Not that you need to know but I just returned from a long, much needed vacation. A month away from work yet paid, barbaric in its paucity by European standards, does a wage-laborer good.
I mention Europe only because that's where I went, traveling among a couple of the heathen national health countries of the U.K.--you know, the one's that have greater life expectancy than the U.S. and a greater percentage of the population with access to quality health care.
But let's not pick nits (unless you have lice...)
And what did I get for my travels? Pneumonia.
But since I'm still up and about, the popular term would be walking pneumonia, as if the infiltrate in my left lower lobe has sprouted legs and become a peripatetic infection!
No, it's just pneumonia. Probably been living too high. What are vacations for?
Monday, July 7, 2008
Saturday, June 7, 2008
None of This Has Anything to Do with Nursing
The hospital at which I work is much more than just a building. It is a bureaucratic organization of interrelated statuses and roles stratified upon a hierarchy of authority and power coordinated to provide health care to our community. Most members of the community only see the end result. When they are sick or injured, they come to us and we care for them.
What the community doesn't see or see often is the corporate culture embraced by some elements of the organization. This culture is characterized by all the slap and tickle, buzzwords, and managerial guru crap popular in corporate culture these days. Some at my hospital are completely ga-ga for it.
Take for instance their newest corporate embrace, a program supposedly designed to "hardwire excellence," whatever that means. (Don't ask them, unless you want to be drowned in a sea of corporate cliches, 7 habits, and all those cool folks you're supposed to meet in heaven!)
The program is the infamous source of the low-middle-high performance assessment tool. And what a handy tool it is...for determining not so much the worth of employees as their allegiance to corporate authority and their willingness to agree with and align their own interests with managers and administration, even against their own ethics and best interests.
Fully 75% of the assessment tool in this program is subjective! Questions like, how much does this employee accept and support the decisions of his/her managers? How comfortable do I (the boss) feel when this employee is on shift? What is the attitude of the employee toward his/her workplace, manager, administration?
Now, if ours was a totalitarian organization, I could see where these questions might truly reflect the value of an employee. Or at least ferret out those who need to be eliminated. But, let's be honest, these questions have very little to do with how well an employee does his/her job!
Objective questions could do that, and would be easier to defend as a true performance assessment, while keeping the subjectivity of like and dislike out of it. Why wouldn't a health care organization that wants to provide quality nursing services be more interested in how well nurses perform rather than how well they mouth the words of the corporate line (for they really don't want nurses to say anything)?
One reason is that an assessment tool of objective criteria of nursing performance is harder to devise than one based on subjectivity. You can't really get it out of a guru's book, and I'm not sure that they are smart enough to do it themselves.
A second reason has more to do with the manner in which the subjective assessment tool can strike fear into the workplace of those who have it used capriciously against them (see the most recent two entries). No objective criteria to tell me I'm a bad nurse? Just tell me I have a negative attitude! That's a great reason to fire a good nurse, despite this era of nursing shortages.
Of course, as I mentioned in the last entry, the low-middle-high assessment tool is a one way street: those at the top evaluate those underneath them, and never have to be evaluated by them. That means, the top dog is the one whose attitude and belief system is what everyone else in the organization has to agree with or at least espouse, at least at work. But the top dog isn't the pope, doesn't wear a funny hate, and isn't infallible. Excellence hardwired doesn't seem to account much for that fact.
And, if you're not the top dog, don't go mentioning it; you'll be labeled a low-performer.
What the community doesn't see or see often is the corporate culture embraced by some elements of the organization. This culture is characterized by all the slap and tickle, buzzwords, and managerial guru crap popular in corporate culture these days. Some at my hospital are completely ga-ga for it.
Take for instance their newest corporate embrace, a program supposedly designed to "hardwire excellence," whatever that means. (Don't ask them, unless you want to be drowned in a sea of corporate cliches, 7 habits, and all those cool folks you're supposed to meet in heaven!)
The program is the infamous source of the low-middle-high performance assessment tool. And what a handy tool it is...for determining not so much the worth of employees as their allegiance to corporate authority and their willingness to agree with and align their own interests with managers and administration, even against their own ethics and best interests.
Fully 75% of the assessment tool in this program is subjective! Questions like, how much does this employee accept and support the decisions of his/her managers? How comfortable do I (the boss) feel when this employee is on shift? What is the attitude of the employee toward his/her workplace, manager, administration?
Now, if ours was a totalitarian organization, I could see where these questions might truly reflect the value of an employee. Or at least ferret out those who need to be eliminated. But, let's be honest, these questions have very little to do with how well an employee does his/her job!
Objective questions could do that, and would be easier to defend as a true performance assessment, while keeping the subjectivity of like and dislike out of it. Why wouldn't a health care organization that wants to provide quality nursing services be more interested in how well nurses perform rather than how well they mouth the words of the corporate line (for they really don't want nurses to say anything)?
One reason is that an assessment tool of objective criteria of nursing performance is harder to devise than one based on subjectivity. You can't really get it out of a guru's book, and I'm not sure that they are smart enough to do it themselves.
A second reason has more to do with the manner in which the subjective assessment tool can strike fear into the workplace of those who have it used capriciously against them (see the most recent two entries). No objective criteria to tell me I'm a bad nurse? Just tell me I have a negative attitude! That's a great reason to fire a good nurse, despite this era of nursing shortages.
Of course, as I mentioned in the last entry, the low-middle-high assessment tool is a one way street: those at the top evaluate those underneath them, and never have to be evaluated by them. That means, the top dog is the one whose attitude and belief system is what everyone else in the organization has to agree with or at least espouse, at least at work. But the top dog isn't the pope, doesn't wear a funny hate, and isn't infallible. Excellence hardwired doesn't seem to account much for that fact.
And, if you're not the top dog, don't go mentioning it; you'll be labeled a low-performer.
Friday, June 6, 2008
Labor Remembers (For P.R.)
On a more somber note, the same administrative players who attempted to terminate me turned around and did the same number on my boss, the ER director. Oddly enough, one of their complaints about her, what they say made her such a "low performing" manager, was that she failed to leave a paper trail long and deep enough for them to fire me without fear of a wrongful termination lawsuit.
Of course, they didn't say it in so many words.
The fact that both events occurred within the same week and the fact that it was the CNO's last week of employment in the organization suggests to me that both were attempted hatchet jobs. The fact that the CNO chose her last day and her last two hours of work to attempt to discipline my ER boss suggests that she (the CNO), and not my boss, had done her job poorly.
Think about it.
You are the Chief Nursing Officer in an organization, the tallest hog at the RN trough, and yet you tolerate and fail to reprimand two "negative" and "malcontent" nursing employees for almost two years, waiting only until your last week on the job to do anything about their "divisive" behavior? Talk about a bad manager! Low performer, indeed!
But Idaho is a "right-to-work" state (read: right to be fired at will for any reason at all) and so I guess you don't have to be good at managing or administrating in order to fire an employee any time you want to, regardless of whether or not you've followed your own organizational policies (which, in fact, in my case, they didn't). Power seems to be the administrative remedy for lack of competence, finesse, or adherence to organizational rules.
My boss and I took different paths, however. I chose to fight back and keep my job. My boss chose to tell the CEO (for the CNO had already cut and run) to take the job and their evaluation of her and shove 'em.
I respect her for that, and for sticking up for me when she did. Just goes to show, the ethical aren't always the winners, and those at the top who think they've won aren't always ethical, or winners.
In fact, if I had to rate their administrative performance, I'd say they're pretty low performers because they really made a mess out of this. Not only am I still an employee, but now the ER is in shambles for lack of a director. Makes me wonder who is the greater threat to the organization's ability to meet its stated goal of quality and compassionate health care.
Of course, they didn't say it in so many words.
The fact that both events occurred within the same week and the fact that it was the CNO's last week of employment in the organization suggests to me that both were attempted hatchet jobs. The fact that the CNO chose her last day and her last two hours of work to attempt to discipline my ER boss suggests that she (the CNO), and not my boss, had done her job poorly.
Think about it.
You are the Chief Nursing Officer in an organization, the tallest hog at the RN trough, and yet you tolerate and fail to reprimand two "negative" and "malcontent" nursing employees for almost two years, waiting only until your last week on the job to do anything about their "divisive" behavior? Talk about a bad manager! Low performer, indeed!
But Idaho is a "right-to-work" state (read: right to be fired at will for any reason at all) and so I guess you don't have to be good at managing or administrating in order to fire an employee any time you want to, regardless of whether or not you've followed your own organizational policies (which, in fact, in my case, they didn't). Power seems to be the administrative remedy for lack of competence, finesse, or adherence to organizational rules.
My boss and I took different paths, however. I chose to fight back and keep my job. My boss chose to tell the CEO (for the CNO had already cut and run) to take the job and their evaluation of her and shove 'em.
I respect her for that, and for sticking up for me when she did. Just goes to show, the ethical aren't always the winners, and those at the top who think they've won aren't always ethical, or winners.
In fact, if I had to rate their administrative performance, I'd say they're pretty low performers because they really made a mess out of this. Not only am I still an employee, but now the ER is in shambles for lack of a director. Makes me wonder who is the greater threat to the organization's ability to meet its stated goal of quality and compassionate health care.
Sunday, June 1, 2008
Nursing Interventions for Corporate Amnesia
"I am not a critical person by nature."
I said this a lot when I was in graduate school studying sociology. My friends noticed about me a propensity to be hyper-critical when it came to examining the hypocrisy and unfairness of power structures. In saying this about myself, my point was that it is not natural to be so critical...one has to learn the skill. I learned it well.
No longer a social scientist by trade, I have not been able to shake off the critical legacy of those years. Even as a nurse, when faced with bureaucracy, hierarchy, and corporatism, I tend to revert to my sociological underpinnings to reveal the negative aspects of these realities in my workplace.
Others around me--nurses and administration--don't seem to understand this, and I am not sure why. Wouldn't my nursing and my understanding of the organizational context within which I do it be different if I brought to it a different background: literature, law, mortuary science? Of course.
In short, some don't understand why I think about such things. More specifically, administration does not understand why I, as a nurse, think at all.
Recently, I was fired. Ostensibly, the reason for the termination was said to be "insubordination," a euphemism (in my opinion) for having a different opinion.
In fact, the reasons stipulated on the disciplinary action plan that they eventually agreed to after tempting me to voluntarily resign rather than face termination, had more to do with subjective interpretations of my words and attitudes than they do any objective assessment of my nursing skills, performance, or any realistic "threat" I present to the administration or the organization, in general.
Ironically, the overall attitudinal problem they seem to think I have is that of believing the organization is divided into two main groups, nursing staff and administration, and that when problems arise, this division often plays out as a "them versus us" scenario. Ironic because the very concept they accuse me of believing and espousing (at times) is the reality they were using to try to eliminate me as an employee!
As Yosarian said, "That's some catch, that Catch-22!"
Okay. Am I a member of the same bureaucratic organization as they are? Does the same hierarchy of power exist in their world as mine? Does one's position--them on the top, me/us near the bottom--really blind one to an understanding of the nature of authority and the perceived inviolability of command?
What dream world do they live in?
I once heard--and I think E. P. Thompson, the famous English labor historian originally said it--that the real difference between owners and workers, between corporations and labor unions, is that the latter have memory while the former exhibit selective amnesia. In corporate hospital culture, even though in this case it is a non-for-profit corporation, the same is true.
How else to explain how the CEO and CNO can tell me I'm fired one day and then several days later confront me with smiles on their faces, wanting to chat about how things are in my life? If they are just trying to save face, I wonder what sort of face they see in the mirror.
Call it my negative attitude, call it my dark humor, call it my knee-jerk reaction to authority. But don't sweep it under the rug! Challenge me, make me explain myself, TELL ME I'M WRONG!!!
No. It's easier for them to say I'm rude or sarcastic...so much easier than saying I'm mistaken, or wrong, or a bad nurse.
What is the cure for this corporate amnesia? Learn to be critical, learn to be honest, learn to speak truth to power. That's what I've tried to do with my life. I did it when I was a social scientist; I'll do it now as a nurse. For I didn't leave everything behind when I became a nurse.
Wonder why they don't understand this?
I said this a lot when I was in graduate school studying sociology. My friends noticed about me a propensity to be hyper-critical when it came to examining the hypocrisy and unfairness of power structures. In saying this about myself, my point was that it is not natural to be so critical...one has to learn the skill. I learned it well.
No longer a social scientist by trade, I have not been able to shake off the critical legacy of those years. Even as a nurse, when faced with bureaucracy, hierarchy, and corporatism, I tend to revert to my sociological underpinnings to reveal the negative aspects of these realities in my workplace.
Others around me--nurses and administration--don't seem to understand this, and I am not sure why. Wouldn't my nursing and my understanding of the organizational context within which I do it be different if I brought to it a different background: literature, law, mortuary science? Of course.
In short, some don't understand why I think about such things. More specifically, administration does not understand why I, as a nurse, think at all.
Recently, I was fired. Ostensibly, the reason for the termination was said to be "insubordination," a euphemism (in my opinion) for having a different opinion.
In fact, the reasons stipulated on the disciplinary action plan that they eventually agreed to after tempting me to voluntarily resign rather than face termination, had more to do with subjective interpretations of my words and attitudes than they do any objective assessment of my nursing skills, performance, or any realistic "threat" I present to the administration or the organization, in general.
Ironically, the overall attitudinal problem they seem to think I have is that of believing the organization is divided into two main groups, nursing staff and administration, and that when problems arise, this division often plays out as a "them versus us" scenario. Ironic because the very concept they accuse me of believing and espousing (at times) is the reality they were using to try to eliminate me as an employee!
As Yosarian said, "That's some catch, that Catch-22!"
Okay. Am I a member of the same bureaucratic organization as they are? Does the same hierarchy of power exist in their world as mine? Does one's position--them on the top, me/us near the bottom--really blind one to an understanding of the nature of authority and the perceived inviolability of command?
What dream world do they live in?
I once heard--and I think E. P. Thompson, the famous English labor historian originally said it--that the real difference between owners and workers, between corporations and labor unions, is that the latter have memory while the former exhibit selective amnesia. In corporate hospital culture, even though in this case it is a non-for-profit corporation, the same is true.
How else to explain how the CEO and CNO can tell me I'm fired one day and then several days later confront me with smiles on their faces, wanting to chat about how things are in my life? If they are just trying to save face, I wonder what sort of face they see in the mirror.
Call it my negative attitude, call it my dark humor, call it my knee-jerk reaction to authority. But don't sweep it under the rug! Challenge me, make me explain myself, TELL ME I'M WRONG!!!
No. It's easier for them to say I'm rude or sarcastic...so much easier than saying I'm mistaken, or wrong, or a bad nurse.
What is the cure for this corporate amnesia? Learn to be critical, learn to be honest, learn to speak truth to power. That's what I've tried to do with my life. I did it when I was a social scientist; I'll do it now as a nurse. For I didn't leave everything behind when I became a nurse.
Wonder why they don't understand this?
Thursday, May 8, 2008
Follow-up Care
The other day a former-ER patient called and asked for Ed. I told him that there is no one named Ed who works in the ER.
He seemed confused and flustered. He also sounded intoxicated.
Often, patients call to follow up on discharge instructions, or to ask questions about what they are supposed to do next to take care of themselves.
So, I asked the patient the nature of his call and the nature of his original complaint, and I attempted to verify whether or not he was taking his prescribed medications properly, one of which was a narcotic pain reliever.
After speaking with him for about five minutes, I realized that he was taking about twice as much pain medication as he should have been. He admitted to drinking alcohol as well, something I immediately advised him not to do while taking narcotics. Then I reiterated that he should not drive or operate machinery, given the potentially dangerous combination of intoxicants he was taking.
Eventually, I had addressed as many of his issues as I could over the phone and I told him if he felt he needed to be re-seen by an ER physician we would be glad to see him again.
He replied, "Thanks. Are you sure Ed isn't there?"
"Sir, I've already told you there is no Ed in our department. Who told you to ask for Ed?"
"It's on my discharge instructions...If problems persist, call Ed."
Silence.
"E-D, sir. As in, Emergency Department."
He seemed confused and flustered. He also sounded intoxicated.
Often, patients call to follow up on discharge instructions, or to ask questions about what they are supposed to do next to take care of themselves.
So, I asked the patient the nature of his call and the nature of his original complaint, and I attempted to verify whether or not he was taking his prescribed medications properly, one of which was a narcotic pain reliever.
After speaking with him for about five minutes, I realized that he was taking about twice as much pain medication as he should have been. He admitted to drinking alcohol as well, something I immediately advised him not to do while taking narcotics. Then I reiterated that he should not drive or operate machinery, given the potentially dangerous combination of intoxicants he was taking.
Eventually, I had addressed as many of his issues as I could over the phone and I told him if he felt he needed to be re-seen by an ER physician we would be glad to see him again.
He replied, "Thanks. Are you sure Ed isn't there?"
"Sir, I've already told you there is no Ed in our department. Who told you to ask for Ed?"
"It's on my discharge instructions...If problems persist, call Ed."
Silence.
"E-D, sir. As in, Emergency Department."
Monday, April 21, 2008
Types of Patients XI: Animal Bites
I've already mentioned the mandate that ER nurses notify law enforcement when we have reasonable suspicion that a crime may have been committed. As well, a reader's comment mentioned the interest of public safety in such reporting. This is never more true than in the case of wounds caused by animal bites.
Regardless of whether or not an animal bite constitutes a crime, reporting such events to law enforcement or to public health is essential to avoid the possibility that a menace to public safety is left unchecked. The menace might be a mean dog (provoked or not), a feral cat, or (and, yes, I have seen this) a vicious squirrel, etc.
The purpose of mandatory reporting of animal bites is not punitive; it is to improve public safety. Whereas cases involving pet owners (e.g., pet dog bites passing neighbor) may seem to be predicated upon sanctions--for the owner and the pet--in fact, very few responsible pet owners are prosecuted if they do the right thing by their pet and by the public (i.e., up-to-date vaccinations, payment of damages, hospital expenses, etc.) and few end up losing their pet.
Irresponsible pet owners suffer more. These are the owners who don't vaccinate their animals, don't attempt to train them, and usually don't put much stock in animal restraints. In fact, some owners of this ilk actually intend to produce vicious animals mostly for the purpose of protecting property.
Mandatory reporting does not require that I as an ER nurse investigate or understand the reasons for the incident. I leave that to law enforcement. As I told one dog bite patient who didn't want me to notify the police about the neighbor's dog that attacked him because he thought it was his (the patient's) fault: "What if you were a four year old child?"
And I've seen four year old children scarred for life in just this way. I do not pretend to know that it is somebody's fault. Many of these incidents are, in fact, accidents. Mandatory reporting intends to minimize the repetition of such "accidents" in the same way that mandatory seat belt laws intend to save lives.
The ABCs:
A -- Most animal bite victims have injuries to extremities; therefore, airway is usually not a problem.
B -- For similar reasons, breathing is usually not an issue either unless there exists some sort of co-morbidity, such as asthma, attacks of which can be exacerbated by the intensity or ferocity of the animal attack.
C -- But bleeding can be an issue. Like other bleeding injuries, animal bites require direct pressure to stop bleeding. Tourniquets are ill-advised unless used as a last resort.
Animal bites also require copious wound care. Wound irrigation. Closing the wounds either by sutures, staples, steri-strips, or occlusive dressings. And antibiotic administration (either oral or IV) to prevent further adventitious infections.
And lastly, because animal bites represent a disruption in skin integrity, tetanus vaccination status must assessed, discerned, and updated if necessary.
No one likes being bit by an animal, domestic or wild. And very few pet owners like to hear that their pet bit someone. I don't really like reporting such incidents to law enforcement, but I do because I realize it might be my child next time, and the bite might not be so very innocent.
Regardless of whether or not an animal bite constitutes a crime, reporting such events to law enforcement or to public health is essential to avoid the possibility that a menace to public safety is left unchecked. The menace might be a mean dog (provoked or not), a feral cat, or (and, yes, I have seen this) a vicious squirrel, etc.
The purpose of mandatory reporting of animal bites is not punitive; it is to improve public safety. Whereas cases involving pet owners (e.g., pet dog bites passing neighbor) may seem to be predicated upon sanctions--for the owner and the pet--in fact, very few responsible pet owners are prosecuted if they do the right thing by their pet and by the public (i.e., up-to-date vaccinations, payment of damages, hospital expenses, etc.) and few end up losing their pet.
Irresponsible pet owners suffer more. These are the owners who don't vaccinate their animals, don't attempt to train them, and usually don't put much stock in animal restraints. In fact, some owners of this ilk actually intend to produce vicious animals mostly for the purpose of protecting property.
Mandatory reporting does not require that I as an ER nurse investigate or understand the reasons for the incident. I leave that to law enforcement. As I told one dog bite patient who didn't want me to notify the police about the neighbor's dog that attacked him because he thought it was his (the patient's) fault: "What if you were a four year old child?"
And I've seen four year old children scarred for life in just this way. I do not pretend to know that it is somebody's fault. Many of these incidents are, in fact, accidents. Mandatory reporting intends to minimize the repetition of such "accidents" in the same way that mandatory seat belt laws intend to save lives.
The ABCs:
A -- Most animal bite victims have injuries to extremities; therefore, airway is usually not a problem.
B -- For similar reasons, breathing is usually not an issue either unless there exists some sort of co-morbidity, such as asthma, attacks of which can be exacerbated by the intensity or ferocity of the animal attack.
C -- But bleeding can be an issue. Like other bleeding injuries, animal bites require direct pressure to stop bleeding. Tourniquets are ill-advised unless used as a last resort.
Animal bites also require copious wound care. Wound irrigation. Closing the wounds either by sutures, staples, steri-strips, or occlusive dressings. And antibiotic administration (either oral or IV) to prevent further adventitious infections.
And lastly, because animal bites represent a disruption in skin integrity, tetanus vaccination status must assessed, discerned, and updated if necessary.
No one likes being bit by an animal, domestic or wild. And very few pet owners like to hear that their pet bit someone. I don't really like reporting such incidents to law enforcement, but I do because I realize it might be my child next time, and the bite might not be so very innocent.
Thursday, April 10, 2008
Deathday?
Why does our society not have a specific term that refers to recognizing the anniversary of a person's death?
Anniversary generally refers to marriage. Birthday, of course, refers to just that. But we have no term expressing our commemoration of the day a person died.
Perhaps it is because death is sad, and we don't want to acknowledge our sadness over someone's death in a public way year after year, as we would celebrate birthdays and anniversaries.
Perhaps it is because death is fearful, and recognizing the passing of others on a yearly basis in a public way reminds us too much of our own mortality. But some other cultures do. The Mexican Day of the Dead is a very good example.
Perhaps it is simply the harsh, guttural alliteration of a term like "deathday."
To be sure, it is not a festive event to memorialize the day a loved one left this world. But it is fitting and respectful.
Today is the deathday of my friend and co-worker, A.R., in 2001. I want to always remember this day and all the days before that I knew her.
Anniversary generally refers to marriage. Birthday, of course, refers to just that. But we have no term expressing our commemoration of the day a person died.
Perhaps it is because death is sad, and we don't want to acknowledge our sadness over someone's death in a public way year after year, as we would celebrate birthdays and anniversaries.
Perhaps it is because death is fearful, and recognizing the passing of others on a yearly basis in a public way reminds us too much of our own mortality. But some other cultures do. The Mexican Day of the Dead is a very good example.
Perhaps it is simply the harsh, guttural alliteration of a term like "deathday."
To be sure, it is not a festive event to memorialize the day a loved one left this world. But it is fitting and respectful.
Today is the deathday of my friend and co-worker, A.R., in 2001. I want to always remember this day and all the days before that I knew her.
Wednesday, April 9, 2008
HEC
With all the acronyms and CorporateSpeak in the health care industry these days, I sometimes wonder if any of us health care workers will ever speak in plain, unabbreviated English again. From the look of the work place project in which I am now involved, it doesn't seem so.
Our ER is preparing to change from a paper-based patient charting system to an electronic medical record (EMR). The project is called HEC (Healthcare Electronic Charting), and the program template that has been presented to us by the corporate provider (to remain nameless for obvious reasons) is filled with acronyms and some very bad grammar. The corporate representatives (I call them THEM) don't seem to be bothered by this.
Both of these facts, that the template is so poorly written AND that the corporate people don't seem to care, infuriate me. Together, THEM and a group of my co-workers and I spent two days looking at the template, THEM doing their corporate slap and tickle and me getting more and more frustrated the whole wasted time.
When I was a college professor (see entry 8/25/2007) I was sometimes confronted by students who did not think I should correct their spelling, grammar or punctuation because, after all, "this isn't an English course." Apparently, I was one of those mean, unreasonable professors who demanded students be as accountable for the accuracy of their expression as for the quality of its content.
I'm finding similar problems in the HEC project.
The most important issue I see in contemplating and preparing for a change from paper to computer charting is whether or not the electronic medium will improve charting. Two subcategories of this issue are efficiency and quality, and therefore, two questions need to be answered positively.
1) Will electronic charting increase the ease and speed with which charting is accomplished and a completed chart generated?
2) Will electronic charting improve the quality of charts in terms of accuracy and precision?
It is interesting to consider technological development in health care for a moment. Some technologies accomplish the former (efficiency) without affecting the latter (quality). Dictaphones are a good example. Doctors can dictate their charts easier via the device, but the quality of the dictation is only as good as the doctor's ability to communicate.
Other technologies can do both. Automatic sphygmomanometers (blood pressure measurement devices) enable nurses to take successive blood pressure measurements easier (i.e., remotely) and more accurately because of the elimination of subjective differences among human operators.
Will electronic charting accomplish both?
Given what I've seen of HEC, the system has tremendous potential to increase efficiency. Potential. What has to happen is THEM have to stop their corporate mucky-muck yucky-yuck and begin to examine the work methods and rhythms well-established in our ER, what THEM call "nurse work flows" (and I wonder if the mean "floes?"). So far, this has happened minimally, and when I called this to their attention, they looked at me as if I had two heads. Then, relenting a bit, responded in a shocked tone of corporate voice, "That's a good idea."
Glad I thought of it. When do I get paid?
However, also given what I've seen of HEC, I'm not certain that the program will improve the accuracy of charting. Call me anachronistic, call me a language Luddite, but I sense the electronic format THEM have provided us ruins the ability for nurses to express themselves accurately by constraining them to badly worded (and sometimes badly spelled) pre-established charting responses.
One small example.
The template allows us to indicate the Informant who provides the nurse with information about the patient. Informant. Singular. All of the response categories are also consistently singular with one peculiar exception: Parents. Why this is the only plural response category I have no idea.
Do THEM assume that when patients come in with Parent(s) that they always come in with both? In this day and age? Rampant divorce. Custody issues.
I requested that the response category be changed to singular or an S in parentheses be used, and allow the nurse to further indicate whether or not the Parent(s) is/are mother, father, or both. I even thought it might be important to indicate biological versus social parents.
I was told by THEM that the template could not be changed in this way at this time, but in the next version the change will be considered.
I cannot believe that I was they first one to raise such an objection!
Okay, it seems small, but the ramification is that we will be generating potentially inaccurate charts, charts that are considered legal documents! I can't imagine why any health care organization would willingly do this.
We'll see how things turn out. Until then, sitting in meetings with THEM, I feel like I'm really in HEC.
Our ER is preparing to change from a paper-based patient charting system to an electronic medical record (EMR). The project is called HEC (Healthcare Electronic Charting), and the program template that has been presented to us by the corporate provider (to remain nameless for obvious reasons) is filled with acronyms and some very bad grammar. The corporate representatives (I call them THEM) don't seem to be bothered by this.
Both of these facts, that the template is so poorly written AND that the corporate people don't seem to care, infuriate me. Together, THEM and a group of my co-workers and I spent two days looking at the template, THEM doing their corporate slap and tickle and me getting more and more frustrated the whole wasted time.
When I was a college professor (see entry 8/25/2007) I was sometimes confronted by students who did not think I should correct their spelling, grammar or punctuation because, after all, "this isn't an English course." Apparently, I was one of those mean, unreasonable professors who demanded students be as accountable for the accuracy of their expression as for the quality of its content.
I'm finding similar problems in the HEC project.
The most important issue I see in contemplating and preparing for a change from paper to computer charting is whether or not the electronic medium will improve charting. Two subcategories of this issue are efficiency and quality, and therefore, two questions need to be answered positively.
1) Will electronic charting increase the ease and speed with which charting is accomplished and a completed chart generated?
2) Will electronic charting improve the quality of charts in terms of accuracy and precision?
It is interesting to consider technological development in health care for a moment. Some technologies accomplish the former (efficiency) without affecting the latter (quality). Dictaphones are a good example. Doctors can dictate their charts easier via the device, but the quality of the dictation is only as good as the doctor's ability to communicate.
Other technologies can do both. Automatic sphygmomanometers (blood pressure measurement devices) enable nurses to take successive blood pressure measurements easier (i.e., remotely) and more accurately because of the elimination of subjective differences among human operators.
Will electronic charting accomplish both?
Given what I've seen of HEC, the system has tremendous potential to increase efficiency. Potential. What has to happen is THEM have to stop their corporate mucky-muck yucky-yuck and begin to examine the work methods and rhythms well-established in our ER, what THEM call "nurse work flows" (and I wonder if the mean "floes?"). So far, this has happened minimally, and when I called this to their attention, they looked at me as if I had two heads. Then, relenting a bit, responded in a shocked tone of corporate voice, "That's a good idea."
Glad I thought of it. When do I get paid?
However, also given what I've seen of HEC, I'm not certain that the program will improve the accuracy of charting. Call me anachronistic, call me a language Luddite, but I sense the electronic format THEM have provided us ruins the ability for nurses to express themselves accurately by constraining them to badly worded (and sometimes badly spelled) pre-established charting responses.
One small example.
The template allows us to indicate the Informant who provides the nurse with information about the patient. Informant. Singular. All of the response categories are also consistently singular with one peculiar exception: Parents. Why this is the only plural response category I have no idea.
Do THEM assume that when patients come in with Parent(s) that they always come in with both? In this day and age? Rampant divorce. Custody issues.
I requested that the response category be changed to singular or an S in parentheses be used, and allow the nurse to further indicate whether or not the Parent(s) is/are mother, father, or both. I even thought it might be important to indicate biological versus social parents.
I was told by THEM that the template could not be changed in this way at this time, but in the next version the change will be considered.
I cannot believe that I was they first one to raise such an objection!
Okay, it seems small, but the ramification is that we will be generating potentially inaccurate charts, charts that are considered legal documents! I can't imagine why any health care organization would willingly do this.
We'll see how things turn out. Until then, sitting in meetings with THEM, I feel like I'm really in HEC.
Tuesday, April 8, 2008
Soooo, the CAH-lege Kid says... (Part 2)
There seems to be a run of female patients being brought in by friends or ambulance for problems related to over-indulgence in alcohol. Similar to the patient I reported on recently who couldn't believe that alcohol alone would cause her to be unconscious at her sorority, many of these are college-age women...
...like the female patient who returned today to find out about culture results from a urine specimen obtained the night she was brought in by the local police, drunk, an alcohol level of 0.17. I dutifully reported the results.
The young woman asked me if I could tell her the names of the officers who were with her that night. I told her we don't usually document that, but if she told me what they looked like, maybe I would know.
"They were wearing police uniforms."
I think drinking is the least of this college student's concerns...
+++
And for all those who don't believe that obesity is a growing problem (no pun intended), check out the recent article in the NY Times that discusses the need to build different EMS equipment to accomodate large patients...gurneys and ambulances designed to lift and transport patients up to 1600 pounds.
These devices usually cost about 40% more than regular equipment built to accomodate patients within a normal range.
If only obese patients were paying for this extra service, that would be one thing. But all of us pay via the increased cost of service equipment. This means that all of us are disadvantaged by other peoples' poor health and poor eating habits.
Just like with smokers. And I don't see anyone willing to pay more for Smoking versus Non-smoking ambulances!
...like the female patient who returned today to find out about culture results from a urine specimen obtained the night she was brought in by the local police, drunk, an alcohol level of 0.17. I dutifully reported the results.
The young woman asked me if I could tell her the names of the officers who were with her that night. I told her we don't usually document that, but if she told me what they looked like, maybe I would know.
"They were wearing police uniforms."
I think drinking is the least of this college student's concerns...
+++
And for all those who don't believe that obesity is a growing problem (no pun intended), check out the recent article in the NY Times that discusses the need to build different EMS equipment to accomodate large patients...gurneys and ambulances designed to lift and transport patients up to 1600 pounds.
These devices usually cost about 40% more than regular equipment built to accomodate patients within a normal range.
If only obese patients were paying for this extra service, that would be one thing. But all of us pay via the increased cost of service equipment. This means that all of us are disadvantaged by other peoples' poor health and poor eating habits.
Just like with smokers. And I don't see anyone willing to pay more for Smoking versus Non-smoking ambulances!
Thursday, April 3, 2008
HIPAA
File this under "Don't blame the ER nurse..."
Frequently, we receive phone calls from people requesting information about patients. Usually it is someone who knows the patient--family, friend, co-worker. Other times it is someone who only has a passing interest--the good samaritan who brought the patient in, law enforcement officers, reporters from the local newspaper.
If the patient is present, awake, and able to converse, we transfer the call to the patient so they can give any information they choose. However, if this is not the case, ER nurses are bound by law to protect the privacy of the patient.
Some people don't understand this.
Once, I received a call from a person who identified herself as a patient's mother. She wanted to know why her son was in the ER, how he was doing, and if he was going to be admitted or discharged. The patient in question was drunk and unconscious, and an adult. Legally I couldn't tell the woman anything.
"But I'm his mother!"
People always say things like this, as if parentage trumps federal law. Who am I more afraid of, this woman or the feds?
ER nurses and others in the health care industry are restricted in the amount and type of information we can release about patients. The federal law that stipulates this is called the Health Information Portability and Accountability Act (HIPAA). Like most legislature "acts," HIPAA is verbose, complicated, and confusing, and has a misleading monniker. A better name would be "HIPPA: the Health Information Privacy and Protection Act".
The act does allow us to reveal the following. For a patient who is identified by name, HIPAA allows me to tell a caller whether or not the patient is in the ER, discharged, admitted to the hospital or transferred to another facility, and give a one word description of the patient's condition (e.g., critical, serious, fair, stable, poor, etc.)
That's it! It does no good to ask for more. People do, but I don't tell them. My stubborn refusal to do so angers most callers.
+++
Probably the most bizarre incident of not being able to disclose information about a patient that I've experienced occurred when a patient's wife called about 2 hours after he had been discharged. She asked the typical questions: why had he been in the ER, what did we do, and what should he do now.
Me: "We did have a patient by that name. He was discharged in stable condition."
Her: "I know. He's right here, at home. Why was he in the ER?"
"I'm sorry, ma'am. By law, because the patient is an adult, I am not allowed to disclose any other information to you without his expressed consent."
"But I'm his wife!"
"I understand that, ma'am. Allow me to suggest that you ask your husband why he was here."
"I did."
"And...?"
"He won't tell me."
"Won't tell you? And I'm suppose to?"
"Yes. I'm his wife!"
"You've already said that, ma'am. But I'm sorry. If I tell you any other information, then I will have violated your husband's right to privacy...AND a federal law."
"But I'm his wife!"
"I understand that, ma'am. What I'm asking you to understand is that that doesn't matter. I can't tell you anything else about the patient."
There was a long pause.
"But I'm his wife!"
"Yes, ma'am. Is there anything else I can do for you, ma'am?"
Frequently, we receive phone calls from people requesting information about patients. Usually it is someone who knows the patient--family, friend, co-worker. Other times it is someone who only has a passing interest--the good samaritan who brought the patient in, law enforcement officers, reporters from the local newspaper.
If the patient is present, awake, and able to converse, we transfer the call to the patient so they can give any information they choose. However, if this is not the case, ER nurses are bound by law to protect the privacy of the patient.
Some people don't understand this.
Once, I received a call from a person who identified herself as a patient's mother. She wanted to know why her son was in the ER, how he was doing, and if he was going to be admitted or discharged. The patient in question was drunk and unconscious, and an adult. Legally I couldn't tell the woman anything.
"But I'm his mother!"
People always say things like this, as if parentage trumps federal law. Who am I more afraid of, this woman or the feds?
ER nurses and others in the health care industry are restricted in the amount and type of information we can release about patients. The federal law that stipulates this is called the Health Information Portability and Accountability Act (HIPAA). Like most legislature "acts," HIPAA is verbose, complicated, and confusing, and has a misleading monniker. A better name would be "HIPPA: the Health Information Privacy and Protection Act".
The act does allow us to reveal the following. For a patient who is identified by name, HIPAA allows me to tell a caller whether or not the patient is in the ER, discharged, admitted to the hospital or transferred to another facility, and give a one word description of the patient's condition (e.g., critical, serious, fair, stable, poor, etc.)
That's it! It does no good to ask for more. People do, but I don't tell them. My stubborn refusal to do so angers most callers.
+++
Probably the most bizarre incident of not being able to disclose information about a patient that I've experienced occurred when a patient's wife called about 2 hours after he had been discharged. She asked the typical questions: why had he been in the ER, what did we do, and what should he do now.
Me: "We did have a patient by that name. He was discharged in stable condition."
Her: "I know. He's right here, at home. Why was he in the ER?"
"I'm sorry, ma'am. By law, because the patient is an adult, I am not allowed to disclose any other information to you without his expressed consent."
"But I'm his wife!"
"I understand that, ma'am. Allow me to suggest that you ask your husband why he was here."
"I did."
"And...?"
"He won't tell me."
"Won't tell you? And I'm suppose to?"
"Yes. I'm his wife!"
"You've already said that, ma'am. But I'm sorry. If I tell you any other information, then I will have violated your husband's right to privacy...AND a federal law."
"But I'm his wife!"
"I understand that, ma'am. What I'm asking you to understand is that that doesn't matter. I can't tell you anything else about the patient."
There was a long pause.
"But I'm his wife!"
"Yes, ma'am. Is there anything else I can do for you, ma'am?"
Wednesday, April 2, 2008
Soooo, the CAH-lege Kid says to the POE-lice...
Drunken university students are a dime a dozen on weekend nights in our ER. Many are unconscious, some are abusive, and others are downright funny. Most blame their inebriation on their "friends" who plied them with drinks they don't even remember consuming.
Friends?
+++
When nurses treat patients whose condition or injuries suggest that a crime may have been committed (e.g., an assault, child molestation, etc.), we are required to report our suspicion (sometimes via our supervisor) to law enforcement, despite the fact that this may place us in an awkward or even adversarial position vis-a-vis some patients, especially those who would rather their injuries not be disclosed to the police or who would rather protect others from prosecution.
However, in the case of underage drinkers (which most of our drunken college students are) when we KNOW a crime was committed (underage drinking), we are not required to report this. In fact, because the drinking age is 21 but patients are legally adults at 18 and therefore accorded certain federal rights to privacy, we are not permitted to report a patient's drunkenness to police, the university or even to the patient's parent(s) without the patient's consent.
+++
Coincidentally, many underage drunken students are covered by their parent's insurance which ends up being charged for the ER service.
+++
An underage sorority sister called the other day to find out the details of her ER experience the night before when she was brought in by ambulance after being found unconscious in her sorority house. She wanted to know what tests were done and especially whether or not a drug test had been performed.
I felt sorry for her for several reasons. First, she had no recollection of the experience. Drunk is fun (maybe); drunk and unconscious is dangerous.
Second, we conducted multiple lab tests and very expensive cervical spine xrays and head CAT scans (because in her unconscious state, injury could not be ruled out any other way). Drunk is fun (maybe); drunk, unconscious, and requiring ER treatment is expensive.
Lastly, she wanted to know if a drug test was done because she suspected that someone had slipped her a drug that would explain her unconsciousness. I had to explain to her that, although a drug test was not performed and therefore foul play could not be ruled out, I was pretty certain that her blood alcohol content (BAC) could more than account for her unconsciousness.
Her ETOH (alcohol) level was 0.3...drunk three times over by state standards!
Triply drunk and unconscious with a huge ER bill. There's no crime in that?
Friends?
+++
When nurses treat patients whose condition or injuries suggest that a crime may have been committed (e.g., an assault, child molestation, etc.), we are required to report our suspicion (sometimes via our supervisor) to law enforcement, despite the fact that this may place us in an awkward or even adversarial position vis-a-vis some patients, especially those who would rather their injuries not be disclosed to the police or who would rather protect others from prosecution.
However, in the case of underage drinkers (which most of our drunken college students are) when we KNOW a crime was committed (underage drinking), we are not required to report this. In fact, because the drinking age is 21 but patients are legally adults at 18 and therefore accorded certain federal rights to privacy, we are not permitted to report a patient's drunkenness to police, the university or even to the patient's parent(s) without the patient's consent.
+++
Coincidentally, many underage drunken students are covered by their parent's insurance which ends up being charged for the ER service.
+++
An underage sorority sister called the other day to find out the details of her ER experience the night before when she was brought in by ambulance after being found unconscious in her sorority house. She wanted to know what tests were done and especially whether or not a drug test had been performed.
I felt sorry for her for several reasons. First, she had no recollection of the experience. Drunk is fun (maybe); drunk and unconscious is dangerous.
Second, we conducted multiple lab tests and very expensive cervical spine xrays and head CAT scans (because in her unconscious state, injury could not be ruled out any other way). Drunk is fun (maybe); drunk, unconscious, and requiring ER treatment is expensive.
Lastly, she wanted to know if a drug test was done because she suspected that someone had slipped her a drug that would explain her unconsciousness. I had to explain to her that, although a drug test was not performed and therefore foul play could not be ruled out, I was pretty certain that her blood alcohol content (BAC) could more than account for her unconsciousness.
Her ETOH (alcohol) level was 0.3...drunk three times over by state standards!
Triply drunk and unconscious with a huge ER bill. There's no crime in that?
Tuesday, April 1, 2008
To Thump or Not to Thump?
In my comments on The Abyss back in September, 2007, I suggested that misconceptions people have of medical interventions for serious medical problems are often reinforced by the misrepresentation of these in movies and television.
Viewers believe what they see. Therefore, they believe things like patients in asystole (the proverbial cardiac flatline) can have their hearts "jump started" with defibrillation; that many patients spontaneously revive with just a few seconds of CPR; that long large needles pre-filled with epinephrine are often stabbed right into a patient's heart when it stops, etc.
In cases of sudden collapse with suspected cardiac arrest, one misrepresentation seems ubiquitous in movies and on TV (and occurs in a recent movie with Morgan Freeman and Greg Kinnear, entitled Feast of Love): the fist strike to the patient's chest, often accompanied by medical personnel jumping onto gurneys and straddling the patient, etc.
Otherwise known in medical circles as a precordial thump, this practice was a component of early Cardiopulmonary Resuscitation (CPR). The theory was that striking the sternum could produce a mechanical shock to the heart that would instigate a spontaneous rhythm. The practice has since been discontinued because it was found to be highly ineffective and more likely to injure a patient who was mistakenly thought to be having a heart attack.
In the movie mentioned above, a young male character collapses during a friendly football match. When he does not arouse, several people run to his aid including a female character who we know to be an emergency physician. In my willing suspension of disbelief concerning Hollywood portraying resuscitation attempts accurately, I actually thought the doctor might follow the ABCs for resuscitation. But what did she do? THUMP! THUMP! What happened? The patient regained a pulse!
Well, I won't spoil the movie and tell you what happens thereafter, but I'll point you in this direction:
http://www.nytimes.com/2008/04/01/health/research/01heart.html?nl=8hlth&emc=hltha1
If you witness someone collapse, don't be a movie star. Don't thump the patient. Just follow the ABCs. Call 911. Then...
Does the patient respond? Yes? STOP No?
Check the patient's Airway. Obstructed? Open the airway. Unobstructed?
Is the patient Breathing? Yes? STOP and wait for EMS. No?
Does the patient have Circulation (a pulse)? Yes? Reassess A and B. No? Press hard and fast on the lower portion of the patient's sternum until EMS arrives.
No Hollywood, No Heroics. Just the common sense of ABC.
Viewers believe what they see. Therefore, they believe things like patients in asystole (the proverbial cardiac flatline) can have their hearts "jump started" with defibrillation; that many patients spontaneously revive with just a few seconds of CPR; that long large needles pre-filled with epinephrine are often stabbed right into a patient's heart when it stops, etc.
In cases of sudden collapse with suspected cardiac arrest, one misrepresentation seems ubiquitous in movies and on TV (and occurs in a recent movie with Morgan Freeman and Greg Kinnear, entitled Feast of Love): the fist strike to the patient's chest, often accompanied by medical personnel jumping onto gurneys and straddling the patient, etc.
Otherwise known in medical circles as a precordial thump, this practice was a component of early Cardiopulmonary Resuscitation (CPR). The theory was that striking the sternum could produce a mechanical shock to the heart that would instigate a spontaneous rhythm. The practice has since been discontinued because it was found to be highly ineffective and more likely to injure a patient who was mistakenly thought to be having a heart attack.
In the movie mentioned above, a young male character collapses during a friendly football match. When he does not arouse, several people run to his aid including a female character who we know to be an emergency physician. In my willing suspension of disbelief concerning Hollywood portraying resuscitation attempts accurately, I actually thought the doctor might follow the ABCs for resuscitation. But what did she do? THUMP! THUMP! What happened? The patient regained a pulse!
Well, I won't spoil the movie and tell you what happens thereafter, but I'll point you in this direction:
http://www.nytimes.com/2008/04/01/health/research/01heart.html?nl=8hlth&emc=hltha1
If you witness someone collapse, don't be a movie star. Don't thump the patient. Just follow the ABCs. Call 911. Then...
Does the patient respond? Yes? STOP No?
Check the patient's Airway. Obstructed? Open the airway. Unobstructed?
Is the patient Breathing? Yes? STOP and wait for EMS. No?
Does the patient have Circulation (a pulse)? Yes? Reassess A and B. No? Press hard and fast on the lower portion of the patient's sternum until EMS arrives.
No Hollywood, No Heroics. Just the common sense of ABC.
Friday, March 21, 2008
RN, LPN, BSN...Hike!
A recent article in a Idaho newspaper described the education of a smalltown mayor as including a "registered nursing degree." Aside from being a political non sequitor, this strange piece of information illustrates the widespread misunderstanding about nursing education and licensing. In fact, a registered nursing degree does not exist!
Like many professions, working as a nurse requires both completion of an accredited educational degree as well as passing the state board exam for the purpose of being licensed. Achieving the former does not necessarily mean obtaining the latter. However, obtaining the latter requires the achievement of the former.
Clear as mud? Okay, here:
There are four types of nursing degrees. There is the "gold standard" Bachelor of Science in Nursing (BSN) which is fast becoming the "entry level" nursing degree required for obtaining a nursing-related job in most states. A BSN is like any of bachelors degree in the sciences and requires four years of college-level education.
Another common degree is an Associate Degree in Nursing (ADN). This degree is a two-year degree focusing on the brass tacks of nursing (i.e., clinical skills) and eshewing the more esoteric ancillary courses typically included in a traditional four-year college program (e.g., nursing management, health care finance, etc.).
BSN and ADN graduates are eligible to take the state board exam to become licensed as Registered Nurses (RNs), so-called because they become licensed by the state (registered) to practice as a licensed professional nurse.
Alternatively, with a lesser amount of education, one can obtain a licensed practical nurse (LPN) license. The scope of practice of an LPN is more narrow and restricted and LPNs are not very prevalent in the profession as a whole.
Does a BSN or ADN have to become licensed? Only to work as a nurse. In essence, becoming an RN is no more necessary than becoming a CPA after obtaining a bachelors degree in accounting!
Two other nursing degrees, Master of Science in Nursing (MSN) and a Doctorate of Nursing (PhD) also exist, as well as several "advanced practice" state licenses. Advanced practice nurses have MSNs in a particular field of nursing and may become licensed/certified in that field. For instance, those who obtain MSNs in anesthesia programs may become CRNAs (Certified Registered Nurse Anesthetists) and those who obtain degrees in midwifery may become CRNMs (Certified Registered Nurse Midwives), etc. Nurse Practitioners (NPs) are Advanced Practice Nurses with MSNs.
My point is, a nursing degree and a nursing license are two different, mutually exclusive accomplishments. Don't assume an RN has a bachelor's degree, but equally, do not assume a BSN has a license!
Like many professions, working as a nurse requires both completion of an accredited educational degree as well as passing the state board exam for the purpose of being licensed. Achieving the former does not necessarily mean obtaining the latter. However, obtaining the latter requires the achievement of the former.
Clear as mud? Okay, here:
There are four types of nursing degrees. There is the "gold standard" Bachelor of Science in Nursing (BSN) which is fast becoming the "entry level" nursing degree required for obtaining a nursing-related job in most states. A BSN is like any of bachelors degree in the sciences and requires four years of college-level education.
Another common degree is an Associate Degree in Nursing (ADN). This degree is a two-year degree focusing on the brass tacks of nursing (i.e., clinical skills) and eshewing the more esoteric ancillary courses typically included in a traditional four-year college program (e.g., nursing management, health care finance, etc.).
BSN and ADN graduates are eligible to take the state board exam to become licensed as Registered Nurses (RNs), so-called because they become licensed by the state (registered) to practice as a licensed professional nurse.
Alternatively, with a lesser amount of education, one can obtain a licensed practical nurse (LPN) license. The scope of practice of an LPN is more narrow and restricted and LPNs are not very prevalent in the profession as a whole.
Does a BSN or ADN have to become licensed? Only to work as a nurse. In essence, becoming an RN is no more necessary than becoming a CPA after obtaining a bachelors degree in accounting!
Two other nursing degrees, Master of Science in Nursing (MSN) and a Doctorate of Nursing (PhD) also exist, as well as several "advanced practice" state licenses. Advanced practice nurses have MSNs in a particular field of nursing and may become licensed/certified in that field. For instance, those who obtain MSNs in anesthesia programs may become CRNAs (Certified Registered Nurse Anesthetists) and those who obtain degrees in midwifery may become CRNMs (Certified Registered Nurse Midwives), etc. Nurse Practitioners (NPs) are Advanced Practice Nurses with MSNs.
My point is, a nursing degree and a nursing license are two different, mutually exclusive accomplishments. Don't assume an RN has a bachelor's degree, but equally, do not assume a BSN has a license!
Wednesday, March 12, 2008
The Immaculate Infection
I wasn't surprised by the recent news item that reported a study showing 1 in 4 teenage females between the ages of 14 and 19 have a sexually transmitted disease.
I wasn't surprised by the apparent fact that the rates of STD infection are highest among African-Americans and Mexican-Americans.
What surprised me was that the majority of the female subjects with STDs in the study denied ever having sex!
Apparently 1 in 4 teenagers have an STD, but 1 in 2 suffer extreme denial! Might be how they come by the STD in the first place.
I wasn't surprised by the apparent fact that the rates of STD infection are highest among African-Americans and Mexican-Americans.
What surprised me was that the majority of the female subjects with STDs in the study denied ever having sex!
Apparently 1 in 4 teenagers have an STD, but 1 in 2 suffer extreme denial! Might be how they come by the STD in the first place.
Tuesday, February 19, 2008
Types of Patients X: Alcohol Detox
Despite (or maybe because of) its status as a legal drug, alcohol consumption is nearly culturally universal, as is addiction and abuse, and the health complications of alcohol use occur across the lifespan.
Although recent research has shown that certain races and individuals with specific genetic profiles may be predisposed to alcoholism, defined as physical dependency upon ethyl alcohol (ETOH), the social and psychological aspects of alcohol addiction exist in all races and cultures.
As well, whereas legal consumption of alcohol is restricted in most societies to certain age groups, the negative health consequences of alcohol use effect all age groups. From alcohol-related accidents to fetal alcohol sydrome (FAS) to liver disease, etc., alcohol consumption, excessive or not, results in untold costs in terms of lives and health care dollars.
One group of individuals often ignored when we talk about the effects of alcohol addicition and abuse is, ironically, the addict. News stories and statistics usually track the unintended victims of abuse--sober accident victims, infants born with FAS--but addicts themselves are usually blamed for their problem and therefore the negative health effects of alcoholism upon them are usually assumed to be chosen, inexcusable, unnecessary...ultimately, a drain on the health care system.
For this reason, alcoholics seeking treatment for alcoholism present a challenge of compassion to ER nurses. Usually we treat patients whose injuries or illnesses are unintentional. With alcoholism, we treat an illness that is the result of the patient's volition. Other illnesses are similarly the result of individual's choices--smoking and lung disease, obesity and just about everything else!--but addiction to alcohol (or other drugs) seems a less sympathetic and more dangerous consequence of an obnxious habit.
I focus on the physical aspects of alcoholism and the nursing interventions necessary to protect the patient seeking detox from the untoward side effects not of alcohol abuse but of the detox process, itself. Attention to the psychological aspects of alcohol abuse and addiction is a more proper intervention while the patient is inpatient, not in the ER. Therefore, aside from supporting the patient's decision to seek detox, I leave philosophical and psychological discussions out of my nursing care.
A-B-C-Ds. Not hard. Usually patients seeking detox are functional, at least from the standpoint of body functions.
However, in the secondary survey (a nursing assessment that takes place after the primary ABCs are assessed and intervened, if neccessary), the D indicates differential diagnosis and/or disability. Aside from the psychological difficulty of breaking a habit, there are potential physical dangers to the patient attempting detox. The initial intervention for these occurs in the ER.
Alcoholics are often relatively malnourished and the sudden cessation of drinking can induce biochemical changes with serious side effects. The most serious side effect is seizure activity. Relative deficiencies in various B-complex vitamins due to malabsorption, specifically Thiamine and Folic acid, predispose the patient to seizures.
Nursing, therefore, must intervene by administering these essential nutrients, usually via IV, and engaging seizure precautions: intravenous access, oxygen and suction supplies at the bedside, and the administration of a benzodiazepine. Usually lorazepam is used because it has both sedative/anticonvulsant as well as anti-anxiety properties.
The anxiolytic property is necessary to permit the patient to get beyond the physical effects (mostly euphoria) of alcohol intake that are often the source of compulsive drinking. The more anxiety the patient experiences, the more likely their decision to detox wanes. Successful detox, therefore, relies upon the transient use of a substitute drug.
Basic lab work is also necessary before the patient is admitted. Complete blood count (CBC), comprehensive metabolic panel (CMP), blood alcohol content (BAC, or medical ETOH), and a urinary drug assay.
The rest, of course, is up to the patient. I can treat detox patients but I can't ultimately detox them. They have to do that for themselves.
Although recent research has shown that certain races and individuals with specific genetic profiles may be predisposed to alcoholism, defined as physical dependency upon ethyl alcohol (ETOH), the social and psychological aspects of alcohol addiction exist in all races and cultures.
As well, whereas legal consumption of alcohol is restricted in most societies to certain age groups, the negative health consequences of alcohol use effect all age groups. From alcohol-related accidents to fetal alcohol sydrome (FAS) to liver disease, etc., alcohol consumption, excessive or not, results in untold costs in terms of lives and health care dollars.
One group of individuals often ignored when we talk about the effects of alcohol addicition and abuse is, ironically, the addict. News stories and statistics usually track the unintended victims of abuse--sober accident victims, infants born with FAS--but addicts themselves are usually blamed for their problem and therefore the negative health effects of alcoholism upon them are usually assumed to be chosen, inexcusable, unnecessary...ultimately, a drain on the health care system.
For this reason, alcoholics seeking treatment for alcoholism present a challenge of compassion to ER nurses. Usually we treat patients whose injuries or illnesses are unintentional. With alcoholism, we treat an illness that is the result of the patient's volition. Other illnesses are similarly the result of individual's choices--smoking and lung disease, obesity and just about everything else!--but addiction to alcohol (or other drugs) seems a less sympathetic and more dangerous consequence of an obnxious habit.
I focus on the physical aspects of alcoholism and the nursing interventions necessary to protect the patient seeking detox from the untoward side effects not of alcohol abuse but of the detox process, itself. Attention to the psychological aspects of alcohol abuse and addiction is a more proper intervention while the patient is inpatient, not in the ER. Therefore, aside from supporting the patient's decision to seek detox, I leave philosophical and psychological discussions out of my nursing care.
A-B-C-Ds. Not hard. Usually patients seeking detox are functional, at least from the standpoint of body functions.
However, in the secondary survey (a nursing assessment that takes place after the primary ABCs are assessed and intervened, if neccessary), the D indicates differential diagnosis and/or disability. Aside from the psychological difficulty of breaking a habit, there are potential physical dangers to the patient attempting detox. The initial intervention for these occurs in the ER.
Alcoholics are often relatively malnourished and the sudden cessation of drinking can induce biochemical changes with serious side effects. The most serious side effect is seizure activity. Relative deficiencies in various B-complex vitamins due to malabsorption, specifically Thiamine and Folic acid, predispose the patient to seizures.
Nursing, therefore, must intervene by administering these essential nutrients, usually via IV, and engaging seizure precautions: intravenous access, oxygen and suction supplies at the bedside, and the administration of a benzodiazepine. Usually lorazepam is used because it has both sedative/anticonvulsant as well as anti-anxiety properties.
The anxiolytic property is necessary to permit the patient to get beyond the physical effects (mostly euphoria) of alcohol intake that are often the source of compulsive drinking. The more anxiety the patient experiences, the more likely their decision to detox wanes. Successful detox, therefore, relies upon the transient use of a substitute drug.
Basic lab work is also necessary before the patient is admitted. Complete blood count (CBC), comprehensive metabolic panel (CMP), blood alcohol content (BAC, or medical ETOH), and a urinary drug assay.
The rest, of course, is up to the patient. I can treat detox patients but I can't ultimately detox them. They have to do that for themselves.
Tuesday, February 12, 2008
(Don't) Dial-a-Nurse
One of the most frustrating aspects of working in an ER is fielding calls from people who want to discuss their symptoms over the phone and expect a diagnosis, home treatment plan, or advice about whether or not to seek emergency treatment. Sometimes these individuals are calling about themselves, but most often it is a parent calling about a child's symptoms.
Ostensibly, my hospital does not permit ER nurses to give advice over the phone. The reason for this is liability. If I gave advice to someone about symptoms I cannot properly assess in person, I run the risk of misdiagnosis or mistreatment or both.
Similarly, I have a 50/50 chance of recommending correctly whether or not someone needs to seek emergency treatment. If I tell them to come to the ER and they do and, in fact, they have an emergent condition, then I might be their hero. But when they are stuck with a bill for an unnecessary ER visit, I'm the villian.
And, worse, if I suggest that they do not have an emergent condition when in fact they do, perhaps life-threatening, and they don't come in, well...
The belief that it is easy to distinguish emergent or life-threatening conditions over the phone is the subject of this short (and scary, to an ER nurse) article.
www.nytimes.com/2008/02/12/health/12magn.html?_r=1&th&emc=th&oref=slogin
Regardless of my hospital's policy, the administration continues to publish the ER's phone number against our requests and will not allow us to have a phone message to answer as many other businesses, doctors' offices, and health care agencies do (a message that usually begins, "If you have an emergency, hang up and dial 911..."), claiming that such a message is too impersonal.
(Ironically, the only department in our hospital that has such a messaging service is Human Resources!)
How do I negotiate this mine-field?
I try to put myself in the caller's place and tell them what I would do if I were experiencing or witnessing the symptoms they are relating to me. Telling them what I would do if I were them or if it was my child strikes me as offering an informed opinion, not advice, and is a reasonable way to communicate what I think but ultimately leave the decision up to the caller.
They should just be happy I don't give them my mother's stock advice: "It'll be better in the morning."
Ostensibly, my hospital does not permit ER nurses to give advice over the phone. The reason for this is liability. If I gave advice to someone about symptoms I cannot properly assess in person, I run the risk of misdiagnosis or mistreatment or both.
Similarly, I have a 50/50 chance of recommending correctly whether or not someone needs to seek emergency treatment. If I tell them to come to the ER and they do and, in fact, they have an emergent condition, then I might be their hero. But when they are stuck with a bill for an unnecessary ER visit, I'm the villian.
And, worse, if I suggest that they do not have an emergent condition when in fact they do, perhaps life-threatening, and they don't come in, well...
The belief that it is easy to distinguish emergent or life-threatening conditions over the phone is the subject of this short (and scary, to an ER nurse) article.
www.nytimes.com/2008/02/12/health/12magn.html?_r=1&th&emc=th&oref=slogin
Regardless of my hospital's policy, the administration continues to publish the ER's phone number against our requests and will not allow us to have a phone message to answer as many other businesses, doctors' offices, and health care agencies do (a message that usually begins, "If you have an emergency, hang up and dial 911..."), claiming that such a message is too impersonal.
(Ironically, the only department in our hospital that has such a messaging service is Human Resources!)
How do I negotiate this mine-field?
I try to put myself in the caller's place and tell them what I would do if I were experiencing or witnessing the symptoms they are relating to me. Telling them what I would do if I were them or if it was my child strikes me as offering an informed opinion, not advice, and is a reasonable way to communicate what I think but ultimately leave the decision up to the caller.
They should just be happy I don't give them my mother's stock advice: "It'll be better in the morning."
Saturday, February 2, 2008
Nursing Compliments
Recently, I completed a recommendation letter for a fellow nurse who is applying to a graduate program in trauma nursing. She wants to become a Clinical Nurse Specialist, similar to a Nurse Practitioner. I've known her for awhile, like her, and thinks she's a good nurse. It was not hard to think of a few good things to say.
But I didn't just want to say "good things." I wanted to say the best thing!
Thomas Merton, a Trappist Monk, once wrote, "Build a chair as if for an angel." His meaning was clear. If you are going to produce something, do it in the best way and for the highest good you can imagine.
Writing a recommendation letter for someone is tricky business. You don't know who will read it. Who are the members of the selection committee? Is there a selection committee? Will the reader be a sticky organizational bureaucrat, or is there room for creativity, levity? Knowing these things is important if one is trying to say the best thing for the circumstances.
I erred of the side of saying the best thing I could say regardless of the circumstances. Along with all the hagiographic blah blah blah, I simply wrote: "I would have no difficulty entrusting Ms. (Nurse) with my patients, with myself as a patient, or with any of my family members as patients."
Certainly the highest compliment one nurse can bestow upon another.
But I didn't just want to say "good things." I wanted to say the best thing!
Thomas Merton, a Trappist Monk, once wrote, "Build a chair as if for an angel." His meaning was clear. If you are going to produce something, do it in the best way and for the highest good you can imagine.
Writing a recommendation letter for someone is tricky business. You don't know who will read it. Who are the members of the selection committee? Is there a selection committee? Will the reader be a sticky organizational bureaucrat, or is there room for creativity, levity? Knowing these things is important if one is trying to say the best thing for the circumstances.
I erred of the side of saying the best thing I could say regardless of the circumstances. Along with all the hagiographic blah blah blah, I simply wrote: "I would have no difficulty entrusting Ms. (Nurse) with my patients, with myself as a patient, or with any of my family members as patients."
Certainly the highest compliment one nurse can bestow upon another.
Friday, February 1, 2008
Hospital O'Hare
I've been a nurse for awhile, and after a few years, like any other job, I've exhausted the opportunity for new and unique experiences. Most of what I do everyday on the job is like what I do every other day on the job. As monotonous as that sounds, at least these ordinary experiences are fun and interesting to me.
That said, I experienced a "first" a few days ago.
When I started working as a nurse, I was on a medical-surgical unit. This is the main nursing floor in most hospitals, a place where patients stay for awhile, either with an illness that is not quickly treated or after surgery, recovering.
What I liked about this sort of nursing was the familiarity of patients from day to day. Often I would have the same four or five patients for days at a time. The length of time I had with them allowed me to build reporte, often finding out more about their ordinary lives, their likes and dislikes, what made them tick. This amount of time also gave me a greater opportunity to influence their thoughts about health habits and how they might change their behaviors to encourage and maintain maximum health.
But this consistency also had some draw backs, the most depressing of which was taking care of really obnoxious patients for days at a time.
In the emergency room, however, I see patients for maybe a couple of hours, half a shift at most (6 hours). This means I see more patients and a greater variety of patients in each twelve hours I work. The trade-off is I also have less opportunity to chat, figure them out, influence their health-related choices.
Not so the other day.
The other day I received report on a patient from the night nurse--the patient had arrived at 0545--and I duly reported off on the very same patient to the very same night nurse twelve hours later. In all, the patient spent fifteen hours in our ER, long enough to develop new symptoms that she hadn't even come in with! That was a first for me.
I attribute this to a scatter-brained, passive-aggressive ER doctor, an internist by training who has no sense of time-management and who has to fix everything about a patient (and sometimes their families!) This doc had patients circling for hours that day--my patient wasn't the only one--like "Discharged from ER" was a busy airport where patients couldn't land. I've seen worse up-in-the-air at O'Hare!
And it was an overtime shift for me...
That said, I experienced a "first" a few days ago.
When I started working as a nurse, I was on a medical-surgical unit. This is the main nursing floor in most hospitals, a place where patients stay for awhile, either with an illness that is not quickly treated or after surgery, recovering.
What I liked about this sort of nursing was the familiarity of patients from day to day. Often I would have the same four or five patients for days at a time. The length of time I had with them allowed me to build reporte, often finding out more about their ordinary lives, their likes and dislikes, what made them tick. This amount of time also gave me a greater opportunity to influence their thoughts about health habits and how they might change their behaviors to encourage and maintain maximum health.
But this consistency also had some draw backs, the most depressing of which was taking care of really obnoxious patients for days at a time.
In the emergency room, however, I see patients for maybe a couple of hours, half a shift at most (6 hours). This means I see more patients and a greater variety of patients in each twelve hours I work. The trade-off is I also have less opportunity to chat, figure them out, influence their health-related choices.
Not so the other day.
The other day I received report on a patient from the night nurse--the patient had arrived at 0545--and I duly reported off on the very same patient to the very same night nurse twelve hours later. In all, the patient spent fifteen hours in our ER, long enough to develop new symptoms that she hadn't even come in with! That was a first for me.
I attribute this to a scatter-brained, passive-aggressive ER doctor, an internist by training who has no sense of time-management and who has to fix everything about a patient (and sometimes their families!) This doc had patients circling for hours that day--my patient wasn't the only one--like "Discharged from ER" was a busy airport where patients couldn't land. I've seen worse up-in-the-air at O'Hare!
And it was an overtime shift for me...
Thursday, January 31, 2008
Fact, Not Fact: Statistics By Any Other Name
I received this tidbit yesterday. Proof-positive that whereas statistics don't lie, people can lie with statistics.
"Guns don't kill people, doctors kill people!
"According to the U.S. Department of Health and Human Services, there are 700,000 physicians in the United States. The number of accidental patient deaths per year is 120,000. Therefore, accidental deaths per physician is 0.171.
"According to the F.B.I., there are 80,000,000 gun owners in the United States. The number of accidental gun deaths per year is 1,500. The number of accidental deaths per gun owner is 0.000188
"Statistically, doctors are approximately 9,000 times more dangerous than gun owners.
"NOT everyone has a gun, but almost everyone has at least one doctor. Please alert your friends to this alarming threat.
"Ban Doctors, Not Guns!"
Okay, so it was sent to me tongue in cheek, but many similiarly ludicrous ideas about safety are based on similiarly silly statistics.
Like this one: You're safer flying than driving because statistically there are more car crash fatalities per year than fatalities in plane crashes. Fact is, the average person travels in a car far more often than they do in an airplane, therefore the likelihood of being in a car accident is much higher. In fact, also, it is far more likely that one will survive multiple car crashes, whereas surviving an airplane crash is far less likely.
Or this one: You're safer not getting a tetanus immunization shot because statistically you're more likely to die of an anaphylatic reaction to the shot than you are of tetanus infection. Fact is, the reason more people die from the shot than from tetanus is not because the shot is more dangerous, but because tetanus infection is rare due to widespread immunization. However, the likelihood of surviving anaphylatic reactions is far greater than surviving tetanus, which, if you get it, has a survival rate of almost 0%.
And if one more person tells me that you're safer in a rollover accident without your seatbelt on because you're less likely to get stuck in your crushed or burning vehicle...
"Guns don't kill people, doctors kill people!
"According to the U.S. Department of Health and Human Services, there are 700,000 physicians in the United States. The number of accidental patient deaths per year is 120,000. Therefore, accidental deaths per physician is 0.171.
"According to the F.B.I., there are 80,000,000 gun owners in the United States. The number of accidental gun deaths per year is 1,500. The number of accidental deaths per gun owner is 0.000188
"Statistically, doctors are approximately 9,000 times more dangerous than gun owners.
"NOT everyone has a gun, but almost everyone has at least one doctor. Please alert your friends to this alarming threat.
"Ban Doctors, Not Guns!"
Okay, so it was sent to me tongue in cheek, but many similiarly ludicrous ideas about safety are based on similiarly silly statistics.
Like this one: You're safer flying than driving because statistically there are more car crash fatalities per year than fatalities in plane crashes. Fact is, the average person travels in a car far more often than they do in an airplane, therefore the likelihood of being in a car accident is much higher. In fact, also, it is far more likely that one will survive multiple car crashes, whereas surviving an airplane crash is far less likely.
Or this one: You're safer not getting a tetanus immunization shot because statistically you're more likely to die of an anaphylatic reaction to the shot than you are of tetanus infection. Fact is, the reason more people die from the shot than from tetanus is not because the shot is more dangerous, but because tetanus infection is rare due to widespread immunization. However, the likelihood of surviving anaphylatic reactions is far greater than surviving tetanus, which, if you get it, has a survival rate of almost 0%.
And if one more person tells me that you're safer in a rollover accident without your seatbelt on because you're less likely to get stuck in your crushed or burning vehicle...
Saturday, January 26, 2008
Types of Patients IX: "Bad Babies"
A touchy subject.
Yesterday, I accepted the care of a 53 day old female with respiratory distress. There is nothing more frightening to me as a parent and as an ER nurse than a baby that can't breathe or isn't breathing well.
As a parent, I recall a time when my infant son choked on a small cracker, and how the minutes he did not seem to be able to breathe shortened my life, I'm convinced, by years.
I recall, too, the several times I have had to resuscitate him when he did not regain spontaneous breathing after having seizures.
There is nothing worse than a child who will not breathe!
As a nurse, flashes of parents' hopes for their child as I care for him or her rush through my head and I realize that I am somewhat the keeper of these. I also become entrusted by the parents as easily, it seems, as one would entrust their poorly running car to a mechanic. I do not want this responsibility, but by virtue of my training and career, I have tacitly agreed to accept it.
Okay. ABCs.
A. Baby's airway was patent but compromised by mucous and secretions from what we suspected was respiratory syncytial virus (RSV), a viral infection of the lungs and airways of children primarily less than 1 year old. It is a common source of bronchial infection and pneumonia in infants.
Attend to positioning, initiate suctioning, both with a bulb syringe and wall-mounted vacuum suction via a Delee suction device, stimulates baby to breath as well as helps keeps baby's airway clear. Check.
B. As already noted, baby's breathing and oxygenation were poor. Respiratory rate was in the 80s-90s (normal values are in the 40s-50s) and oxygen saturation (a less than completely accurate measure of tissue perfusion, i.e., how much life-sustaining oxygen is getting to the organs and tissues) was approximately 88% (normal is 97%-100%).
Provide supplemental oxygen. But for a small infant this isn't the easiest intervention. Nasal cannulas and infant oxygen masks are notoriously less than effective. What is needed is an environment completely rich in oxygen, like in an incubator. We don't have this technology in the ER.
Thanks to our Respiratory Therapist (RT), a infant "hood"--a plastic dome, sort of like an astronaut's helmet, with a cut-out for the neck and sliding access panels--was placed over the baby's head as she laid on the pad of the baby warmer, a special device for infants that is no more than a treatment table with a warming light over it and oxygen tanks and suction canisters attached.
Check.
C. The baby's heart rate was in the 180s (normal is 130-140s). Increased heart rate is, in part, a compensatory response to poor oxygenation and dehydration, a condition that increases when babies are sick. If tissues aren't receiving enough oxygen, the body will attempt to increase oxygen supply by passing more blood through the tissues. To do this, the brain stimulates the heart to beat faster. However, when the heart beats faster, more oxygen is consumed by the heart and the muscle begins to tire. And so, a vicious cycle ensues.
If intervention is too slow or inadequate, baby will literally wear herself out. With a heart rate of 180 and oxygenation of 88%, we were already "behind the eight ball" as a popular expression goes.
Supplemental oxygen is a good first step. Next, intravenous fluid boluses to increase the volume of fluid in the blood stream to off-set the effects of dehydration. Intravenous access also allows for easier drug administration.
Thanks to a Family Birth Center nurse, IV access was achieved within the hour of baby's arrival in the ER. Why didn't I do it? For the same reason I don't change the oil in my car...I can do it, but there are people who specialize in this sort of thing. Part of being an ER nurse is the wisdom and foresight for judicious use of resources. FBC was my resource in this case!
Circulation, check.
There is a D as well (ABC,D): Differential Diagnosis.
We suspected RSV but other conditions could cause what we were seeing. Cold-stress is another possibility. Hypothermia forces a baby to increase heart rate and breathing in order to maintain body temperature. Assessment: In fact, baby's initial rectal temp was 95.4 (normal is, of course, 98.6). Intervention: warm baby up. Using the baby warmer is standard. Warmed IV fluids helps. A special infant chemical-warming pad was also used.
Hypoglycemia is also suspected. Low blood sugar reduces metabolism; reduced metabolism decreases body temperature. No fuel for the fire. Assessment: Baby's heel stick blood sugar was 66, normal. Intervention: IV glucose (if necessary).
Check.
For three hours, we (RT, the FBC nurse, and I) attempted to improve baby's breathing, all of us, baby included, suffering through pronounced and prolonged apneic periods during which baby would stop breathing for up to 7 and 8 seconds at a time. I began to wonder from which episode baby would not recover, requiring a resuscitation effort, the survival rate of which is low.
I don't pray, but I have wishes. I wished that it wouldn't come to this.
Eventually, we transported baby via helicopter to a pediatric emergency room and, I assume, NICU (Newborn Intensive Care Unit) at the nearest large hospital. Although I haven't heard, I assumed baby's prognosis is good.
I would be lying if I denied being relieved and happy that baby was gone and out of my ER. I know my nursing limits. Baby's condition was pushing and, in some ways, surpassing them. I'm not embarrassed to admit it.
We often joke among ourselves concerning triage that there are two categories of infants: good babies and bad babies. Nearly 97-99% of babies brought in by parents are of the former category. Most of these suffer from what we call PPP, piss-poor parenting. It's the other 1% or so that scare me.
My "bad baby" experience reminds me that, no matter what my demons, I need to be ever-mindful of my skills and abilities and the limits to these, and to swallow my pride when it comes to the health of a infant. I hope I did and will always do the right thing.
Yesterday, I accepted the care of a 53 day old female with respiratory distress. There is nothing more frightening to me as a parent and as an ER nurse than a baby that can't breathe or isn't breathing well.
As a parent, I recall a time when my infant son choked on a small cracker, and how the minutes he did not seem to be able to breathe shortened my life, I'm convinced, by years.
I recall, too, the several times I have had to resuscitate him when he did not regain spontaneous breathing after having seizures.
There is nothing worse than a child who will not breathe!
As a nurse, flashes of parents' hopes for their child as I care for him or her rush through my head and I realize that I am somewhat the keeper of these. I also become entrusted by the parents as easily, it seems, as one would entrust their poorly running car to a mechanic. I do not want this responsibility, but by virtue of my training and career, I have tacitly agreed to accept it.
Okay. ABCs.
A. Baby's airway was patent but compromised by mucous and secretions from what we suspected was respiratory syncytial virus (RSV), a viral infection of the lungs and airways of children primarily less than 1 year old. It is a common source of bronchial infection and pneumonia in infants.
Attend to positioning, initiate suctioning, both with a bulb syringe and wall-mounted vacuum suction via a Delee suction device, stimulates baby to breath as well as helps keeps baby's airway clear. Check.
B. As already noted, baby's breathing and oxygenation were poor. Respiratory rate was in the 80s-90s (normal values are in the 40s-50s) and oxygen saturation (a less than completely accurate measure of tissue perfusion, i.e., how much life-sustaining oxygen is getting to the organs and tissues) was approximately 88% (normal is 97%-100%).
Provide supplemental oxygen. But for a small infant this isn't the easiest intervention. Nasal cannulas and infant oxygen masks are notoriously less than effective. What is needed is an environment completely rich in oxygen, like in an incubator. We don't have this technology in the ER.
Thanks to our Respiratory Therapist (RT), a infant "hood"--a plastic dome, sort of like an astronaut's helmet, with a cut-out for the neck and sliding access panels--was placed over the baby's head as she laid on the pad of the baby warmer, a special device for infants that is no more than a treatment table with a warming light over it and oxygen tanks and suction canisters attached.
Check.
C. The baby's heart rate was in the 180s (normal is 130-140s). Increased heart rate is, in part, a compensatory response to poor oxygenation and dehydration, a condition that increases when babies are sick. If tissues aren't receiving enough oxygen, the body will attempt to increase oxygen supply by passing more blood through the tissues. To do this, the brain stimulates the heart to beat faster. However, when the heart beats faster, more oxygen is consumed by the heart and the muscle begins to tire. And so, a vicious cycle ensues.
If intervention is too slow or inadequate, baby will literally wear herself out. With a heart rate of 180 and oxygenation of 88%, we were already "behind the eight ball" as a popular expression goes.
Supplemental oxygen is a good first step. Next, intravenous fluid boluses to increase the volume of fluid in the blood stream to off-set the effects of dehydration. Intravenous access also allows for easier drug administration.
Thanks to a Family Birth Center nurse, IV access was achieved within the hour of baby's arrival in the ER. Why didn't I do it? For the same reason I don't change the oil in my car...I can do it, but there are people who specialize in this sort of thing. Part of being an ER nurse is the wisdom and foresight for judicious use of resources. FBC was my resource in this case!
Circulation, check.
There is a D as well (ABC,D): Differential Diagnosis.
We suspected RSV but other conditions could cause what we were seeing. Cold-stress is another possibility. Hypothermia forces a baby to increase heart rate and breathing in order to maintain body temperature. Assessment: In fact, baby's initial rectal temp was 95.4 (normal is, of course, 98.6). Intervention: warm baby up. Using the baby warmer is standard. Warmed IV fluids helps. A special infant chemical-warming pad was also used.
Hypoglycemia is also suspected. Low blood sugar reduces metabolism; reduced metabolism decreases body temperature. No fuel for the fire. Assessment: Baby's heel stick blood sugar was 66, normal. Intervention: IV glucose (if necessary).
Check.
For three hours, we (RT, the FBC nurse, and I) attempted to improve baby's breathing, all of us, baby included, suffering through pronounced and prolonged apneic periods during which baby would stop breathing for up to 7 and 8 seconds at a time. I began to wonder from which episode baby would not recover, requiring a resuscitation effort, the survival rate of which is low.
I don't pray, but I have wishes. I wished that it wouldn't come to this.
Eventually, we transported baby via helicopter to a pediatric emergency room and, I assume, NICU (Newborn Intensive Care Unit) at the nearest large hospital. Although I haven't heard, I assumed baby's prognosis is good.
I would be lying if I denied being relieved and happy that baby was gone and out of my ER. I know my nursing limits. Baby's condition was pushing and, in some ways, surpassing them. I'm not embarrassed to admit it.
We often joke among ourselves concerning triage that there are two categories of infants: good babies and bad babies. Nearly 97-99% of babies brought in by parents are of the former category. Most of these suffer from what we call PPP, piss-poor parenting. It's the other 1% or so that scare me.
My "bad baby" experience reminds me that, no matter what my demons, I need to be ever-mindful of my skills and abilities and the limits to these, and to swallow my pride when it comes to the health of a infant. I hope I did and will always do the right thing.
Wednesday, January 23, 2008
Health Care Rights (and Wrongs)
Is health care a right? Should everyone in our society have access to health care? Should this access be free? Equal? Or, should it be based upon need, or an individual's ability to pay, or some other category of restriction (e.g., the relative contributions people make to society)?
These are the fundamental questions about health care that we, as a society, have not yet fully addressed. Currently, our health care system functions upon a sickly jumble of half-answers.
It is easy to say that everyone has a "right" to health care, but very few absolute rights exist. Most rights are accorded with exceptions or with responsibilities and obligations placed upon the recipient. (More about obligations and responsibilities another time.)
What are the exceptions to an individual's right to health care? In our society, most exceptions concern the nature and extent of care one can expect.
By virtue of EMTALA, all individuals regardless of ability to pay have a right (see entry of 9/3/07) to a medical screening in an emergency room of a facility that participates in the federally-funded programs of Medicare and Medicaid to determine whether or not s/he is experiencing an emergent condition requiring treatment and/or stabilization and transfer. However, one does not have a right to demand certain treatments or interventions, even if another person may receive these.
In essence, one has a right to treatment for emergencies, but one does not have a right to an MRI for a headache, or a bone scan for "brittle bones," or a heart/lung transplant for organ failure.
Just as one has a right to free speech, one cannot utilize this right wherever and however one wishes. There are restrictions and exceptions.
In the emergency room, what is prudent and customary care for the condition a patient is experiencing and not simply the patient's ideas and desires or even their ability to pay, determines the sort of care they receive. It is the right of the patient to have what is prudent and customary (sometimes called the "standard of care").
But this is not a right transferable to the private sphere of health care. Just because one has a right to such treatment in the ER doesn't mean they have the same rights at the local Family Medical Clinic, or Dr. Joe's, or even at for-profit, privatized hospitals. These services can be exceptions to the right of health care.
In fact, one of the reasons ERs are often saturated with individuals who are un- or underinsured is because physicians and other clinicians in private practice aren't obligated to fulfill an individual's right to health care. Many private practice physicians only accept patients on Medicaid as a small percentage of their overall clientele, and virtually none accept uninsured patients unless they have cash up front. This is sometimes referred to as The American Way.
What this effects is a two-tiered (actually, multi-tiered) system of health care in which privately insured individuals and those with retirement-age or disability-qualifying Medicare can usually access private health care, while poorer individuals who can't afford private insurance or don't work at jobs that are required to provide it (e.g., part-time, seasonal, small businesses, etc.) must rely on Medicaid or no insurance at all.
These latter individuals are those who the New York Times apparently has a problem with gumming up the ERs. Where else are they to go?
If health care is a right with exceptions and restrictions, then these sorts of problems are going to acutely inconvenience even those at the top of the system. However, I suspect these problems inconvenience those at the bottom more often, in fact, chronically.
Inject for-profit motives of private insurance companies, and these problems multiple precipitously. The system, the entire system, is in need of an overhaul.
These are the fundamental questions about health care that we, as a society, have not yet fully addressed. Currently, our health care system functions upon a sickly jumble of half-answers.
It is easy to say that everyone has a "right" to health care, but very few absolute rights exist. Most rights are accorded with exceptions or with responsibilities and obligations placed upon the recipient. (More about obligations and responsibilities another time.)
What are the exceptions to an individual's right to health care? In our society, most exceptions concern the nature and extent of care one can expect.
By virtue of EMTALA, all individuals regardless of ability to pay have a right (see entry of 9/3/07) to a medical screening in an emergency room of a facility that participates in the federally-funded programs of Medicare and Medicaid to determine whether or not s/he is experiencing an emergent condition requiring treatment and/or stabilization and transfer. However, one does not have a right to demand certain treatments or interventions, even if another person may receive these.
In essence, one has a right to treatment for emergencies, but one does not have a right to an MRI for a headache, or a bone scan for "brittle bones," or a heart/lung transplant for organ failure.
Just as one has a right to free speech, one cannot utilize this right wherever and however one wishes. There are restrictions and exceptions.
In the emergency room, what is prudent and customary care for the condition a patient is experiencing and not simply the patient's ideas and desires or even their ability to pay, determines the sort of care they receive. It is the right of the patient to have what is prudent and customary (sometimes called the "standard of care").
But this is not a right transferable to the private sphere of health care. Just because one has a right to such treatment in the ER doesn't mean they have the same rights at the local Family Medical Clinic, or Dr. Joe's, or even at for-profit, privatized hospitals. These services can be exceptions to the right of health care.
In fact, one of the reasons ERs are often saturated with individuals who are un- or underinsured is because physicians and other clinicians in private practice aren't obligated to fulfill an individual's right to health care. Many private practice physicians only accept patients on Medicaid as a small percentage of their overall clientele, and virtually none accept uninsured patients unless they have cash up front. This is sometimes referred to as The American Way.
What this effects is a two-tiered (actually, multi-tiered) system of health care in which privately insured individuals and those with retirement-age or disability-qualifying Medicare can usually access private health care, while poorer individuals who can't afford private insurance or don't work at jobs that are required to provide it (e.g., part-time, seasonal, small businesses, etc.) must rely on Medicaid or no insurance at all.
These latter individuals are those who the New York Times apparently has a problem with gumming up the ERs. Where else are they to go?
If health care is a right with exceptions and restrictions, then these sorts of problems are going to acutely inconvenience even those at the top of the system. However, I suspect these problems inconvenience those at the bottom more often, in fact, chronically.
Inject for-profit motives of private insurance companies, and these problems multiple precipitously. The system, the entire system, is in need of an overhaul.
Tuesday, January 22, 2008
Roe V. Wade V. Bush
On this day in 1973, the supreme court issued a ruling that stated first trimester elective abortions were indeed legal.
On this day in 2001, President G.W. Bush signed an a "memorandum reinstating full abortion restrictions on U.S. overseas aid" (NYTimes). In other words, according to Bush, abortions were not permitted in countries receiving U.S. aid.
What was I saying about inequality when it comes to the U.S.-style "health" care?
On this day in 2001, President G.W. Bush signed an a "memorandum reinstating full abortion restrictions on U.S. overseas aid" (NYTimes). In other words, according to Bush, abortions were not permitted in countries receiving U.S. aid.
What was I saying about inequality when it comes to the U.S.-style "health" care?
What's in a Name (of a Disease)?
http://www.nytimes.com/2008/01/22/health/22dise.html?th&emc=th
Apparently, much more than the disease itself. Although I am not so sure it's a good thing to have a disease named after you, I am sure it's better than being named after a disease.
And I have not done any research on the issue, but I am sure we could find in the history of medical research and development plenty of instances in which what we know now was, in part, generated by nefarious activities of clinicians and scientists. Some of these were members of the Nazi party; some were American scientists and doctors.
The institution of medicine is not immune to the same racism and sexism that plagues society in general (no pun intended), and often this is seen in the "naming" of conditions, procedures, or remedies.
Even one of the most honorable of health-related issues is subject to this: pregnancy and childbirth.
The EDC, which so many confuse for "estimated date of conception," actually is the acronym for "Estimated Date of Confinement." In other words, that time at which the baby will likely be born and the mother will be "confined" to a hospital bed for a week. Now, we know that this rarely happens any longer, that most new mom's go home within a day or two of an uncomplicated birth. But the term persists.
With multiple miscarriages, a woman hopeful of bringing a fetus to term may be labeled an "habitual aborter"! And with each miscarriage, unless there is a known cause, the failure of a conceived pregnancy is said to be a "blighted ovum". In other words, it's the woman's fault, when in fact there is no reason to suspect the ova over the sperm. But a male-dominated medical institution would hardly want to point fingers at themselves and their kind.
What's in a name? A name. But a load of other things that may bother people.
I hold to my original statement, and I'm glad my name isn't Anna Plastic Tumor.
Apparently, much more than the disease itself. Although I am not so sure it's a good thing to have a disease named after you, I am sure it's better than being named after a disease.
And I have not done any research on the issue, but I am sure we could find in the history of medical research and development plenty of instances in which what we know now was, in part, generated by nefarious activities of clinicians and scientists. Some of these were members of the Nazi party; some were American scientists and doctors.
The institution of medicine is not immune to the same racism and sexism that plagues society in general (no pun intended), and often this is seen in the "naming" of conditions, procedures, or remedies.
Even one of the most honorable of health-related issues is subject to this: pregnancy and childbirth.
The EDC, which so many confuse for "estimated date of conception," actually is the acronym for "Estimated Date of Confinement." In other words, that time at which the baby will likely be born and the mother will be "confined" to a hospital bed for a week. Now, we know that this rarely happens any longer, that most new mom's go home within a day or two of an uncomplicated birth. But the term persists.
With multiple miscarriages, a woman hopeful of bringing a fetus to term may be labeled an "habitual aborter"! And with each miscarriage, unless there is a known cause, the failure of a conceived pregnancy is said to be a "blighted ovum". In other words, it's the woman's fault, when in fact there is no reason to suspect the ova over the sperm. But a male-dominated medical institution would hardly want to point fingers at themselves and their kind.
What's in a name? A name. But a load of other things that may bother people.
I hold to my original statement, and I'm glad my name isn't Anna Plastic Tumor.
Saturday, January 19, 2008
Waiting for Goddarn Doctor (Part I)
http://www.nytimes.com/2008/01/19/opinion/19sat3.html?th&emc=th
Whereas, in my opinion, the New York Times is right-on about the negative effects of two-tiered health care coverage--that emergency room wait times have increased thereby decreasing the speed with which the sickest receive necessary treatment--I disagree with the slant of the editorial, revealed in the first sentence, that these negative effects are mostly a problem because they inconvenience those who are on the top tier.
Let's face it, "insurance" is an immoral business. (It's called "protection" in the world of organized crime.) Corporations and individuals reaping huge profits from other individuals who fear illness and injury and the catastrophic costs associated with treatment. These same insurance companies more often than not hedge their investment by accepting only the healthiest clients or at least those who have the most ability to pay premiums, only to eventually deny claims for reimbursement at every turn until such a time that someone, often the court, makes them pay.
It is time for our society to eliminate the ability of a few to profit from the fear of illness or injury of the many. A single-payer, government-regulated system is the answer.
Whereas, in my opinion, the New York Times is right-on about the negative effects of two-tiered health care coverage--that emergency room wait times have increased thereby decreasing the speed with which the sickest receive necessary treatment--I disagree with the slant of the editorial, revealed in the first sentence, that these negative effects are mostly a problem because they inconvenience those who are on the top tier.
Let's face it, "insurance" is an immoral business. (It's called "protection" in the world of organized crime.) Corporations and individuals reaping huge profits from other individuals who fear illness and injury and the catastrophic costs associated with treatment. These same insurance companies more often than not hedge their investment by accepting only the healthiest clients or at least those who have the most ability to pay premiums, only to eventually deny claims for reimbursement at every turn until such a time that someone, often the court, makes them pay.
It is time for our society to eliminate the ability of a few to profit from the fear of illness or injury of the many. A single-payer, government-regulated system is the answer.
Wednesday, January 16, 2008
Dispatch Interpretations and Other EMS Debacles
Emergency Medical Service (EMS) is an important component of any community's health care system. 911 dispatchers, EMTs (Emergency Medical Technicians) and paramedics, extrication teams, etc. are the individuals who, paid or otherwise, are responsible for ensuring that your medical "emergency" is taken care of.
Why the quotes? Because "emergency" is a euphemism for whatever a 911-caller says is an emergency. It is also whatever the dispatcher thinks is an emergency. Tremendous variation exists.
It begins with the interaction between caller and "dispatch," a group of EMS individuals with limited or no medical training who answer 911 calls--usually answering with the phrase "Police and fire." Dispatchers use latitude in interpreting the emergency nature of any particular call.
In our community there are five response levels for medical emergencies based upon the nature and/or severity of the emergency. These levels indicate to EMTs, etc., what sort of problem the caller is experiencing or witnessing, how serious it may be, and what sort of personnel and equipment might be necessary for a successful intervention.
An "alpha" response is a non-immediate transport of a patient for a minor problem or illness, or the transfer of a stable patient from one medical facility (e.g., nursing home, hospital, etc.) to another.
A "bravo" response is more serious and emergent. It is used for motor vehicle accidents in which unknown injuries may have occurred or for patients with undisclosed medical emergencies, whether injury or illness.
"Charlie" designates a serious emergent illness that is potentially life-threatening (e.g., chest pain, shortness of breath, severe allergic reaction).
A "delta" response may indicate a serious accident in which there are known injuries, a serious traffic accident requiring extrication of patients from vehicles, and/or a serious medical problem like uncontrolled bleeding, etc. EMT and/or paramedic assistance is necessary as soon as possible.
"Echo" response is reserved for problems requiring near-instantaneous attention, like an on-going resuscitation attempt by by-standers or the need for CPR. This response usually means someone is as close to being dead, either because of illness or injury, either this side or that side of death, as they can possibly be. Needless to say, echo responses don't usually result in successful interventions.
However, the amount of interpretation dispatchers employ in translating 911 calls into responses varies.
Some examples. Recently, four patients were brought to the ER by an out-of-area ambulance after it had been dispatched to a rollover accident. Initially, all of the individuals were assessed by EMTs and refused transport. After the ambulance had returned to its station, however, a second call went out for EMS response to the the same accident. Apparently, the "victims" realized they didn't have a ride home!
A woman calls 911 because her husband is bleeding. The woman, an ICU nurse, says to dispatch, "We need an ambulance quick! My husband's cut his arm and is bleeding from an artery." Serious? Perhaps...probably. But here is how it got called out:
"EMT Ambulance, Echo response for a hemorrhage, 41 year male, attempted suicide!"
Where that last part came from, who knows? The man had been working with a metal range hood that fell on him. Clearly, what is interpreted as an emergency, and what are the circumstances of the emergency, are as much affected by who makes the 911 call as they are by the 911 dispatcher who answers.
Why the quotes? Because "emergency" is a euphemism for whatever a 911-caller says is an emergency. It is also whatever the dispatcher thinks is an emergency. Tremendous variation exists.
It begins with the interaction between caller and "dispatch," a group of EMS individuals with limited or no medical training who answer 911 calls--usually answering with the phrase "Police and fire." Dispatchers use latitude in interpreting the emergency nature of any particular call.
In our community there are five response levels for medical emergencies based upon the nature and/or severity of the emergency. These levels indicate to EMTs, etc., what sort of problem the caller is experiencing or witnessing, how serious it may be, and what sort of personnel and equipment might be necessary for a successful intervention.
An "alpha" response is a non-immediate transport of a patient for a minor problem or illness, or the transfer of a stable patient from one medical facility (e.g., nursing home, hospital, etc.) to another.
A "bravo" response is more serious and emergent. It is used for motor vehicle accidents in which unknown injuries may have occurred or for patients with undisclosed medical emergencies, whether injury or illness.
"Charlie" designates a serious emergent illness that is potentially life-threatening (e.g., chest pain, shortness of breath, severe allergic reaction).
A "delta" response may indicate a serious accident in which there are known injuries, a serious traffic accident requiring extrication of patients from vehicles, and/or a serious medical problem like uncontrolled bleeding, etc. EMT and/or paramedic assistance is necessary as soon as possible.
"Echo" response is reserved for problems requiring near-instantaneous attention, like an on-going resuscitation attempt by by-standers or the need for CPR. This response usually means someone is as close to being dead, either because of illness or injury, either this side or that side of death, as they can possibly be. Needless to say, echo responses don't usually result in successful interventions.
However, the amount of interpretation dispatchers employ in translating 911 calls into responses varies.
Some examples. Recently, four patients were brought to the ER by an out-of-area ambulance after it had been dispatched to a rollover accident. Initially, all of the individuals were assessed by EMTs and refused transport. After the ambulance had returned to its station, however, a second call went out for EMS response to the the same accident. Apparently, the "victims" realized they didn't have a ride home!
A woman calls 911 because her husband is bleeding. The woman, an ICU nurse, says to dispatch, "We need an ambulance quick! My husband's cut his arm and is bleeding from an artery." Serious? Perhaps...probably. But here is how it got called out:
"EMT Ambulance, Echo response for a hemorrhage, 41 year male, attempted suicide!"
Where that last part came from, who knows? The man had been working with a metal range hood that fell on him. Clearly, what is interpreted as an emergency, and what are the circumstances of the emergency, are as much affected by who makes the 911 call as they are by the 911 dispatcher who answers.
Tuesday, January 15, 2008
The Danger of Driving on Cell Phones
A picture is worth a thousand warnings. Please do not talk on you cell phone while driving. As the popular bumper sticker in Seattle says, "Hang Up and Drive!"
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