Saturday 18 February 2012

Random Thoughts and Stories

Once in a while I start blogging and then run out of steam. I have many many saved half posts stored on this blog that have never been finished or published.  Here are some thoughts I had.

A Nurse can care for all of her patients some of the time, or she can care for only some of her patients all of the time but she CANNOT care for all of her assigned  patients all of the time.  There are just too damn many of them and constant interruptions to boot.

An example of this that springs to mine is what I saw happen to Mary, a Nurse on my ward in England.  She had a patient start bleeding profusely out of his gastrointenstinal tract.  Earlier in the shift she had recognised that he had potential to crash and she prepared for it.  And he did suddenly crash.  All of the sudden that patient was losing consciousness, his eyes were rolling to the back of his head and his skin was turning white.  This was happening fast, like over a series of minutes. Mary had 15 other patients at this time who were all waiting on scheduled meds, treatments, discharge papers, requesting pain relief etc.  Mary put the call out for her bleeder, got about 100 orders to initiate thrown at her and by the time he was on his way to the intensive care unit it had been 2 hours before she got back to her other patients. Then something else happened and she was again kept away from her patients for a further few hours.  Staffing will not give a ward an extra nurse during a situation like this.  It is one Nurse to 15 patients no matter what.  That is what the ward is budgeted for. We don't get extra help if we suddenly have sicker patients.  The number is fixed. The ratio can go down a Nurse but not up.

The family of the bleeding patient wrote a long thank you note to Mary.  They were impressed at how fast she moved to get their father the help he needed, and how on top of things she was.  They wrote a long letter to administration about how wonderful Mary was.

On the same day that administration got the letter applauding Mary they also received letters condemning her.  These letters were from the other 15 patients that got the shaft because Mary's bleeder was sicker than they were.  They condemned Mary as a vile uncaring Nurse who ignored them for hours and didn't bother to bring their meds on time. 

This happens a lot.  Unless you understand what is going on with your Nurse's (or doctor's) other patients and what it involves and time frames involved you aren't really going to grasp how it is going to effect your care.  I might want to go over your medications and tests with you, but I can't if one of my demented patients just pulled out his central line and caused himself a pneumothorax.  I might want to get to you with your pain meds but it ain't going to happen if one of my patients suddenly and without warning goes into a 19 beat   run of Vtach on the monitor and I got to sort him out and transfer him to CCU.  There is nothing I can do to stop those things from happening at the same time so many of you need me for something else. As you are always sharing your Nurse and Doctor with way too many other patients it might be a good idea to get to grips with the concept of triage and prioritisation. 

My sister in law called me on the phone.  She told me that she was 'JUST LIKE A NURSE' because her kid was sick and she stayed home from work to make him chicken soup and cuddled him on the sofa. "I guess I was a Nurse today just like you, Anne" she says.

I nearly fucking ripped her head off for saying that.  First of all if you are not so laden with anxiety that your hair is falling out you are not anything like a NURSE.  Being a Nurse involves being assigned way more patients that you can handle every single day, day after day.....some of them  are so sick it's like if you blink twice they're dead.  Many of them are non complaint and abusive, with extensive drug and alcohol abuse and psychiatric histories.  You can't even come close to doing the things that you need to do for them because of their behaviour, the acuity on the ward in general as well as the short staffing yet you have total liability.

I wanted to say "Listen dumbass, when you spend 14 hours afraid that you are going to be held responsible for someone getting hurt or dying because you can't be 100 places at once then you will have some kind of clue about what being a hospital ward Nurse is about. Until you experience that complete liability and blame with no control you can just shut the fuck up. Taking care of your sick kid, dog, spouse, grandma is not the same thing at all." 

Doctors have more stress but they also have much more control, which helps manage the stress. But anyway as you can see it doesn't take much for me to snap at family and friends with their dumb ass comments about "Nurses".  The cousin who asked me what the hell it is a Nurse actually has to do at night "because all the patients are sleeping, right" no longer has a scrotum.

I feel nothing anymore.  I was talking to a friend from school who is also a Nurse.  I was telling her (Julie) about how the UK thinks that solving the lack of care in hospitals can be done by teaching nurses about empathy and compassion "the most important part of their job". Whatever. After a shocked silence she responded with "but my god, feeling is the first thing that has got to go if you are going to stay in a job like this, why don't they address RN ratios and resourcing".  I agreed. 

After a few years of general floor Nursing I began to feel nothing, completely numb.  I watched my grandma die of old age and felt nothing.  Honestly, I got to the point where I could have witnessed a plane full of kids crash and not even bat an eyelash.  You just go numb and just try to survive.  It's a defense mechanism. Some Nurses get like this after a few months of the job and with others it takes years.  One day you just realise that you have no feelings anymore and you realise that you have to quit.  People who leave bedside Nursing tell me that feelings do come back again eventually. Having got out of the short staffed clusterfuck hospital I worked in when in England, I have to say that I do believe that this is true. You can't put Nurses in these kinds of situations (21st century clusterfuck acute care) and expect them to be patient and empathetic.  Like Julie said, those traits are the first thing that go.  They have too.  Nursing is a whole different ballgame from what it was in the 60's.   Bedside Nursing is hell and everyone wants to escape.  If all we dealt with was bedpans, drug rounds, shit and puke we would find our jobs easy and stay at the bedside. 

And don't even get me started on the Uncle who said "I could never be a Nurse like you Anne, I would find blood and puke to hard to deal with" no longer has any eyes because I scratched them out.  Poor Joe didn't know what hit him, he thought he was showing me a mark of respect by saying that.  Blood and puke and shit and piss are probably the easiest aspects of my job.  His comment was an insult.

I am sure lots of "Nurses" will come on here and take issue with what I am saying.  But not one of them will be people who work as QUALIFIED Nurses in Med surg, general medicine, short staffed MAUs or heaving  EDs.  Come to acute care/general medicine and then get back to me is my preemptive comment to them.  I have lived it and I have done my research.  What I say is true.  People who think that Nursing is a soft service style job for soft people with strong stomachs are assholes.

Mentioning my grandma in this post reminds me of something else I will post about. And that post will probably be more funny than disturbing.

Thursday 16 February 2012

It's Snowing in Hell.

I can't believe it.  I actually experienced support and back up from a physician the other day.  I am so in shock I can barely type.

I had to 45 Max a patient on this particular evening. 

A 45 max is an emergency call out that a ward Nurse can use if her patient suddenly starts to look like death.  I dial 45 and boom: a nursing supervisor, an ICU nurse, senior medical doctors, and security show up.  It's a great resource for the ward Nurses to have.  I can't dump the emergency on them and go back to my other patients but at least I have help with the patient who is the sickest right away. The doctors and ICU nurse will assess the patient.  They will give me about 250 orders that need to be put into the system and actioned right away for the patient.  The nurse supervisor and ICU nurse arranges transfer to an ICU (critical care) for the patient by hunting for an open bed somewhere.  Security is there in case family members start whigging out.  Maybe the 'looks like death' patient's family is freaking out or ,maybe my other patients' family members are going nuts because they are now being ignored because there is an emergency.

This particular patient was coming straight to my floor from the ED (A&E).  I only had a brief report from a busy ED Nurse.  "The patient I am sending you is a 45 year old male came in with fevers and pain, low BP, IV fluid bolus, IV antibiotics started, chest xray negative. He is alert and orientated, self caring, etc etc etc blah blah blah."    (details changed  to protect confidentiality)

15 minutes later the patient arrives on the floor.  Luckily I was nearby and not with another patient getting grilled by their family when transport brought my new guy into my room.   I took one look at this man and I immediately put the call out for a max 45. He was pale and not responding to me.  I got vitals and his oxygen sats were in the 50's and BP was 50 systolic.  I looked at his bracelet and yes indeedy he was the same guy the ED told me to expect.  He had obviously deteriorated very quickly on the way to my floor from the ED.  The ED staff have to process and get sick patients moved up to the wards way too fast because of all of the bitching by the folks out in the waiting room about the waiting time to be seen. And this is what happens.

So I call the max 45 and am doing my thing.  He could have been septic or had some reaction to something who knows, diagnosis is what doctors do. The first people who responded was an ICU nurse and a medical doctor.  I already got 02 and vitals and blood sugar on the guy and an IV cannula in (the one he had from the ED was hanging out). I  also got rainbow labs (the docs expect the nurse to do this in an emergency immediately before they even get there and yes they were done in the emergency room earlier in the day), etc etc.  The doc ordered the usual life saving stuff and I ran out of the room to get it and the crash trolley just in case.   I was also cognizent of the fact that the orders from the doctor that I was actioning are illegal if they are not entered into the system, even in an emergency.

On my way back to the room with the crash trolley and other stuff the son of an elderly patient accosted me.

He got right in front of me and said "hey you get my mother a snack" He then proceeds to give me an order for what she wants as if I am a waitress and this is a restuarant.  I kindly told him that I had an emergency with another patient and would find a way to get his mother some food as soon as I could.

Well he didn't like that at all. He fucking stands there and starts wailing about how "you can't get any service from these fucking bitch nurses" and of course there was the usual "you don't want to help my mother because she is old" shit.

I think it is too hard for some of these men people to grasp that a 5 foot 2  *gasp* mere Nurse with a ponytail actually has so much responsibility that it is often impossible for her to play up to the Nurse as a service maid stereotype.

Well... the max 45 responding medical doctor overhead the conversation and comes flying out of the room, face beet red, and starts yelling at the son like this:

"how dare you talk to her like that, that nurse has an extremely sick patient, she's not your maid, she is needed in this room right now"

This doc completely flipped.  I was in shock.  Usually physicians like to egg these kinds of family members on at the Nurse.  Well some do.  Others just stay silent.  Multiple doctors will ORDER STAT at  one Nurse 150 things at once...everything from time consuming insulin infusions to heparin drips, cardiac drips, NG tubes to suction etc etc and then tell the patient's and families that the Nurse isn't making them coffee because she "thinks she is above basic care and bedpans".  Management won't back the nurses up either as they are so concerned with satisfaction surveys and customer service goals.  They actually promote the"Nurses have nothing to do but be your maid and hold your hand" stigma whilst overloading the floor nurses with multiple patients who are way too sick and unstable to be on the floor sharing their Nurse with other patients.

So yeah, I was sure that it was snowing in hell on this particular day.

The son was like "oh, yeah, whatever, I'm sorry doctor".  The doctor of course is a man and an authority figure. So the son will accept it when the doctor tells him that the Nurse is unable to play waitress right now.  But if the *gasp* mere Nurse tries to tell a visitor like him that she can't play maid right now, visitor will accuse her of being lazy.

At this point we were already back in the "looks like a  corpse" patients room and after 20 minutes of sorting him out we were locked and loaded and on our way to ICU. I was anxious to get him over there and transfer his care to the ICU nurse because I was in the middle of  a drug round, a blood transfuson and a discharge for my group of patients when all this started.  I do actually care about getting back to my other patients who were feeling neglected whilst wondering just where the hell I was with their stuff. 

Still can't believe that I got that kind of back up from a Doctor.  He was an older guy too.

Rock on elderly old school white coat wearing doctor I say.

General medical wards are hell everywhere but at least over here the staffing is a bit better and the back up is good in an emergency as opposed to the UK.   Families are nuts over here too (worse probably, we have armed security at my hospital because of them) but I feel better able to deal with them sometimes.    I do miss English MAUs though as far as admissions go.  Ours are direct from the ED. 

Wednesday 1 February 2012

Horrible things that Doctors do to Nurses

In my last post prior to this one I talked about my sincere respect for Junior Doctors and all they go through.  And that wasn't bullshit. I do respect and admire them.   But for the sake of balance let's talk about all the horrible things that doctors do to nurses.  The number one thing that causes Registered Nurses to run away from the ward and frontline care is their Physician colleagues. Number one. Numero Uno. We don't hate cleaning up body fluids, or dealing with bedpans and death and dying.  We don't mind washing patients, doing dressings or getting our hands dirty as well as all the skilled jobs that Nurses have to do.  We leave the wards and healthcare in general because we want to get the hell away from Physicians.  The junior ones are still pretty human towards the Nurses.  They work hard, take a lot of crap and we respect them.  But once they get past the level of "junior" I just want nothing to do with them.  Not personally or professionally.  Not anymore.

The abuse of Nurses  by their medical colleagues is nothing new.  Even Claire Raynor reported a surgeon throwing instruments at her decades ago.  My godmother, an RN in the 1960's and 1970's, tried desperately to talk me out of Nursing school.  "Doctors are mad at the world and it's the Nurses that they lash out at;  you never want to work with one of these people" she told me.  At that time I pictured my friendly family doctor and just laughed her off.  I had only ever had experience with doctors as a patient.  Working with these people is a whole different experience. The medical profession has a cruel streak and it is directed at Nurses.  Always, always has been.

I don't even go to the doctor when I am sick.  I try to tough it out unless I become convinced that I am going to die. He might find out that I am an RN.  I told him that I am a homemaker, but he might find out that I am really a Nurse. Then he'll act like a creepy bastard towards me.  It's no better with female doctors.  They hate Nurses even more I think.  The word is 'hate'.  Make no mistake about it.   And it has nothing to do with the bad nursing care on the wards (docs don't give a shit about nurse staffing), or the grumpy nurse who was mean to them when they were struggling students.   Doctors need to decompress and registered nurses are not only an easy target but the only target.  If they treated anyone the way they treated RNs they would probably be in jail.

I have seen many a Nurse fired for a physicians' mistakes.  Too many to recollect all.  Doctors are valuable and an RN is easy to blame and cheaper to sack.   Doctors will lie through their teeth in order to pass the blame onto an RN.   They lie about orders they gave or did not give. A lot. If a treatment goes bad they can pass the blame onto the scummy, incompetent Nurse. It's very, very easy for them to do. 

As an NHS staff nurse I once had a new patient admitted to my ward.  He has necrotic toes and was in agony.  I looked on his drug chart and no pain medicine had been prescribed.  I cannot give pain medication without a hospital doctor's order and approval from pharmacy.  This is a time consuming process.  I phoned the doctor on duty to get the order.  His reply was "fuck off" and he hung up on me. I called him back.  He told me to tell the patient to "deal with it" and hung up.  I called him back at which time I got about 15 minutes of abuse and name calling.  Then he refused to call me back.  I finally got a doctor to prescribe for my patient.  But that time the patient had been in agony for way too long.  On the ward round the next day the abusive doctor says to the patient "You poor thing, your nurse never bothered to give you pain medicine, I will deal with her" and then he actually smirked at me.  I've come to expect this kind of behaviour.  If I told the patient what really happened I would lose my job. 

Path lab once called me to tell me that my patient had a hgb of 7.  I looked at yesterday's results.  Yesterday her Hgb was 11.  She was weak and short of breath.  I took her obs and her blood pressure had dropped.  My job in this situation is to look for signs of bleeding and notify the doctor of my findings. I called to notify the doctor of the critical lab value "I'm too busy for this crap, so just fuck right off" was the response I had from this patient's doctor.  Then he hung up on me.  Later on during the ward round the consultant wanted to know why a blood transfusion had not been prescribed yet.  "The nurse never reported the low Hgb to me" replies the doctor who had hung up on me nearly 4 hours before.  That got me a long lecture from the consultant explaining (yelling at me in the middle of the ward) to me why a sudden drop in hgb is something that needs to be reported to the attending doctor.  Well, Duh.  I did try.

Natalie was a nurse on my ward.  She had a patient with a really complicated dressing change.  The dressings that needed to be used were expensive and much more specialised than simple gauze.  The damn things had to be ordered from pharmacy which is a mission itself. The patient had waited 5 hours for a dressing change by the time Natalie obtained the necessary materials.  She set them up on a trolley and was on her way out of the treatment room and down the ward to the patient when a doctor saw her.  He wanted a trolley for his notes and couldn't find one.  So he grabbed the trolley from Natalie, dumped all of her materials onto the floor, did a little dance on them, piled his notes onto the trolley and walked down the ward.   At that point pharmacy was out of the stuff and the patient had to wait days for more.  Which of course got blamed on "lazy, neglectful Nurses'.

Report these Physicians at your own risk, Nurse.

I had a patient express a desire to have a sleeping tablet prescribed.  I cannot prescribe, obviously, so I called the doctor on duty to get an order for something.  "Tell her that this isn't a hotel" was the response of the doctor just before he hung up on me.   Then he never returned my calls.   The senior doctors above him consider it beneath them to take calls for this kind of stuff.  She never got her sleeping tablet.  The patient complained the next day about the Nurse not bothering to give her a sleeping tablet. The doctor told her that "no one had asked him".  Liar.

When a doctor refuses to return our calls, hangs up, tells us to fuck off, insults that patient, lies etc etc we are not allowed to document it that way.  We have to write " notified doctor of patient's request, awaiting orders".  Not "doctor told me to to fuck off, that Gladys is a pain in the arse, and hung up on me".  If the doctor lies and says "but the nurse never told me......"  There is nothing that the Nurse can do.  The doctor's word is the doctor's word.  And that is the case even if their are other Nurse witnesses to his behaviour.

In a sudden emergency a doctor gave a strong verbal order to one of my Nurse colleagues.  "Nurse give this patient 10 mg of dangerdrugacin" he shouted.  The rule is that we are not allowed to give anything without a doctor's order in writing.  But an emergency is an emergency and if you ask a doctor to write out an order in the middle of one he will rip your head off and kick it down the ward.  The Nurse gave the drug that the doctor verbally ordered.  The patient had a terrible reaction and died.  The Nurse got fired.  They had to blame someone to appease the family so they used the fact that the Nurse gave the drug "without a doctors order".  As the doctor never put anything in writing, he was off the hook.  Two other people heard the doctor give the order to the Nurse and said so.  She still got fired.

I had a 30 stone patient admitted to my ward with respiratory distress.  While I was admitting her I noticed that she had a stage 3 pressure ulcer on her sacrum.  Her husband informed me that even though she can walk she refuses,  and rarely moves at home. She sleeps, eats and does everything in her mobility scooter.  I asked if she had been in hospital or under the care of nurses in the last year and he said no. The doctor came into see her.  I told him that she had a pressure ulcer that looked infected.  "Well that is the fault of the Nursing profession, you Nurses don't turn people" he shouts in front of the patient. I calmly informed him that the patient came into hospital with the ulcer. "Well it's still your fault" he says.  At that point I asked the patient if she could stand up.  She did so and asked her husband to bring her scooter up to the ward so that she could go out for a fag.  When she was outside  I asked the doctor if a pressure ulcer in a  fully mobile patient who has not been in hospital under the care of Nurses was still the Nurse's fault. "Oh Fuck off, she has a pressure ulcer because she is a fat pig" he said.   I then asked him why he told the patient and her husband that it was the fault of the nursing profession that she had a pressure ulcer.  "Because I can" he said.

Doctor came to see the patient and told her that she could go home.  Then he left the ward for 10 hours.  He did not write her discharge orders or her drug prescriptions before he left.  It took me 10 hours to get him back to the ward to do this.  I am unable to discharge the patient without it.   When I called him I was told "I'm busy, tell the patient to fuck off about her discharge" etc etc.  When he finally came back to the ward the patient said to him "Doctor, you told me that I could go home this morning , why have the nurses made me sit here all this time".   "Because the Nurses on this ward don't have it together" he told her.

How many times have doctors left orders for meds on the drug chart that should not have been there, only for the Nurse to get blamed when the drug was given?  Seen that more times than I can count.

Nursing homes and social workers take 6 weeks to arrange a place for patients who need one.  At least.  The hospital nurse has no power over this.  But that doesn't stop consultants for screaming at Nurses because "that patient is still here, don't you understand that she could get an infection because you fucking nurses didn't get her out of here, it is YOUR FAULT IF SHE DIES, YOUR FAULT".  Usually this kind of stuff is said within ear shot of all the patients.

I once saw a doctor scream "You dirty pig" at a housekeeper (A HOUSEKEEPER) who dropped some cups on the floor. He then turned to the husband of a patient he was chatting with and said "We have to keep these dirty pig nurses in line or they would hand out the filthy cups that landed on the floor to the patients".  The husband just nodded.   The doctor knew that she was a housekeeper and that she was heading back towards the dishwasher with the cups. He was just being an asshole, because he can.

If a doctor forgets to order lasix cover between units of blood it is "the nurse's fault, because she should have reminded me".  If a doctor order's something incorrectly "it is the Nurse's fault for not catching it".

If a doctor doesn't come and see a patient for hours and hours despite repeated calls from the Nursing staff it is also "the nurse's fault".  If a ward nurse is forced by management to take care of 30 patients on her own, it is also her fault if the patients get neglected or an order gets missed, according to the doctors.    If kitchen sends up the wrong food: doctor screams at the Nurse.  CT department can't fit that scan in today: doctor screams at the Nurse.  Social services delays nursing home placement: Doctor screams at the Nurse.  Patient who has been ordered to be nil by mouth sneaks food behind the Nurse's back: Doctor screams at the Nurse.  Patient refuses prescribed treatment or medication: Doctor screams at the Nurse.  Pharmacy takes forever to dispense drug and refuses to stock the ward: Doctor screams at the Nurse.  Patient decides to be noncomplaint with his fluid restriction nd renal diet and sneaks 10 litres of cherry fucking coke behind the Nurse's back: Doctor screams at the Nurse.  You know damn well that neither can we watch your patients constantly nor get them to listen to us! Physio and OT avoid patient: Doctor screams at the Nurse.  And he usually does this in front of patients to undermine the Nurse and make himself look like the hero.

Fuck this shit, Doctor.  I am not a babysitter.  I am not some self sacrificing angel who exists to take the fall for you. And neither am I a punching bag because your are frustrated with your job.  Nurses CANNOT control your crazy, noncompliant patients, the allied health professionals, the waiting times in the GI department, nor pharmacy, nor social services nor blood bank nor relatives nor transport.

It's no better in the United States.  The doctors here don't do shit.  We Nurses have been told that if a doctor wants to prescribe a med that HE has to enter the order into the system.  But he doesn't want to 99% of the time.  He says "enter it yourself or your patient doesn't get it".   And then he hangs up.  If I enter it wrong or the patient has a bad reaction I will get the blame because I entered it.   Or the doctor can say "I told her 2mg not 4 mg" even though he really did say "4 mg".  They can basically change their order after the fact this way and pass the blame onto the Nurse.   Thank god I only have 6 patients here.  The doctors throw so many orders out at the Nurses but they refuse to enter them into the system.  If I had 15+ patients like I do in the UK I would have to spend the entire day on the computer entering their orders for them.  If the patient is actually going to get the treatment, the order has to be in the system.  If the Nurse doesn't do it for them, and the patient doesn't get their treatment, the Nurse gets blamed.  I can feel the eyes of the patients and relatives burning holes through the back of my head while I am on the computer.  They probably think I am on facebook or something.

Oh my, I could go on for 100 pages with these kinds of stories. 100 pages easy.  But you get the gist.

If a Nurse leaves general ward nursing, she gets away from this. Full stop.  Well usually.  You might want to read this:

It always kills me when doctors say that Nurses leave ward nursing because we don't want to be bothered with bedpans.  The truth is that we want to get away from Physicians.