be incorrect, based on a mis-reading of a fluid balance chart.


• A dopamine infusion advertised as 5 mcg/kg/min by an anaesthetist that was in fact 10 mcg/kg/min. Sort of explained the extremely 'healthy' blood pressure we were getting.

I mention these not to try to sound clever, but to illustrate that the process works both ways. You make some mistakes, you catch some mistakes. There's a peculiar kind of ego-supression that has to go on in order to survive in this environment, where you swallow your pride and realise that you're not super-nurse or super-doc but rather a mere fallible mortal who gets it wrong some of the time.

I know that people who come into hospital would much rather believe that mistakes don't happen, but the truth is that little mistakes happen all the time. Big mistakes, thank god, are much rarer and (if you're careful, and lucky) tend to be the sort of thing you hear about but don't see.

The same themes recur throughout incident reports submitted when a mistake is made: haste. Overwork. Overtiredness. Inexperience. The risks inherent in understaffing are well documented. A less popular admission among hospital staff is that, even under the best circumstances, errors will still occur.

More About Money

I don't normally state plainly what country I'm blogging from following the closure of GeekNurse, although it's fairly easy to look up which is why I don't try too hard. Hence the ambiguity of my previous post on finances.

In that post I was out by quite a long way. Told you I was bad with money! I make $37 613 in US dollars before tax. I lose 25% in tax and a further 7% in student loan repayment, so by subtracting 32% we get the unhealthy net amount of $25 577 USD. This is after 8 years of clinical experience.

As you can see, it wouldn't be hard to do better on US RN wages, even taking cost of living into account. In fact, with rentals the way they are where I live, and with accommodation often provided for in travel nursing contracts, I'd probably be quite a bit better off. But I love my country, I love the way we practice intensive care here, and it's just not the right time. So I should stop complaining!

I can increase my earning slightly by 'upgrading' myself according to our hospital's mind-numbing grade system, which ranks how competent I am by asking me to produce a large body of 'evidence' and fill out a vast form. Sheer laziness on my part (and a certain amount of resentment at having to do it in the first place) has so far prevented me from complying.

If you don't mind disclosing, how about posting your own income from nursing (converted to USD) in the comments section? Here's a currency converter if you need one.