Saturday 28 January 2012

Respect the Junior Doctors

I had some real bad days as an NHS staff nurse. I felt like the stress and frustration would kill me. But there was a never a day where I felt like I would rather be a Junior Doctor. Those kids run their asses off.

They often carry the pager for the whole hospital. They are dealing with incredibly complex cases at the same time as routine stuff with nothing more than 5 seconds between bleeps from yet another staff nurse on another ward. We nurses have to call them for a lot of stupid shit as well, because of dumb rules. Some nurses forget that the medic is trying to be 1000 places at once and get impatient and demanding.

I have seen junior doctors collapse in crying fits at the nurse's station, breaking down to the point where they couldn't answer their bleeps. We tried to help the best we could by answering the bleep and telling the caller that the doctor was busy and would get back as soon as he could. We knew that the consultant would show the juniors no mercy and we tried to protect them. Well some of us did. Others were so worn out and mired down in the bullshit clusterfuck that is ward Nursing that they just lashed out as a way to cope. It's like they enjoyed watching other health care professionals squirm and suffer.

Junior doctors would lash out too. But I found that, as a group, they were more of a friend to Registered Nurses than any other health care professional group out there.

Once I made a mistake as a newish nurse (thank god no harm came to the patient). When I realised the mistake, the first thing I did was call the junior doctor on call, who was already very busy I'm sure. He was very kind and reassuring on the phone. He came to my ward straight away and reviewed the patient and then he calmed my anxieties, wiped away my tears and reassured me that everything was fine. He said that he thought what I did may have been good for the patient rather than bad. Those words of encouragement from him helped me to get through the rest of my shift.

In turn I always tried to encourage and reassure the junior doctors whenever I could.

I saw this blog this morning and it reminded me of so many things I saw at work. It's a great read. Have a look at it.

Must be time as a young doctor: Running like a mad man: When a crash bleep goes off on your first day you know there is only one explanation. You’ve been cursed. That’s it, must be the only op...

Thursday 26 January 2012

Worry grows as second senior nurse leaves NMC | News | Nursing Times

Worry grows as second senior nurse leaves NMC News Nursing Times

My god. I hadn't actually realised that the Nursing and Midwifery Council has so few actual Nurses on staff. According to this article, they practically have none. The Nursing and Midwifery council is the organisation in the UK that licenses and regulates RNs. In order to work as an RN we have to by law be registered with these people. And they are expensive.

I always knew that they were brain dead and living in a fantasy world but I just put that down to the fact that they were older Nurses who haven't worked clinically in years.

But the truth is that they are not Nurses at all. There is not one person in that organisation that is able to grasp what a Registered Nurse actually is and neither are they able to grasp the idea of Nurse vs unlicensed assistive personel.

If they haven't worked on a ward as an RN responsible for a large number of critically ill patients, they simply won't be able to comprehend the situation. No one can unless they have done it. It is too complicated. Even RNs who left the wards in the 80s cannot comprehend the situation. At all.

This sure explains a lot about why the NMC is so useless.  And it sounds like they are "divided" over the licensing of health care assistants.

If they license the health care assistants, then health care assistants will be counted as "Nurses".   Your local trust will use this as a way to decrease the number if Nurses working at the bedside. 

Health care assistants cannot give meds, action and evaluate doctors orders, respond to emergencies, communicate with physicians regarding consults, hang IV infusions, assess for changes in condition, notice a potential emergency arising or plan nursing care around priortizing in a chaotic ward. 

They simply change beds and do skills without thinking.  It would never occur to a health care assistant to notice that the black tarry stools you are passing whilst on a heparin drip may signify the need to contact a doctor, get a PTT ordered, maybe get the drip held and watch closely.

Doctors, I hope you are getting ready to action your own orders, medicate your own patients, titrate your own drips, drop your own NG tubes, program your patient's IV pumps, watch for a million one possibilities for each patient (everything from pre renal failure to hypoglycemia and changes in LOC), do your own ward admissions and discharge planning, escort patients to tests in case they crash in the lift on the way, mix and administer all the IV antibiotics you order, and chase down pharmacy and fight to get the meds you want your patients to have.  The care assistants cannot do this.  You will have to do it when the RNs are gone.

Doctors, I really hope you are getting ready to handle all of that as well as your own jobs.  See the writing on the wall.   The RNs are being whittled away. They are going to license health care assistants so that they can get away with replacing Nurses with cheaper alternatives.

People think that all you need for a nurse is a kind heart and a willingness to clean up shit.  You'll have that in the HCAs, but that is all you will have.   Those wards will have nothing but health care assistants. Health care assistants cannot and will not get involved with any of the things I have suggested that you get ready to do.  You poor bastards are going to have to do the job of a ward RN as well as your own job.   There are so many real nurses unemployed right now and desperate to work on the wards,  but they are unable to find jobs.   This will get worse when health care assistants are licensed.

And once the health care assistants are licensed the Hospitals will legally be able to say "but we have 6 nurses on the ward" when really there are only 6 health care assistants and no Nurse. 

Hospital Doctors, if I were you I would hunt down the ward nurses to find out how to program an IV pump, do a drug round, mix iv meds, do trach care, peritoneal dialysis and the quickest route to pharmacy. All these things that you order (and expect to be done instantaneously) are going to have to be done by you when the RN posts are lost. I am sure that the RNs will show you the ropes before they are all made redundant.

The Nurse's Lament

What does Bill Paxton's performance in the movie Alien have to do with NHS Nurses, you ask?

In this clip he sounds just like an NHS general ward RN at the START of her shift. She is going to sound worse after it ends.

When I arrived to work (when I worked in the UK) and found out:
1. That I am going to be forced to take on way more patients that I can handle
2. I'll be the only qualified Nurse for 16 patients who are already either pissed off, or dying, or both.
3. The patients I am assigned are way too critically ill and complicated to be on my general ward, but there they will stay......
4. Bed management is going to slam us with admissions and take staff away even though we are already fucked.
5. The only staff I will have with me are useless clerical types and allied health professionals who will sit at the Nurse's station gossiping all day, really pissing me off.
6. The phone calls from angry relatives will all be directed towards me all day long.
7. The mean doctor who never calls back and just hangs up on us if he does is the one holding the bleep today.
8. The realisation dawns on me that I will be held accountable for anything and everything that goes wrong, happens, gets omitted etc, even though I have no control.
9. In addition to all this, 4 or 5 patients are going to be going off the ward EVERY hour for tests and procedures requiring a Nurse escort. We have two nurses for the entire day.

I come out of handover sounding just like Bill Paxton in the movie Alien. We all sound like this. "Game over, man, game over. What the fuck are we supposed to do now". And then it goes downhill from there.

It's really the most realistic portrayal of medical-surgical RNs talking that I ever saw from the movie industry, and they weren't even trying to depict us.   Both pre and post project 2000 nurses who work on the wards currently sound just like Bill Paxton's alien charactor.  Can you feel his state of mind as he screams "game over man, game over"?  Now picture someone in that state of mind acting "loving, caring, patient, and empathetic". 

Wednesday 25 January 2012

The Violence

Once upon a time in the spring of 2010 ( I think) I was scheduled to work a night shift from 8 at night until 8 in the morning.   This wasn't unusual because all staff nurses have to work night shifts once in a while.  Sometimes we work a whole week of nights.  Other times our night shifts are mixed into the same week as day shifts.  Our work schedules have no regular pattern and we get very little notice of what we are going to be scheduled to work.  

On this particular night I came into work at 7:40 PM to start getting my report sheets with my patients' info together so I could be organised and not miss anything.  I learned that on this particular shift I was going to be the Nurse for beds 1 to 15.  Beds 16 to 30 were going to be covered by Jenny.

Jenny is a wonderful Nurse.  She is about 60 years old, trained in the old days, and had been doing this job since before I was born.  We just love her. 

The staffing for the shift consisted of myself (a younger RN), Jenny (an old fashioned trained RN), and Kayla a care assistant.

Jenny and I are both RNs.  We both do the same job for the same pay despite our backgrounds.

In my section I had beds 4, 8, and 11 empty.  They had been empty for about 45 minutes as three patients were discharged around 7PM.  I know that A&E is always full and at anytime I would be getting a phone call that admissions were coming into those beds.    I was going to have to handle that as well as handle the other patients I already had.  Predicting when those new admissions were going to come in is impossible.  All I knew is that I had to rush meds, assessments, infusions and everything else that needs to be done for my already present patients as fast as possible so that I could deal with the admissions.  I hoped that they wouldn't come until after I saw all my patients.

Jenny was taking over beds 16 -30. In her section beds 19 and 28 were empty.  There had been a death in bed 19.  Bed 28 had become critically ill around teatime and the day nurse had just arrived back from transferring her to ITU.  The patients in beds 16-30 had no care for about 3 hours at this point.  The day nurse had to deal with the critically ill patient and then transfer him to ITU.  So Jenny also was going to be getting admissions at some point too.  And she also was going to have to catch up many things. The nurse who had my soon to be team of patients tried to help out with beds 16-30 but it wasn't enough.

I dread admissions. Admissions are pretty complicated and require an hour or two of focused attention to ensure that you don't miss something important i.e. a doctors order for blood, an allergy, etc.  There are thousands of things that the Nurse has to think about with an admission. Usually when admissions come to the ward it is very unclear what is going on with them and what they require.  It takes a bit of detective work on the part of the Nurse to find out and act on it.  Has this patient had the IV bolus that the admitting doc ordered?  Why are no pain meds prescribed?  I can see in the history that he has chronic back pain and takes meds at home..but no pain meds are prescribed?  His hgb is 5 but no one has prescribed blood. Call the doctor and see if he wants it given otherwise get yelled at for not asking.  And on and so forth.   Too make a long story short, admissions are a bitch.

Jenny found the day nurse who was caring for patients 16-30 and started getting handover from her.  I found the day nurse who was caring for beds 1-15 and started getting handover in a different room from Jenny.  If both of us listened to the information on all 30 patients we would be in report forever and that would just slow us down even more. 

Straight in the middle of report (handover).  The bed management people phone.  "Your two new admissions are coming within 10 minutes, we have yet to assign your other empty beds but A&E is full, so we soon will be." she says. 

"We only have two staff nurses (me and jenny) and one care assistant (kayla), can we please have more staff" I ask.  "No, dear" she says, and hangs up on me.
"Great" I say.  I haven't even got through report on my other patients yet, let alone seen them.  But new patients are sent when it is necessary for the sending department and not when it is safe for the ward nurse to take an admission.

At that moment Jenny comes flying into the room where I am getting report.  She looks white as a ghost.

"OMG, what just happened" says me. The look on her face made me assume that someone either just died or fell or was in the process of crashing.

"My new admission for bed 19 is here.  It's Jimmy".

Oh no no no no noooooooooooo .  Jimmy has been here before. Many times.  He's an alcoholic with a massive psychiatric history and he tends to kick the shit out of people.  Jenny informs me that he is getting admitted into her bed 19 for detox and a possible GI bleed. 

Jenny and I run onto the ward.  Bed 19 is in a bay with 5 other patients.  And that is the bed that bed management has assigned to Jimmy.  Bed 20 has a man dying of cancer. Bed 18 has an elderly man with confusion and fall history who has been diagnosed with a blood clot and is on a heparin drip that needs to be closely monitored. Bed 17 is a brittle and non complaint diabetic on an insulin drip.  Both heparin drips and insulin drips require close monitoring by the staff nurse.  Bed 16 has a young man recovering from pnuemonia. Bed 15 was a renal patient. And of course there are still my 15 patients and Jenny's other patients in the bed 16-30 assignment as well.

The porters dumped Jimmy into bed 19 and walked away. Thank god in heaven he looked asleep.  Jenny and I checked him over quietly to ensure that he was breathing. Then I flew to the phone and called bed management. "how can you dump a violent patient onto a ward with frail, vulnerable, medically unstable patients and hardly any staff" I yell.  "Look Anne, stop whining, put on your big girl knickers and deal with it" says bed management.  And then they hung up on me before I got another word in.

Now Jenny and I were raging.  We called the nursing supervisor on call for the hospital. While we waited for him to call us back we finished getting report on our other patients so day shift could go home.  They had been there for over 14 hours at that point.

Now it is 9PM and no patient has had any care from the last few hours of day shift and the first hour of night shift.

The nursing supervisor comes to the floor.  Jenny and I explain the situation.  "What do you want me to do about it" he says as he shrugs his shoulders.

Now I am breaking out into a cold sweat.  My hospital has no security team.  Jenny, Kayla the carer, and myself were on our own. 

I asked the supervisor just what the heck we were supposed to do when Jimmy wakes the hell up and starts beating patients and smashing the place.

"RUN. Go to the nearest ward and call 999".  he says.

And then he continues with the following statement "Jimmy already broke bones in the ED about a month ago when he was last here, it took 7 members of staff to hold him down. He is sleeping now because they gave him stuff but yes, it is going to wear off.  He spent time in jail for holding an ex partner hostage and torturing her for about a week.  This is the kind of bloke you are dealing with. Just run.  RUN"

I then ask him what I am going to to if Jimmy starts attacking the other patients in that bay. This is a very likely scenario with an alcohol detoxer because they go nuts.  And Jimmy is a violent thug on top of being a detoxer. "I'll have to try and tackle him I guess" I say.

The supervisor shook his head at me. "Come on Anna, he'll kick your head in. If you see him start to stir and wake up, just run off the ward and call 999.  I am sorry, I tried to stop them from admitting him to your ward.  I did. Im sorry. Bed management overruled me and the hospital manager on call has refused to pay for any kind of security. I can't help you any further. I'm sorry you have to deal with this".

And with that statement the supervisor turned around and walked away.  He had to deal with worse things going on in A&E. I'm serious.

"Let's pray that he doesn't wake up till morning when day staff comes in" whispers Jenny. 

I still had 15 patients to attend to and by 10 PM all of the new admissions were rolling onto the ward simultaneously.   Jenny started with her lot by seeing to her patients on heparin and insulin drips.  Those kinds of drips are not something you fuck around with and neglect. That's right, she had to go into the bay that Jimmy was in.  We should have gone in together but I was so concerned about my other 15 patients and the new admits that I just didn't go with her. 

And bed management, those rotten sons of bitches.  They still sent new admissions to the ward and denied us additional staff even though they were very well aware of what the situation was.

At about half past 10 I was with my patient in bed 1. I had gone to her first because she had something going on that needs to be checked every 15 minutes.  It is a med ordered by her doctor. I was listening to her bitch about "not being cared for during the past hour by you lazy nurses and didn't get my pain meds" when I hear a dull sound.  It sounds like a thud, like a body hitting the floor.  Then total silence.  Then I heard a shout and a door slam.

Oh shit.  He woke up.  I guess I should add at this point that we had earlier called the physician and asked him to prescribe additional sedatives for Jimmy so that we could administer them if the shit hits the fan. He never called me back.

So I hear this dull sound and I go running towards bed 19. As I ran out of my bay one of my patients shouts this at me "I'll have your job if you don't give me my meds and tuck me into bed in the next 30 seconds.  I ignored her and just ran while thinking "God I don't even know if my new admission who is bleeding out is even still breathing, and you want me to tuck you into bed, you crazy bitch" and "god why do I have these nasty thoughts, guess I'm burned out"

 I run to room 19. Jenny is on the floor, propped up against a wall.  She had been punched so hard in the face she is insensible.  She is conscious though.  Jimmy and the young pneumonia patient are locked in a full on fight.  I learned later that Jimmy had got out of bed and got Jenny from behind.  The patient witnessed this and tackled him. Jimmy got away from him, grabbed Kayla and started heading for the door.  I took off to the nearest phone to call 999.  Jimmy had dragged Kayla into a bathroom and locked the door.  Then he came back out and headed towards me on the phone.  When he left the bathroom, Kayla re-locked the door for her own safety.  I ran out the door over to the nearest ward.  It happened to be an ITU that was locked. I banged on the door.  A staff member opened it.  I could barely talk. 

I just said "detoxer. beating staff. please call 999".  She ran to the phone and and called the cops and someone else came back down to the ward with me.  I was so afraid for the frail patients in that bay, especially the man dying of cancer. I think the unit I ran too  must have called the supervisor and the medical doctor on call because they were on the ward within minutes.  The medical doctor took one look, mumbled about not wanting to prescribe benzos to someone with liver problems and needing to call his consultant, and then ran off.  The pussy.

The sup and the staff member from the unit had tracked Jimmy to the treatment room where he was sitting on the floor weakened and vomiting blood.  It isn't uncommon for alcohol detox patients to have gastrointestinal bleeds.  Now I knew that he would need a blood tranfusion, that psychiatry would not see him because of his medical issues, and that he would be staying here on my ward. Fuck.

The police came quickly.  I was seriously impressed at their response time.  Like 5 of them showed up.  At least something in that town was well staffed and able to handle an emergency.  The hospital wasn't.

Kayla sat with Jenny. While the police and the nursing sup were with Jimmy I quickly checked on the most unstable, unwell patients (paying particular attention to those with potentionally dangerous meds infusing).   Bed management called at this time and wanted to know if they could send another admission.   "The hospital is on alert as there are no beds anywhere and lots of patients in A&E."

"I haven't even seen the last admissions that you sent to me, nor my other patients. We have no more beds, and a nutcase smashing the place up, I am down a nurse because she got punched in the head.  Do not send me another admission.  My ward is closed" I yelled.  The fuckers sent one up anyway.  A&E was busy, people were on trollies and targets were being breached.  When targets are breached the government fines the hospital, thus taking vital funds away for things like...ummmm...SECURITY AND NURSING STAFF.  

But they sent her up anyway. The people in bed management are not nurses or doctors, they don't care.  New patient was a precious 70 year old with an even more precious daughter who arrived on the ward yelling at me about the wait in A&E and demanding food for herself and her poor starving mum.  Neither of the two of them looked like they were malnourished.  Believe me. God, if they are yelling about lack of food now, just what the hell are they going to do to me when they find out that A. there are no beds to put mam into and B. There's an out of control violent person on this ward. That daughter is going to kill me. Unless Jimmy kills me first.

And it was around that time that the police told me that they had to leave.

Jimmy, however, was staying.

Do you guys want to hear the rest or is it all too insane?  This is the reason  I never posted this back in 2010.

disclaimer. If you think you know any of the people involved with this, you are mistaken.  Names and info have been changed to protect confidentiality.

Wednesday 18 January 2012

A New Start


Well I have been in the States for months now and still haven't bought a PC.  Blogging from a crappy tiny laptop notebook thing would probably cause me to loose my hair.  So I am finally going to buy a real desktop computer.

Is anyone even still interested in this Blog?  Should I let it die because I am no longer in the UK? Or do you want to hear some stories from the NHS frontlines that I never dared to post while I was actually physically present in England?

To be honest I was going to let it go.  But then David Cameron's comments about Nurse's doing hourly rounds nearly caused me to choke to death on my own vomit.

He doesn't seem to grasp that one qualified nurse to 15+ patients is not going to be able to get around to everyone she is responsible for in a 12 hour shift.   The only things she is going to be physically capable of handling are the most high priority doctors orders and tasks and emergencies.  Those things are not going to go away at any point in her shift so that she can round.

What Cameron won't admit is that the government has had hiring freezes on qualified nurses for years, decades even, and that the trusts are refusing to pay for more than one or two qualified nurses to staff  40 bedded wards for a 12 hour shift.   The acute medical wards have the sickest most complicated patients outside of critical care and also have the lowest staffing levels of qualified nurses in the hospital.  In addition to that acute medical wards are also bombarded with elderly patients who need one to one care in order to survive and be treated with dignity.  Bombarded is an understatement.  The system simply cannot cope with the growing population of dependment, medically complicated elderly.  It is the same here in the USA.

When qualified Nurses such as myself would call management crying and asking for help because patients were suffering we were told "tough" "not managements problem"  "not within budget" "you aren't getting any help, deal with it" "grow up" "put on your big girl knickers" etc etc etc.

When we would tell management that forcing qualified nurses to fill in hundreds of forms in order to obtain emergency transfusions, medications, labwork, diagnostics, and equipment stopped us from getting near our patients, we were told "tough".  If I had refused to fill in the forms in order to do a Cameron round on my patients I would have been held 100% responsible for any deaths that occured due to missed transfusions, medications, labwork, diagnostics and lack of equipment.  David Cameron knows that this is the situation.  He is not going to admit that government is NEVER going to finance the hospitals properly or force local managers to staff wards with enough qualified Nurses.  So he is trying to pass on the blame for neglect of patients and save his own skin by depicting Nurses as people who just don't care.    I would hope that the public isn't dumb enough to drink that Kool aid but comments I see in the papers make me despair.

In the early 90's hospitals had the bright idea of trying to control costs by reducing the number of qualified Nurses at the bedside.  The managers who control staffing and budgets are people with backgrounds in finance.  They are not people with a background in health care.  They do not understand how crucial qualified Nurses at the bedside are to patient outcomes.  These people also do not hold a license to practice in the way that a doctor or a qualified nurse does.  Therefore they cannot get held responsible for the lapses in care that are caused by their refusal to staff hospitals with enough qualified people.  They make a lot of money from forcing doctors and nurses to take on uncontrollable workloads and by replacing qualified staff with unqualified people.  And they are not the ones who get labelled as uncaring and incompetent by the papers, even though they have total and sole control. They even make it so bad that as a qualified nurse I cannot even control how long I spend with each patient, except to keep the time to less than a minute.  Junior doctors have it a lot worse when they are carrying the bleep for medicine.  

We do care.  But patients sure aren't going to see that side of us when we are prioritizing, overwhelmed, full of anxiety, hungry, exhausted, panicked and scared shitless. And angry.  We ARE ANGRY.  We are not angels, or superhumans or demons or anything else.  We are just plain people trying to do our best. Granted that health care professionals can handle a lot more than most people.  But we are by no means magical, perfect or superman.

When these finance cunts are told that patients are suffering and dying their response to the health care professionals is often "tough" "deal with it" and "sucks to be you, nursey".

Now who is uncaring?  The Nurses and the Doctors?  Don't think so. 

Caring with no control over the situation equals no care at all.  Your doctors and nurses care.  But they are simply cut off from time, resources, control and support from budget driven cunts with MBAs.

By the way, if you walk onto a ward and see support workers and secretaries sitting at the Nurse's station gossiping and cackling is no indication of how busy the Nurses and Doctors are at that moment.  Unqualified staff cannot help us with most tasks. Just an FYI.

So yeah I was pretty sick over David Cameron's comments, enough to want to start blogging again.

My readers have probably all grown old and died by now ;).  But if anyone out there has looked at this, thanks for reading!