Ask the Great Pumpkin....

Lucy thinks this is bad? She should try working in an ER. I'll take dog germs any day. In recognition of Halloween, I have compiled a list of questions I would ask The Great Pumpkin, who, as we all know, rises out of the pumpkin patch once a year to answer rhetorical questions such as:

Did Dixie McCall ever leave the nurses' station on "Emergency"?

Why is it easier to stay up until 0700 than to get up at 0700?

Why is it that when you have a child requiring transport to a pediatric facility, the patient is well enough to be throwing a football to his nurse when the transport team arrives?

Why would my husband even remotely suggest that I want to watch "Trauma In the ER" on my days off?

Why is it when a law enforcement officer seeks medical attention in the ER, the entire force on duty at that time comes in to say hi? Ditto with the fire guys?

How can they say we don't have universal access to health care when anyone at anytime can walk into any ER for any reason and by law cannot be turned away because of lack of funds?

Why are they always defibrillating patients in asystole on TV?

Have you ever noticed that if the wait is too long, patients will "self-triage" themselves out of the emergency department?

What is it about "No Cell Phones" that is so hard to comprehend?

Why is it that a person will stand in line for three hours for a flu shot and then gripe if their entire ER visit takes the same amount of time?

Ever notice how a warm blanket will soothe the cranky patient?

Why would county dispatch send four ambulances to one ER within 15 minutes when none of the other hospitals are on ambulance diversion?

Ever feel like Sally Brown when you are trying to work and it seems like the entire world is trick-or-treating?

How did the nurse on "ER" auscultate a sys-
tolic BP of 40 without a sphygmomano-
meter or a stethoscope?

Why would a facility feed into the "instant gratification" culture by placing this ad in the local paper: "It takes longer to walk to your mailbox than it does to be seen in our ER"?

And finally, how much candy will be on the break table at work tomorrow?

Happy Halloween! Here's to no tricks and a ton of treats!

Critical Mass....of Nurses

I'm sure we all remember our Wheatena lecture! Why, it was the highlight of my nursing education! Today we have drug reps, back then they must have had Wheatena reps...

I'm a Cream of Wheat fanatic, myself. Freakin' nectar of the gods, it is! Trust me, when you've been NPO for 36 hours and you are status-post intubation, that first swallow is absolute heaven. A little sugar, a little milk.....ahhhh.....the epitome down-home comfort food! I never will figure out how it qualifies as a full liquid, though.

I realize that it has been a long time since I've worked anywhere in a hospital but the emergency department. I realize that life on the telemetry and med/surg units has changed in the last 16 years.
But...

Why on earth does an entire floor have to shut down because one patient goes critical?

Let me give a hypothetical example. Say there is a telemetry floor that holds 50 patients, but the census is at 45. There are nine nurses (5:1 at night), a unit clerk and a charge nurse. A patient at one end of the unit goes critical. At this point:

• The ER cannot obtain a room number for the new admission because

• the charge nurse is busy assisting the nurse whose patient is crashing
  
• only the charge nurse can assign a room number

• If a room number has already been assigned, no nurse on the unit will take report

• because a "patient is crashing" on the unit.
• they are busy
  

• The new admission happens to be assigned to the nurse whose patient is now critical.

Now it doesn't take the logic of Mr. Spock to figure out that:

• The charge nurse

• knows which rooms are available for an admit
• knows which nurses are open for the admit

• doesn't need an hour to figure this out
• can delegate the assigning of the room
• can make a decision and revise prn

• The nurse taking the new admit with room assignment
  

• has an open room ready and assigned
• is not involved with the critical patient
• has no reason not to take report or accept the patient after report has been given

• hectic activity in one room does not preclude giving care in any other room
• is able to assess his/her patients without the charge nurse
• can hold paperwork if necessary until unit clerk is available to process orders

• The nurse of the critical patient, if assigned the new admit, should have the admit given to another nurse and be open for the next admit after they have transferred their patient to ICU.

Am I missing something here?

In the ED we have critical patients on a continuous basis along with a rotating census in every other bed, but the unit does not come to a halt because there is a code going on. Patients keep getting triaged, orders keep getting written and carried out, nurses multitask and take over for each other where necessary.

Two nurses, a doctor and a respiratory therapist (or two) can run a critical patient and get them transferred to ICU. It does not take an army....or an entire unit of nurses.

Can someone shed some light on this?

I just don't get it.

One Child/Multiple Patients: Parents in the ED

I bought this book as part of a Sesame Street series for my first daughter back in the early '80s and now I find it on a "review of antique books" site! Good grief! If this is an antique then I'm a pre-historic relic.

Being a nurse never helped me as a parent. When my first baby ran a temperature of 104.8 I ran to the ER as fast as I could get my old VW bug to fly. When I found my 2-year-old son blue and drooling on the side of my bed after a febrile seizure, we went 911 all the way. Of course by the time I had #3, I was an ER nurse and an experienced parent. She never even saw the inside of an ER until she was 14 and that was only because she was having an allergic reaction.

I know what it is like to be absolutely terrified because your child is sick.

In the ED, the child may be ill but you are caring for the parents as well. I find parents fall into three categories:

• The Newbie: a parent who is dealing with a sick child for the first time. They have no clue about what to do for the fever and they are frantic because the child vomited once and has not stopped crying/fussing. They truly feel this is an emergency. They did not call the pediatrician, having rushed to the ER after the first emesis. They usually have at least one grandmother with them for support. The child is dressed in a diaper, a onesie, a second onesie, a one piece sleeper with footsies, a sweater, a jacket with hood and a thick flannel blanket. They are scared to death.

• The Walking Worried: They've been through this before, only the fever keeps coming back when the Tylenol wears off and the vomiting has been going on "all day". They called the pediatrician and have an appointment for tomorrow but they are too worried to wait that long. There may be new symptoms with this illness or it may have come on very suddenly. They've gone through all the treatments they can do at home (ie nebulizer treatments) but their gut tells them something is not quite right or the child is no better. They aren't panicky, but they are anxious.

• The Veterans: They've seen it all. The kids are older, or the child is the youngest in the family. They can handle the usual stuff at home, so the child will be in with asthma exacerbation, an orthopedic injury or a laceration. They're concerned, but not anxious.

So how do we help the parents while we care for the child?

• Acknowledge that the parents are concerned/worried/anxious.

• Begin treatment at triage. If appropriate, give the medications for fever allowed by the triage protocol. If the child will need to wait to be seen, let the parents know that the fever is being addressed while they are waiting.
  

• Tell the parents that if they become worried about their child while waiting, you (the triage nurse) are available. This will help allieviate some of their anxiety about waiting.
  

• Reassure the parents that although the patient seemed deathly ill at home but is now playing peek-a-boo with the respiratory therapist and trying to stand on their head on the gurney, this is not unusual for children and we do believe their story...

• Discuss the care for the illness as you care for the child. For example, talk about the need for minimal clothing in the presence of a fever as you undress the child for a weight. Go over what a clear liquid diet consists of when offering the child Pedialyte.

• Encourage the parents to ask questions if they are concerned about an aspect of care.
  

• Be sure to reinforce aspects of care that the parents did right. This is especially important for new parents who may not be confident in their ability to care for a sick child.
  

• If the parents are very anxious, they may not retain a lot of what is discussed. Let the parents know that everything will be written in the discharge instructions given at the end of the visit.

• Discuss options for care of future illnesses at discharge. The parents may not realize that there is a doctor on call for their pediatrician 24 hours a day and they are able to give out telephone advice. They may utilize an advice line after hours. During office hours, their pediatrician may be able to fit them in to a same-day appointment. It is important that the parents are not made to feel that bringing their child to the emergency department was wrong.
  

In the beginning of my career in ED nursing, pediatric patients were not my strong suit. Adult intensive care skills did not transfer over to caring for children. I took a PALS class and told my co-workers I wanted every pediatric patient that came through the door for two months. I became comfortable with pediatric assessments and treatments. Now, after 16 years of ED experience I don't think twice when my patient is a child. I learned early on that when you care for a child, you are caring for a family and that the needs of both the child and the parents must be addressed for a successful outcome.

I Can't Get No.... Satisfaction

What is wrong with Nurse Bradley in this old Wyeth ad? Well...

Her uniform is wrinkled, her hat is not starched and for some reason they won't let her in to the OR. Dr. Studley Intern stood her up last Friday, she can't get Thursday off to attend the hemoptysis symposium and she's had 40 patients on the ward instead of the normal 38 three days running. Dr. Ogre yelled at her for existing and her head nurse makes the Drill Instructor in "Full Metal Jacket" look like Mr. Rogers. She's a good nurse but deep in her heart she knows she can be the next American Idol.

Maybe she's tired of being thought of as a consumer product.

Think about it.

People are "health care consumers" who get their care from "health care providers". Hospitals give their staff instruction in "customer service". Those who are sick are "clients", not patients. Hospitals are vying for business, trying to get the highest scores in "Patient Satisfaction" so some give meal service like a restaurant - on demand, like room service. Some advertise that it will take you longer to sneeze than to be seen in their ER.

Something is wrong.

I've taken care of patients ranging from the homeless to those who live in the most opulent areas you can imagine. I've been treated like a domestic servant by people with their nose so high in the air they hit it on the door on their way into the department and I smile and tolerate it in the name of "patient satisfaction". I've been bossed around by folks at the other end of the spectrum whose sole purpose for coming to the ER was to get fed - and I'm the waitress - and I deal with it in the name of "patient satisfaction".

It's no better for the doctors. I've seen doctors order tests because the patients insist, not because it is necessary. Because their co-worker's sister's mother-in-law read in Reader's Digest that someone in Macon, Georgia didn't get this test back in 2003 and they died! Because the patient will perceive her care as "unsatisfactory" if she doesn't get the test. Because they don't want to get sued. A minimum of twelve years of hard work, study and sacrifice to become a physician and all it boils down to is being a conduit for getting tests ordered so the patient will perceive their care as "satisfactory".

Enough!

I'm tired of this. First of all, I am not a consumer product. I don't provide "customer service". I provide nursing care. My care is given because I am a Nurse and it is received by a Patient, not a "customer" or "client". It is not consumed. My patients will perceive their care as "satisfactory" because it will be safe and their needs, both physical and spiritual will be met and their concerns will be addressed, and not because the hospital hires Emeril Lagasse to man the tray line or offers digital cable. My hospital, as wonderful as it is, is not Nordstrom's. Health care is not the equivalent of choosing a pair of shoes. I'm in the best ER I've ever known, but sorry folks, sneeze into your hankerchief if you have to, but you WILL wait like everyone else unless you are having a true emergency, no matter what some PR firm decides to print.

Patients will be satisfied with their care because they are cared for by competent physicians and nurses who are educated to provide health care in partnership with the patient, understanding that the more information and patient education available, the better the patient is enabled to make their health care decisions.

And that results in "Patient Satisfaction".

Grand Round-abouts!

Gather round for this week's Grand Rounds, hosted by Hospital Impact
I'm honored that one of Emergiblog's posts is featured. Go check out what looks to be a great variety of topics this week!
By the way, the picture in the corner is from an area in Minneapolis that
takes you around lakes and parks - the pictures on the website were beautiful. I fell in love with Minneapolis on a short visit years ago and my love of the city was reignited when I discovered James Lilek's web site.
The next time I'm there, I'll be sure to tour the "Grand Rounds".

Hitchhiker's Guide to the Emergency Department

During your travel among the galaxies, it is possible that you will require some form of health care. On Earth, the primary means of obtaining such services is through what Earth inhabitants refer to as an "Emergency Department". It is well for you to remember the Hitchhiker's motto:

It is in the Emergency Departments of Earth that you will learn first-hand about the concepts of "sitting" and "waiting". You will first be directed to an area where you will "sit" and "wait" for a process called "Triage", where you will be instructed to "sit" and give the Nurse your entire health history, unless of course the ED, as it is called, is horrendously busy at which point nobody cares about the nose bleed you had on Alpha Centauri last millennium. You will then be instructed to a room where you will "sit" and "wait" to be assigned a planetary medical source number, or in Earth parlance, be "registered".

Once you are called to "Registration", you will "sit" and give the data collector your planetary information. As in Triage, this will have to be done verbally, as earthlings are not equipped with telepathic sensors. This does not, however keep some earthlings from assuming that nurses and doctors already know everything about them because it is "in the chart". Oh, and do speak in English as Babelfish are not indigenous to the planet. However, if you have landed anywhere in the region known as California, Spanish works just as well as it seems to be the main language of approximately 51.8% of the population. You will then resume "sitting" and "waiting".

You will then be escorted to a health care cubicle where you will be instructed to replace your clothing with what appears to be a garment of dubious construction. The doctor will then arrive and, while you "sit", proceed to ask you the same questions presented to you in Triage. It is important that you vary your story slightly in key areas, in keeping with the Earth tradition of never telling the same story to both doctor and nurse. Should you need to see a specialist, who will ask you the exact same questions you have already answered twice before, you can vary the story a second time, thereby insuring that the ER doctor and nurse look like, as they say on Earth, idiots.

Once the physical examination is complete, you will "sit" and "wait" for serum to be taken from your portals. You will "sit" and "wait" for radiographic photos and something known as a Computerized Axial Tomography scan of your cranium. Having completed that, you can "sit" and "wait" for the results.

It is possible that while "sitting" and "waiting", you received a consciousness-altering plant derivative highly sought after by earthlings with cranial discomfort. The Hitchhiker's Guide to the Galaxy, Medical Edition suggests that you do not travel through hyperspace for 24 hours after reception of such derivatives and that you refrain from drinking Pan Galactic Gargle-Blasters for 48 hours. Virgin Pan Galactic Gargle Blasters, are, however, permitted. Ignoring these recommendations could result in quite forceful regurgitation of gastric contents. While this is considered a polite compliment on Seti Alpha 5, it is quite repugnant to earthlings.

Once the doctor releases you from the health care area, you will "sit" and "wait" for discharge instructions. They are rarely read or followed by the average earthling. You may find them of interest as a cultural artifact. They are given on the theory of "covering one's derriere", although earthlings do not attach them to that area. The precise origin of this theory is rumored to be related to an Earth game called "suing" where great sums of currency are given to the "sue-er" after a big competition to see who has the better attorney, the patient or the hospital.

The End

(My apologies to the late Douglas Adams. I was watching "Hitchhiker's Guide to the Galaxy" on DVD last night and couldn't resist a parody.)

Nurse Blogging - Herb Caen Style!

....Now I'm pretty thrilled when I find gas at less than $2.85 a gallon, and I've heard of nurses getting excited that their post-op patients are passing gas, but I think this is WAY over the top, don't you? For the life of me, I can't figure this one out. There is nothing about nursing in the text. Nada...

(...something just occurred to me after I posted this....this may not be a nurse, could it be a woman with a white scarf on her head? Shhhhh......keep it between you and me...)

...I usually keep my politics to myself, but some might call me "conservative". As in: compared to me the fine citizens of Mayberry would be flaming liberals. So it came as quite a shock when I glanced at the local news the other day only to see none other than Warren Beatty addressing the California Nurses Association at their bi-annual convention. With Sean Penn in the audience.
The sound that nearly woke you out of a sound sleep was the sound of my jaw hitting the floor. The next day, I was studiously reading over the Propositions for the special election in November when I noticed the name of a CNA bigwig at the bottom of a letter against parental notification laws for abortions. EEEEE...nough! I pay CNA almost $1000 a year in dues. They are a wonderful bargaining agency and I have great pay and benefits (and wonderful staffing ratios) because of their involvement in collective bargaining. But...I don't want my money funding issues that I do not agree with. But, I am required to be a member and I do want to support CNA itself. So I emailed membership. I received a phone call from staff who told me that my dues can be designated to go to the "general fund" and not to any political action committees. I was impressed by the fact that (1)they called instead of just emailing and (2) relieved that I was not tied into funding issues that I do not agree with. I feel much better now....

...Oh man, I'm a Crawly Amphibian in the TTLB ecosphere again. Yesterday I was up to Slithering Reptile. Was it something I said?...

...Speaking of gas, I've noticed an increase in the number of post-op and post-partum patients we are seeing in the ED presenting with abdominal distension and pain. In ancient times, when Jimmy Carter was President and the Bee Gees ruled the world, patients were not discharged after surgery or delivery until they had produced the sacred Bowel Movement. The nurses would assess, many times a day, whether The Bowel Movement arrived. In fact you were stuck on clear liquids until the arrival of Flatus, the precursor to The Bowel Movement. Patients were not discharged until production of The Bowel Movement was verified and subsequently described in minute detail in the nurses' notes, having been observed in excruciatingly fine detail by the RN. This was a required course of study in med/surg nursing. I studied adjectives to describe feces in my classes on post-op patient care. So why on earth am I seeing patients who are a week or more past surgery or delivery who still have not produced The Bowel Movement? Are they getting sprung from the hospital before production these days??? Or to put it in nurse speak, are they being discharged with their "elimination, alteration in" diagnosis unaddressed? Med/surg nurses of the world, where are you? Fight for your patient's right to eliminate before discharge! It's tradition!...

...You know you've been blogging for a long time when you can't remember if you already wrote about a topic or not. Stop me if you've heard this one already. One of the ED docs I know is a whiz kid on just about anything mechanical. So before our last JACHO visit, he made a flashing sound monitor. If the noise at the nurses station gets above a certain decible level, the light bulb goes off. It's really effective because the noise level drops dramatically post-flash. Except....I have this propensity for setting it off. A lot. Now, I was a cheerleader in my younger days but it's not like I'm leading a rousing yell from the sidelines, ya know? I reach up and touch my ear; it goes off.
I put the chart on the desk; it goes off. I say hi to someone in the cafeteria two floors below; it goes off. Oh come on! (it's making me vewwy self- conscious)....

(BTW: Herb Caen was a columnist for the San Francisco Chronicle for fifty years. He wrote about the San Francisco scene....the people, the places. He would write using what I've heard termed "three dot journalism".... back in the '80s I attended an opening of the San Francisco Symphony at Davies Symphony Hall. Post- symphony parties were held inside with the orchestra and outside in a tent with a rock (I believe the group was "Pride and Joy") band. Of course I'm out with the rock band and who do I see dancing next to me? Herb Caen! The man had to be in his 70s but he was out there rockin' to the Motown beat. He passed away a few years back and San Francisco still isn't the same....)

The Contusion That Wasn't

The only person NOT unhappy in this old Parke-Davis ad is the nurse! The kid looks upset, the mother looks hostile and the doctor looks like he is watching to make sure the nurse doesn't mainline the immunization. This pretty much sums up nursing: scared patients, hostile families and grumpy old doctors who can't let a nurse swab an injection site without ordering it done in a clockwise direction.

Just kidding!

Humility is a noble trait. My humility gene got a kick in the pants this week. Here's the scenario:

Female patient, 36 hours post forearm-injury secondary to a sport. No swelling. No deformity. No decrease in range of motion. No bruising. No point tenderness (and I was all over that arm like white-on-rice, looking for point tenderness). Was able to continue playing after injury. Chief complaint: it began hurting again after initial improvement. Nurse-With-Overarching-Pride-In-Assessment-Skills (aka: me) tells ED MD that it just sounds like a contusion. ED MD evaluates patient and orders x-ray. "What???" I say incredulously. "You have got to be kidding!" ED-MD-With-Patience-Of-Saint assures me he is not joking, that (1) patient requested an x-ray and (2) there is an area of point tenderness where ball met forearm (an area I had palpated rather thoroughly). To make a long story short:

The patient had a fracture. There it was. In all three views.

I had a red face.

No freakin' way!!! Uh....yes freakin' way!! I picked up my jaw and returned my humbled self to the triage room.

So what did I learn?

• Fractures are one of the most commonly missed diagnoses in the ED.

• DOH! Before smooshing around looking for point tenderness, ask the patient where it hurts the worst and work your way around from there. It's amazing what you discover when you actually listen to the patient.

• Doctors are doctors for a reason. I am not a doctor, although I will occasionally play one in my mind.

• Nobody's perfect (sniff)!

I have always felt that we learn more from our mistakes than we ever do from success, and I know I'll be much less inclined to dismiss a potential diagnosis because it doesn't meet "by-the-book" criteria in the future.

You can never be too old or too experienced.

Live and learn.

Ladies and Gentlemen, The EmergiAwards!

And the EmergiAward is presented for:

Fastest Relief From a Pain Shot Award: 5 minutes. Patient is writhing, moaning with tearful sobs, nauseated, photosensitive, holding the sides of their sunglasses as they rock their head from from side to side. Injected with Dilaudid and Phenergan. After five minutes, sitting painfree on the side of the bed and very appreciative.

Worst. Luck. Ever. Award: Patient gets hypodermic needle through sandal while walking in a park.

Worst ED Set Up Award: Goes to a local university teaching hospital, world renown for just about everything else except the lay out of the ED. While the rest of the facility is state-of-the-art, the ED is a 1960s time warp. The metal detector you have to go through to enter the ED is modern, though. The staff is great, the care (both medical and nursing) is competent, but the unit itself is small, cramped and swarming with nurses, interns, residents, attendings and, oh yes, patients. Even the trauma room is small. Which leads us to the....

Worst Assignment Ever Award: while employed by the above university teaching hospital, I was given the "Hell Hole" assignment. This meant that I was responsible for six monitored patients in a small, windowless room AND the psych isolation room right across the hall that required q 15 minute observations/documentation on the patient locked inside. One RN. No LVN. No tech. Just me. And, oh I almost forgot..... about a gazillion interns/residents/attendings/ all wanting to know where the labs were and why Patient X was still in the ER. Or informing me that Patient X wasn't getting admitted yet because twenty other Medical Services had to see them and it HAD to happen in the ED. Or sitting at my desk hogging my charts (except the interns....I let them use my desk, they were cool). Funny, the administration was shocked, shocked that I resigned after 10 weeks. I've heard through the grapevine that the unit is now staffed more appropriately. I don't mind working hard, but I will never tolerate working stupid.

Most Ridiculous MD Order Award: Conscious sedation. Patient: child with a laceration. In the middle of the night. On a major holiday. In a full ED and with 8-9 patients in the waiting room. With only two RNs, one of whom would be tied up with this patient for a full ninety minutes. Let me put it succinctly: No way, dude. No freakin' way.

You Can Run, But You Can't Hide Award: Patient on west coast recognized by a nurse who just moved from the east coast as one of the known drug seekers in her old east coast hospital. Busted!

Oddest Response To a Negative X-ray Award: Look of absolute devastation when told extremity not fractured. Poor guy, don't you just hate it when dreams of an insurance settlement slip through your fingers? Patient giddy with delight over crutches, however, so positive patient feedback expected....

Most Patients Presenting In a Single Family At One Time For Triage Award: Six (ages 6,5,4,3,2,1)! They all had colds.

Sweetest Man In the Entire World Award: Patient is elderly, frail delusional female who presents with the belief that her eyes are falling out. ED MD tells her that not only are her eyes not falling out, but that they are beautiful.

Unclear On The 911 Concept Award: Patient with multiple, penetrating thoracic trauma picks up spouse at home before stumbling into ED, pale, diaphoretic and near syncopal.

Just Plain Stupid Award: ER staff allows 35-year-old female with acute abdominal pain and bleeding to fill bladder by drinking two liters of water before pelvic ultrasound, only to then say, "Gosh, you are going to surgery! Here is an NG tube...." and I can give the details of this one because I was the recipient of the NG-induced epistaxis! I will never, ever consent to an NG tube again as long as I live unless I put it in myself. At least I know how to DO it!

Best Straight Shooter Award: Intoxicated, combative, restrained patient needs to urinate immediately. Patient turns to the left side, inches gown up and proceeds to shoot a stream of urine TWELVE FEET away from the gurney. Standing ovation received from all male staff in a thirteen-foot radius.

Who's The Parent Here? Award: Parent offers liquid antibiotic to Toddler, who says NO!
Parent turns sheepishly to ED RN stating, "Oh dear, he doesn't want it". Five seconds later, the medication is traveling down the toddler's esophagus via a syringe wielded by said RN. RN advises parent to remember that parent is (1) older (2) bigger (3) in charge and (4) it doesn't matter a rat's tutu what Toddler wants or doesn't want; some things are NOT negotiable. Parent marvels as though hit by an epiphany.

And so there you have it. The first group of EmergiAward recipients. Unless stated otherwise, the above situations have all been sanitized for patient protection and are composites of many, many patients, nurses and doctors I have worked with over the years. ; )

Life As A Nurse: One Decision, A Thousand Possibilities

I am a rational person.

I am a mature adult.

I detest USC.

I will detest USC forever.

I detest their football team.

I detest their band.

I detest their cheerleaders.

And now, in spite of the fact that I am going through all four stages of grieving at once, I shall attempt to turn my attention to my honorable profession. Thank you.

Go Irish!

hhhhhhhhhhhhhhhhhh

I sometimes find it funny that ol' Cherry had so many different jobs as a nurse. I mean, whoever does that? Then I started to think about all the jobs in nursing that I've had. If a book series was written using my career as a guide you'd have:

• Medical/Surgical Nurse
  
• Coronary Care Nurse
• Telemetry Care Nurse
• Intensive Care Nurse
• Nurse Preceptor
  
• Psychiatric Nurse
• Pediatric Telephone Advice Nurse
• Emergency Department Nurse
• Charge Nurse
• Nurse Blogger
  

Okay, I'm kidding on the last one. But I've had all these opportunities and I'm still 22 years from retirement; who knows what I'll want to do next?

The point is, as a nurse, you have the option of doing anything you want to do. On the Choose Nursing website there is a poster I was unable to reproduce here that states, "Nursing: One Choice, A Thousand Opportunities". I cannot think of another profession that offers the flexibility and variety of nursing.

There are some nurses who will work all of their career in one hospital. Others will travel the country, experiencing a new environment every couple of months. Others will work per diem in many facilities at once. Some will find their niche early on, others will experiement with new specialties as their interests change. It's all good.

Back in ancient times (when Disco ruled the world and nurses made $7.00 an hour), it was believed that nurses should pay their dues with at least a year on a med/surg floor before before being considered for any specialty. Now there are new graduate programs for emergency, intensive care, neo-natal intensive care and I've even seen some programs for labor and delivery.

With nurse/patient ratios being defined and salaries/benefits at an all time high, it's a good time to be a nurse. With all the opportunities out there, it's a great time to be entering the profession.

(I just realized that if I, God willing, am able to work until the age of 70, I will have been a nurse for 50 years. Oy vey!)

A Grand Round Was Had By All, Part Deux

If it's Tuesday, it must be Grand Rounds! Welcome to all who are visiting Emergiblog through Doulicia.

As always, there are very interesting topics this week and I am happy and humbled to find that one of the Emergiblog posts made it into the list. Thanks, Doulicia!

I was fortunate to have discovered Doulicia prior to her hosting of Grand Rounds and it's a joy reading about her experiences as a labor doula. Be sure to check out her other posts!

Nursing: What Do You Think Hospitals Are For?

We didn't have toys like this when I was a kid! Heck, I still want it! This is from Playmobil. Check out the bed; it's adjustable! With a trapeze thingy! The drawer of the bedside table opens! All we need is a linen hamper and a sharps container and we're in business.

It's funny, nurses do not wear caps anymore, but caps are still recognized as a symbol of nursing. I noticed this in both the Playmobil and the Fisher-Price medical/nursing toys.

Do you realize that the only reason for hospitalization is the need for nursing care? Think about it. If you don't need the 24 hour presence of a nurse, you can go home. You can come to the hospital for surgery and go home the same day unless you need nursing care. You can come in, have your baby and go home the same day unless you need nursing care. You can come to get your intermittent infusions from an infusion center nurse and then go home, unless you need nursing care. If you took away the nurses, you would not have a hospital.

Let's take "downsizing", for example. In the world of nursing this means:

• Nurse as pharmacist: when they "downsize" pharmacy by not keeping it open 24 hours, the nursing supervisor delivers needed medications if they don't lock the pharmacy. Or the ER nurses give out "starter packs" of medication during the off hours, including counseling the patient on the medication itself. Hmmm...that sounds a lot like "dispensing" and I thought only a pharmacist could do that...at any rate, the pharmacy budget looks great because nursing has taken up their slack.

• Nurse as housekeeper: there is only one housekeeper at night for the entire hospital because they have "downsized" the department. That housekeeper is kept on the run by the ER and L&D units. So the nurses empty the garbage, the nurses change the linen bags and the nurses mop up the mess on the floor in addition to all their other patient care duties. Now that was okay in Florence's time, but we have just a tad more responsibility these days, wouldn't you say? So the Housekeeping department's budget looks great because nursing has taken up their slack.

• Nurse as Phlebotomist: why have phlebotomists come and draw blood when nurses are available? So let's "downsize" the lab to a skeleton crew of a few techs and nurses will draw all the patients. Which means that all nursing responsibilities stop at 0500, so that the nurses can now take on the lab responsibilities; draw all the ordered bloods and get it to the lab on time. And the Lab budget looks great because nursing has taken up their slack.

• Nurses as Registrar: why have a registrar when the nurses can take down all the information and copy the ID and insurance cards? So the nurses take the information and register the patient. The Admitting department budget looks great because nursing has picked up their slack.

But god forbid that a nursing floor EVER be overstaffed. Staff will be sent home mid-shift if the census drops due to the budget. Nurses will be cancelled if the census drops due to the budget. No chance of being able to spend extra time with fewer patients or more time with acute patients because the Nursing Department might be "overbudget". I've had supervisors tell me that their hands are tied because they will get in trouble if they do not staff by specific acuity numbers. I've had supervisors tell the ER that they need "one more admission" or they will have to cancel a nurse.

None of the scenarios above are fictional; I've been witness to every one of them.

Who would take care of the patients if the nursing department were downsized? I can bet it wouldn't be the pharmacist, the housekeeper, the phlebotomist or the admitting clerk. Not even the doctors have licenses to practice nursing.

Kinda makes you wonder why hospital administrations don't treat us with a little more respect, doesn't it?

It All Comes Out in the End

That's funny. I learned the importance of toilet tissue when I was about 2 years old. I don't remember any toilet tissue unit in Maternal/Child Health class, nor do I remember doing a visual inspection of the roll prior to my patient's use. What is she looking for?

Maybe she is counting the squares. That's what my great-grandmother would do. She said you should never use more than three squares. Yeah, right....never mind that my sisters and I are personally responsible for a good portion of the planet's deforestation. I just figured"Three-squares-per-wipe" must have been a Depression-era slogan. Did they ration toilet-paper in the Depression?

It has been my deepest belief from the time I entered the hallowed world of emergency nursing that assistance with elimination of solid waste from the body did not fall into the realm of the emergent assignation. In other words:

ENEMAS ARE NOT A FUNCTION OF THE EMERGENCY DEPARTMENT.

Ever. Period. End of discussion.

Say a patient comes in with abdominal pain. There is no obstruction; no appendicitis. The patient is acutely "FOS" or "full of stool" (feel free to vernacularize). There is no reason the patient cannot be given an oral preparation to initiate the free flow of flatulance. Or given a suppository to use at home. Or an enema preparation to use at home. And don't get me started on soapsuds/tap water enemas. Water in, water out. They aren't worth the H2O they are printed on and are a waste of emergency department time and resources.

Yes, I am passionate about this.

Now, what about the patient who presents with the chief complaint of "Constipation" ? They are literally sitting in triage because their regularity has been disrupted for, oh, what...TWO DAYS? Maybe three? Did they call their doctor. No. Did they try anything at home first? No.
And the ultimate response: I called my doctor and he/she said to come to the emergency room. (!!!!)

A pox upon that doctor's house.

Emergency room doctors feel they must do something so they order enemas. Do they understand that anything other than a Fleets takes up valuable ER nursing time? The patients can do it themselves at home. It can be done at a nursing home. It can be done as an inpatient if that is where they are headed. While the nurse is working in the land where-the-sun-don't-shine, their other patients are not getting EKGs, labs, meds or anything else. Or worse, because enemas are not a priority, the constipated patient waits and waits until all urgent/STAT/god knows what else is taken care of. And then they are miffed and beg to go home and then write to the head of the ER about how long they had to wait with their non-urgent problem. There goes the Patient Satisfaction rating....

I wonder how many enemas would be ordered if they had to be done by the ER doctors?

Of course, the patients never know this. They are "enema-ized" as ordered. I always tell them that I understand it is uncomfortable and not to be embarrassed, we deal with it all the time and they will feel better soon. Then at discharge we discuss how they can keep it from happening again.

But everything I do for them could have been done at home. For a lot less than $1000 plus dollars. For about the price of a Fleets, actually.

Give me a freakin' break.

Burning Down the House

What did YOU accomplish this morning? I managed a cup of coffee, my email and some blog reading, as a matter of fact! I don't even read newspapers anymore. I sit with my cup of coffee, curled up on the couch with 2-3 cats and my laptop. When you write your blog, remember that someone may be reading it with their mouth full and don't write anything that makes them spray it all over the monitor! Nothing like a "spit-take" to start your day....

I was thrilled to find a copy of this ad. If I could, I'd get a paper copy and have it matted and framed. I first saw it while suffering from an overpowering case of burnout many years ago. It helped me refocus on why I was a nurse; it gave me a sense that what I did with my life was important.

I knew I had crossed the line into severe, pathological burnout when I was standing at my kitchen sink and heard an ambulance in the distance. I put down the dish towel, turned around with my hands on my hips, surveyed my house and thought, "...now where am I going to put them?" It sounds comical to me now, but at the time it was the final straw in a deep downslide into the world of the burnt-out nurse.......

The term "burnout" gets tossed around very lightly but it can be a serious, depressive state. Your soul is a black hole. You have absolutely nothing left to give anyone, you're hollow. It takes every ounce of your strength to move your 5000 pound arms. You're an emotional zombie giving an eight-hour "performance" five times a week during which you smile and "act" like a nurse. When the curtain comes down you leave the stage of your unit, numb. You're on the verge of tears, but they never come. Your chest is heavy and breathing almost too much trouble. There is no enjoyment of time off because you dread the next shift - even if it is two days away. You feel trapped, without options. The world is siphoning off your will to function. I hated nursing.

That was me in 1987. I had it bad.

Here are a few suggestions based on my experience.

• Don't overwork.
  

• Double shifts, double backs, extra shifts and long stretches will take a cumulative toll on your body and your psyche. It's one thing to help out occasionally but there are hospitals out there that will want you every single day for one hole in the schedule or another.
  

• Learn to say no. Practice it. It's hard to say no to "The Call" when you have nothing planned but relaxation for the day, but you can't be all things to all people all the time. The sooner you realize that the better.

• Mark yourself as "unavailable" or "N/A" on the schedule to decrease the chance you will get a call.

• If you can't say no, get a message machine and screen your calls. If you are not available, don't answer it.

• The extra pay is nice, but it isn't worth your mental health. And you know what? After awhile it's the law of "diminishing returns" - meaning that most of that pay goes to taxes anyway!
  

• If you do work extra or do a double shift, try to negotiate comp time, i.e. another day off if you pick up the extra.
  

• Take advantage of flexible schedules and creative uses of holidays and paid-time-off to give yourself "mini-vacations" on a regular basis, short stretches of time off that you can look forward to.
  

• Realize that you have options.
  

• The flexibility of nursing is its best asset. Take advantage of it. Feeling restless, bored, empty, depressed?
  

• Change your hours, your shift. Look at what other facilities are offering. Better hours? Better pay? Weekends only? No weekends? Less commute? More challenge? Less stress?
  

• Realize that one position may not fit your needs, or your lifestyle for your entire career. Don't be afraid to explore, to step out and try new areas/specialties.

• We are being actively recruited. New graduates are being accepted into specialty preceptorships and experienced nurses are highly sought after.

• A wide variety of experiences makes you even more desirable to nursing employers.
  

• Take care of yourself. It's not a cliche. If you are sleep deprived and eating poorly your ability to cope with the stress of nursing will be greatly diminished. If you aren't physically healthy your mental health will suffer.

Burnt? I was crispy fried, folks.

Without making it too simplistic, I was able to work my way out of the pit of my burnout-that-lead-to-depression by following the points above, working with a counselor and in my case, using a brief period on antidepressants. It worked. I regained my passion for nursing and more importantly I was able to feel compassion for my patients. I could care again.

My advice? If you start to feel the twinges of burnout, take steps to stop it STAT.

It is much easier to avoid burnout than it is to cure it.

The Call of the Nurse

Having worked as a psychiatric nurse, I'm very interested in the field of mental health. Dr. Deborah Serani , a psychologist (and blogger) specializing in trauma and depression, reminds us that this week is Mental Health Awareness Week. Check out her blog at the link above for information on the National Depression Screening Day scheduled for October 6, 2005 (today!) in locations in both the United States and Canada.

hhhhhhhhhhhhhhhhhhhhhhhhhhhhhh

Well that was interesting! I hit the "h" key in the "Webdings" font and it was an ambulance! How appropo!

In my search for nursing ephemera I've found many images and slogans. Some are funny, some are serious. Some are just plain corny. I was attracted to this poster because it speaks of finding self through service to others; a rather profound philosophy to sum up in one sentence.

I have always felt that nursing was a "calling", that the urge to care for the sick and the ability to do so was a gift from God. Everything I did, every class I took from the age of nine onward was geared to accomplish the goal of being a registered nurse. Without deviation. How many nine-year-olds are that focused? I was writing to diploma programs for catalogs by the time I was ten. I could not believe I was accepted to the first program I applied to, nearly just out of high school. As I entered the field and worked as a nurse there were times I fought it, times I hated it, times I wished I could do anything else, but instinctively I always knew that it was what I was supposed to be doing with my life.

So it was illuminating to find out that this was not the standard experience of other nurses!
Interestingly, some men I know, who chose nursing as a second or third career, were attracted to the pay, the job security and the flexibility of hours. No sense of a "calling" there at all. Hmmm. What about the women? Well, one says she can't remember a time that she didn't want to be a nurse but never felt it was any kind of a spiritual calling. Another had such a wretched experience watching incompetent nurses deal with the death of a relative that as a teenager she thought, "I can do better". And she does! She is a great nurse, loves her job, but never thought of it as a "calling" per se. My last "interviewee" said she made the decision at the age of 18 but it was a rational decision to focus on that area of study. No "calling" involved.

So gee, is it just me? These old posters and vintage photos depict nursing as a "noble" profession; maybe I was just born 20 years too late or never got over my "CherryAmesItis". I know it was never addressed in my training. No classes on the history of nursing or the contributions of nurses to society. The more modern recruitment campaigns ("If caring were enough, anyone could be a nurse." ) surely don't focus on it. And compare this ad to the one above. "Because I'm A Nurse"? What, I can stand there with my arms crossed looking like a
bad-ass-don't-mess-with-me chick? This poster was up in our ER and I was trying to understand what the message was.

It certainly wasn't about finding yourself through caring for others.

Someone who is into nursing only for the money, the benefits, the hours and the flexibility won't last a year in this profession. They had better be into nursing for the patients because that is where the entire heart of the profession resides. I would like to see this fact mirrored in the recruitment drives because while there are wonderful, tangible benefits to the job, it's the ability to care and to translate that care into action that makes the profession a vocation. Because it isn't true that if caring were enough, anyone could be a nurse.

It takes a unique person to "care" the way a nurse cares.

R-E-S-P-E-C-T

This gem of a shot is by photographer Ewing Galloway.

This is exactly how I felt at work tonight. I had exactly four patients. Four. One was a 1:1 for 3.5 hours. Every one of them had the "short of breath = rectal sphincter discharge" syndrome. I haven't changed that many diapers since my 15-year-old was born. Someone snuck a puppy into the ER and he sniffed me once and growled.
I swear the olfactory ambiance of my room had permeated my clothing. I suspected my co-workers were avoiding the geographical area of my assignment, but it's pretty bad when a dog withdraws from you.

I'm pretty even-tempered but I daresay I was a bit snappy tonight (at the desk, never in front of my patients). So it is ironic that this photo describes me because when I first saw it I immediately thought of a cranky doctor! Actually, I thought of many cranky doctors. Then I realized that I had witnessed a trend over the years; a decrease in the number and intensity of cranky doctors. Why?

Here are a few factors that have contributed:

• Doctors and nurses have a more collegial relationship now. "ME-DOCTOR-you-nurse" is no longer the predominant attitude of either profession. This is likely due to:

• More women in medicine and more men in nursing. The old male/female paradigm has changed.

• The increased responsibilities nurses have in patient care. (Nursing: it's not just pill-passing anymore, folks!)

• The need to do more with less; doctors have to increasingly depend on nurses to be their eyes and ears at the bedside.

• The youth of the medical workforce. They've never known nurses any other way (see above). And it is just me, or are the doctors getting younger every day? When you are old enough to be the mother of a doctor you work with....well, it's very strange!
  

• The aging of the nursing workforce. A nurse who has been in the trenches for 30 years is not likely to put up with an attitude from anybody, including doctors (of any age).

• A mutual understanding that we are all working under the same health care system and that the frustrations that arise are due to the system, not each other.

On a personal level, I have developed an increasing amazement for what doctors have to accomplish to get to where they are. And you know what's funny? Space is at a premium in my department so I'll give a doctor who needs to chart my seat at the nursing station. Not because I have to, but out of civility and respect.

Cherry Ames would be proud.

Gratuitous Journey

What on earth does this picture have to do with emergency nursing, you ask? Well, one of these people happens to be yours truly. The other one is Jonathan Cain of Journey. The nursing profession may have my soul, but rock and roll has my gut and my heart belongs to Journey. At the moment I am hearing impaired, barely able to talk due to laryngitis and so sore I can hardly change positions. Such are the health risks of dancing and singing for three hours in fourth-row-center seats at a Journey concert.

Now, having posted this gratuitous photo and revealed my private life as a secret rock groupie, I now return you to my regularly scheduled blog.

One Of These Things Is Not Like The Other

.......Let us bow our heads in a moment of respectful silence for the football team of Purdue University, Indiana, who got their gluteus maximi KICKED by the Fighing Irish of Notre Dame!!!! Whooo hoooo! Apparently Purdue gave a football game and the team forgot to show up (figuratively speaking). NOTRE DAME ROCKS!!!!
(silence)
To those who are students or alumni of Purdue, my sympathies. Go Irish......



You can be a Trained Nurse. As opposed to what, an untrained nurse? This reminds me of something one of my nursing instructors said to me during my very first quarter of nursing school. Claudia was the epitome of the tall, cool professional. I secretly wanted to be just like her when I grew up (and I mean "grew up"...I was 18). My partner and I had managed to make a hospital bed within the required five minutes during our first skills lab and I joked, "....another exciting development in medical science". She immediately informed me that it was nursing science, separate and distinct from medicine. So I said, "...okay, another exciting development for nurses' training!" At which point she intoned that dogs are trained, nurses are educated. Well, I felt like an idiot but I never forgot what she said.

This came back to me recently as I listened to a group of my colleagues try to talk a pre-med student into nursing instead of medicine. They brought up many arguments. Nursing school could take as few as two or three years instead of eight (including residency). Nurses can work part-time with benefits. The pay is good. You can work in many different areas during your career as opposed to specializing in just one. Okay, all of those things are true...but then they said that nursing was easier; why go through all the bull of medical school when nursing was so....doable? After I picked my jaw up off the desk, I had to open my mouth.

I told the student that becoming a nurse was only the right thing to do if she wanted to practice nursing. Yes, they are related, but medicine and nursing are not the same profession. Nursing isn't something you do if you don't feel like going to medical school. I asked her what she wanted to study. Did she want to focus on the diagnosing and treatment of illness? Did she want to care for patients, assessing, planning, implementing and evaluating their responses to their treatment, both physical and emotionally on a daily basis? Doctors see their patients sporadically. Nurses spend up to twelve hours at a time with those same patients. Doctors set up the medical plan of care. Nurses set up a nursing care plan that supports and enhances the patient's ability to heal, that recognizes and helps the patient cope with the impact of the diagnosis in all areas of their life.

Well, that sort of threw a bucket of water on the conversation, but I thought I should say something. I'm all for recruiting nurses, but not by promoting it as a second-choice to medical school. Nursing is its own discipline.

Gee, I guess I grew up to be a little like Claudia, after all.