Insights from a Girl Who Knows Better

Jun. 13, 2015

From Me to Mother Ocean

A second away I can touch you
A minute away I can see you
An hour away I can smell you
A day away my heart aches for you
A decade away is unimaginable
A lifetime away is a lifetime lost
May. 28, 2015

ER Nurses: The Cycle of Violence

I often say that ER nursing mirrors an abusive relationship. It's a predictable cycle of violence. 
In previous blogs I have mentioned that in my opinion the enemy we as ER nurses face shouldn't be each other. Our enemies are injuries and illnesses. Don't you agree?   I know you do. It is counter-productive to attempt to add each other to our list of enemies...but we do it and for the life of me I cannot figure out why.  I do have a few theories but haven't made a true conclusion to explain the inexcusable passive-aggressive violence that ER nurses  project upon each other. 
 
1. Treating each other badly is a way to control something, ANYTHING, in a chaotic environment. 
2. Tearing others down makes some people feel better about themselves. 
3. Some people have a constant hunger for power and degrading others feeds this hunger. 
4. Keeping the spotlight on someone else means that the spotlight isn't on them. 
5. Some people are just jerks. 
 
I'm sure that there are multiple other explanations for lateral violence in emergency medicine. These are all reasons that there is a constant need to walk on eggshells while at work. Most ER nurses have Type-A personalities. It is excruciating and exhausting for a Type-A personality to continually walk on egg shells.  Type-A people are assertive, sometimes overly so. Type-A people have a tendency to speak their minds and feel that their way of doing things is the absolute BEST way of doing things. Unfortunately, if Type-A people are true to themselves at all times in the ER, they will end up in the supervisor's office on a regular basis. (Hence the walking on egg shells approach.) This creates a bit of a pressure cooker situation. 
 
Sometimes it only takes a few shifts, other times it takes months or even years but it is inevitable...every ER nurse explodes.  It's not pretty and there are usually victims involved. I have seen it time and time again. That sweet nurse that always smiles, is always grateful, always positive...they are a ticking time bomb just waiting to explode. Trust me. That sweet nurse is one tiny incident away from making a complete ass out of themselves. It might be a loud explosion with multiple witnesses, complete with tears, snot, and drool. OR it might be a slow-leaking explosion manifested in poor attitude, decreased participation, and feelings of helplessness. Either way, it happens and then the fall-out begins. 
 
It only takes a moment or two for the ER nurse to think, "Oh shit. Whyyyy did I dooooooo that?!?"
They immediately know that their explosion has instantaneously placed them in the spotlight. They also know that this is not where they want to be. Being in the spotlight means every move you make will be scrutinized. Every patient complaint, any tiny detail that was missed in charting, any possible misunderstanding between you and another staff member...these are all excuses for management to write you up which gives them ammunition to support the fact that they are going to FIRE you. Yep. Fire you. Or worse. Burn you at the stake after shoving bamboo shoots under your fingernails. It's petrifying. There are a few clues you can look for to know whether or not you are on the current hit list:
 
1. Your manager or supervisor won't look you in the eye, uses forced smiles when glancing in your direction, or they just avoid you like the plague. 
2. You hear whispers that your charts are being reviewed. 
3. You are being called into the office for petty reasons. 
 
Trust me. If this is what you are experiencing at work you have hit the part of the cycle where you need to start showing the love through hearts and flowers. Your option of laying low is completely out the window. You must now become involved in a committee, mentor someone, and pick up extra shifts when the department is short. You have got to prove to them that you are still on board and drinking gallons of departmental Kool aid daily.  This leads to walking on egg shells which leads to another explosion which leads to hearts, flowers and remorse which leads to walking on egg shells which leads to another explosion which leads to....you get the picture. 
 
It all seems a bit silly, doesn't it? One big game. I guess my question now is whether or not this is present in other areas of nursing or just in the ER? Either way I would like to see this cycle banished from ERs across the nation. I'm so sick and tired of this work place drama adding to the stack of tasks we must complete every 12 hour shift that we work.   Seriously. STOP THE MADNESS!!!!!! In the words of Michael Jackson, just start with the man in the mirror. Support your fellow staff member. Be honest with those around you. Give excellent patient care and treat your patients like you would want to be treated.  I just can't figure out why we continue to make this job harder than it actually is. Harder than it needs to be.  Let's work together from this point forward the break this cycle of violence. Everyone. Seriously. Staff, management, and administration joining hands to break the cycle. Is that too much to ask?
 
 
May. 20, 2015

Transgender: Let's talk about Bruce

 

I have been watching the Kardashian's lives unfold over the past few years. I am a little embarrassed to say it, but I really do enjoy their show. They are a funny, drama-filled family that to a certain degree I can empathize with. (Aside from the millions of dollars and plastic surgery). I can openly say that my top three members of that family are Khloé, Scott, and Bruce. I love Khloé because she has gone through hell down her path with Lamar Odom, rumors that she isn't a full biological sister, and her battle with her weight. Watching her persevere has been super inspiring to me. She is a rock star and a great role model for us all.  Scott is the "outsider" that makes me laugh. His over-the-top antics have been so entertaining to me. He has even inspired some practical jokes that I have played on the people around me. And then there's Bruce...The all-American guy that's always been a little zany, who doesn't seem to get sucked into all of the drama, who each season has been less and less involved...and now we know why. 
 
Watching "About Bruce: parts 1 & 2", I found myself glued to the television, hanging on every word spoken from each member of the family.  The emotion was so raw. My heart truly ached for all of them. For the children who fear the loss of their father, for Kris trying to wrap her head around the fact that the man she has been in love with for decades has been living a lie and that she wasn't more in tune with who he really was...but most of all my heart is truly hurting for Bruce Jenner. 
 
Bruce has lived his entire life loving everyone but himself. According to the family, he has been an amazing father and husband. Their accounts of him included a father who was truly engaged in their lives, teaching them how to ride bikes, giving advice, and stepping up to the plate whenever he was needed. How heartbreaking it is that he has had to hide his "true self" for all of these years. 
 
I'm not saying that I completely understand those who see themselves as transgender. I don't. Using Bruce as an example it all gets pretty confusing: Bruce feels like a woman on the inside which makes him a woman but he/she is attracted to women which technically makes him/her a lesbian...its a lot to sort through. 
 
My question to society is "Why do we need to sort through it?"  I am not a clinical psychiatrist.  It's not my job to sort through it all. It's my job to love my fellow man as Jesus loved me.  That's it. 
 
When I look at Bruce, I am not judging. When I look at Bruce, I see a human being full of pain, confusion and a desire to be accepted. I see a person who has been trapped inside of a box for over 6 decades trying to please the people around him. Someone trying to be the person that he thought he was supposed to be. 
 
I think we all do that to some degree. We played sports that our parents wanted us to play, learned instruments and chose jobs based on the hopes and aspirations that others had for us. How many of us truly choose our paths based on what WE want for ourselves? 
 
My point is this: when dealing with our fellow man we will encounter things we do not understand, whether it be religion, taste in music, sexuality, race... I would like to challenge you that instead of wasting time trying to understand, we should instead try to be understanding. 
 
And to the people in my life who are struggling with anything that they feel they have to hide, I would like to remind you that I love you. Unconditionally love you. I hope that you realize that I am here to help you get out of the box in which you are feeling trapped. 
 
 
 
*understanding- a state of cooperative or mutually tolerant relations between people
May. 8, 2015

Oh the glory of Magnet

 How Magnet, Press-Ganey and Obamacare are Taking the Nurse Out of Nursing

In 1983 the American Academy of Nursing Task Force on Nursing Practice conducted a study in hopes to attempt the identification of hospitals that were able to retain their nurses while providing quality care to their patients. These hospitals were referred to as "Magnet" hospitals.
With nursing shortages continuing to be a growing concern, there was a definite need to help improve both patient satisfaction and staff retention. The program developed into a nationally recognized status for hospitals.
Whether a hospital meets those credentials depends on its capability of meeting five key components: Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations, & Improvements; and Empirical Outcomes.

It is a coveted recognition for hospital administrators across the nation. In America's hospitals, the very low percentage that actually meet Magnet standards (close to 7%) are considered to be upper crust and on paper they are, but what does it feel like to be a nurse employed by a Magnet hospital? When you add in Press-Ganey, the survey that random patients receive regarding whether or not they had a "very good" experience while in the hospital and the constant looming threat of Obamacare it all becomes pretty overwhelming. (Please keep in mind that Press-Ganey is the survey to be used by the government to determine a percentage of medicare/medicaid reimbursement that the hospital will receive)

Most nurses say they felt a "calling" into their field. They either had an experience that led them to nursing or have felt as though they wanted to help people from when they were a small child. There is absolutely nothing like the feeling of saving a life, holding the hand of a patient who needs to feel loved, embracing a grieving human during a tragedy, holding a newborn as they take their first breath, the adrenaline rush of caring for a trauma victim knowing that seconds count, administering TPA to a stroke victim and watching neurological deficits disappear... Each of these things are miracles in their own right. Those who chose nursing wanted to make a difference. It was a calling.
The problem is that not all nurses who heed to that calling are actually good at their job. Administrators are forced to create policy to govern the quality of care that we as nurses provide. Policies are merely tools for nurses, doctors and other staff members to help implement the notorious "right thing to do". We should all be completely on board with this, right?

Here is where it gets sticky: Gone are the years of entering a patient room, giving good care and trying to make a difference while applying knowledge and healing hands. The powers-that-be have dictated to us the methodology in which we must do this. We have been transformed into scripted robots who aren't allowed to step outside of our guidelines and tap into our humanity. "Hello, my name is Nurse A. I have been a very good nurse for 10 years at this very good Magnet hospital. My goal is to give you very good care. You shouldn't feel my necessary harried behavior and I cannot nor will not tell you that I have numbers and time frames to meet from the very beginning of your entry to the department. I cannot tell you that studies have been done regarding the amount of time you spend in this department and how they correlate with your satisfaction scores. What I must do is trick you into answering "very good" on the survey you receive in the mail."

The prudent nurse should round on each patient hourly, assess them, document vital signs, offer them a warm blanket, a smile and possibly a hand hold or hug when appropriate. During the in-between times they should be checking orders, administering medications, double-checking that the ordering physician hasn't made a mistake, triaging and assessing new patients, answering call lights for unforeseen necessities like going to the restroom, episodes of nausea or vomiting, anticipating patients that are "crashing", calling the lab to find out when results will be posted, transporting patients to radiology, working on getting patients admitted or discharged, and assisting the other nurses in their area. It's doable, right?

The answer is yes. It actually IS doable. Doable that is until you tell THE REST OF THE STORY. In a Magnet hospital, nurses are expected to lead a committee, sit on a committee, implement projects not only to their department but also to other departments and hold a national certification which warrants an extra 80 hours of Continuing Education to be completed on their own time and often their own dollar. They receive 30 emails a day regarding changes that are being made or new responsibilities they must shoulder. They are held personally responsible for staff retention and also the practice of their peers. (Side note- administration is ultimately responsible for the hiring of nurses who won't and don't stay but it is the STAFF who is HELD responsible for their retention) It is all a bit crazy.
So much emphasis is placed on retention that nurses are fast-tracked into leadership positions that they do not have the experience to handle. In the field of nursing, "baby nurses" are orienting "baby nurses" on how to be nurses just so the retention goals are met. Actually, having said that the reason babies are training babies is two-fold. Experienced nurses do not like the trend in nursing and do not want to be held responsible for the new graduates and the type of nurses they will grow to be, so they are not acting as preceptors. The newer nurses, less than 2 years of experience, are hungry for professional growth and the easiest place to start that growth is in the vacancies of the role of preceptors.

New nurses are being placed in the role of triage nurse or trauma nurse before they should be simply a because the department is trying to retain them and one of the easiest ways to do that is to make them feel important. It's all actually pretty dangerous. Bedside nursing is an art. It takes years to perfect it and even those that have perfected it have days in which they leave feeling inadequate. Gone are the days in which it was glory enough to work in a Level I Trauma Center. Now, every nurse feels the need to be on the top of the totem pole. This does nothing but create chaos and mayhem. The new generation of nurses is part of the generation where everyone, even the losers, received a trophy. The trophy in nursing isn't power. The trophy in nursing is the satisfaction of knowing you made a difference. If this isn't enough, maybe nursing isn't the field for you.

On another note, Lets face it. All of these committees are simply a mind trick to make nurses feel empowered. Administrators still make the decisions. Administrators still make the rules. Committees are a financial burden on hospitals who are drowning in debt. Nurses are an expensive necessity to hospitals. Their time on the clock should be utilized in productivity at the bedside not paying them to sit around a table at a bi-monthly bitch session in which very few problems are resolved. Hospitals could actually staff the departments better if they eliminated these committees because they could afford to do so.

Magnet Hospitals are only hiring nurses that have a Bachelor's Degree in nursing. These are generally nurses who want to become nurse practitioners or administrators of some sort. Why are all Registered Nurses not good enough in the eyes of administrators? Didn't they too pass the state-mandated tests to become a nurse?

Magnet has been twisted and turned until it is no longer a way to measure the best hospitals but instead has become an ugly virus of pointless responsibilities that are exhausting our nurses and reflecting on the care we actually provide for our patients. Sometimes the methodology of the past should be embraced. I would personally rather work in a hospital where the staff is actually happy regardless of whether it is reflected  on paper or not.

Apr. 10, 2015

Confessions of a Triage Nurse

Warning: This blog entry is intended for people with a sense of humor.  If you do not have a sense of humor, please stop reading. By no means is this a reflection of the care that ER nurses give nor is it truly intended to act as a guide for patients regarding their illnesses. Only highly trained physicians are capable of diagnosing illnesses, both acute and chronic.

 Our world is funny.  Earlier as I sat at my triage desk watching patients trickle in and listening to their complaints, I realized the true impact of the "everyone gets a trophy" philosophy of our nation. So many people in this world have never had to solve their own problems and thus believe that it is someone else's job to do so.  Now don't start cursing me yet.  I am not talking about LEGITIMATE problems.  I am not referring to unexpected illnesses or unmanageable chronic illnesses.  Obviously if a person is doing their part by utilizing a sidewalk and the driver of a car loses control of their vehicle resulting in the pedestrian being struck down, the pedestrian doesn't really have any level of responsibility in the occurrence.  What I am talking about is the person that almost refuses to do anything or solve anything for them self. Here are common occurrences that I face when I, the trauma junkie, am trapped in triage.

1.  My blood pressure is high

 One of the first questions that follow is whether or not you have an existing diagnosis of hypertension.  If you don't, we will proceed without the voices in my head engaging in preparation for the rapid firing of silent insults that will begin pummeling you.  If you do have an existing diagnosis of hypertension, the next question will be whether or not you have been taking your medication in the manner that the doctor has prescribed.  If your answer to this question is no, you will be immediately discredited as a responsible human being and nothing you say matters to me from this point forward.  Seriously, you might as well stop talking.  I can already predict the path of your life and trust me, it isn't a pleasant path.  You are technically suicidal.  No? You don't think so?  You, my friend are wrong.  You ARE killing yourself.  Slowly.  Painfully. Deliberately.  Eventually you will end up as a stroke victim, trapped inside your body and angry that you are in that situation.  You will be rude to me and every person in this world that takes care of you when you come to the hospital.  You will be so angry that your nurse couldn't get into the room to help you do simple tasks like pulling your blanket up higher or offering you a drink of water.  Guess what? Not my fault.  You did this.  Nothing I did caused your current state. Another possible route for your life will be straight to the dialysis center.  You, the patient that couldn't find the time to pop a pill once or twice a day will now be visiting a local dialysis center 3 times a week.  You, the patient that isn't following doctor’s orders are obviously not caring about the end result: your kidneys will die.  Did you get that?  THEY WILL DIE.  Not might die.  Not could die.  THEY WILL DIE.  Again, this is your fault.  Not mine.  All yours.  TAKE YOUR MEDICINE PEOPLE. I could go on and on with this but I will spare you.

 2. I have a toothache

 THIS IS AN EMERGENCY ROOM.  WE DO NOT EMPLOY DENTISTS.  CALL A DENTIST or better yet BRUSH YOUR TEETH. Please, in the name of GOD, please brush your teeth.  Aside from the obvious breath equivalent to that which can be found in the mouths of the inmates at the local animal shelter, it's just pretty disgusting.  Can't you feel those little sweaters of plaque that form on your teeth after you eat? NEWSFLASH- Toothpaste and a toothbrush will remove that.  The simple task of brushing your teeth might actually raise your IQ and assist in your next job interview.  It could also save you thousands of dollars in trips to the ER because of YOUR failure to brush your teeth.  Seriously people.  BRUSH YOUR TEETH. The only dental complaints that should ever present to your local emergency room are abscesses that could obstruct your airway or those that are causing fever (SIDENOTE- simply brushing your teeth can generally prevent these abscesses) OR trauma that has caused damage to your teeth.  For example, if you are at a baseball game and you take a line-drive to the mouth resulting in broken teeth feel free to present to your local ER.  The staff welcomes actual EMERGENCIES.

 3.  I have vaginal/penile discharge

 You are an idiot.  Don't sleep around and if you do you should visit the local health department for screenings at least 2 times a year.  Snot coming out of your private IS NOT AN EMERGENCY.  You are an idiot and I refuse to talk about this anymore.

4. I need a pregnancy test

 Good for you.  Hike on down to your local dollar store and buy one.  We use the EXACT testing kit that you can buy for $1 at the DOLLAR store but we will charge you about $500.  Good for the hospital.  Bad for you.  We don't fill out Medicaid paperwork so you will get your pregnancy test but you will be paying for another one at your local OBGYN office. You are also an idiot. (It now occurs to me that you probably won't actually be paying your bill.  That will be left to the poor tax payers but that is a whole 'nother blog and I refuse to discuss it here.)

 5. My blood sugar is high

 This can actually be a legitimate complaint. These are the questions that your triage nurse will ask you. Have you been taking your insulin? If your answer is no you should be aware that much like non-compliance with the diagnosis of high blood pressure, non-compliance with diabetes is not my fault.  Want to regulate your blood sugar? Follow the doctor's orders.  (Brace yourself; this might hurt a little ) Part of what you can do is LOSE WEIGHT and EXERCISE.  I know you don't want to hear it but it is a cold, hard truth.  90% of Type II Diabetes is caused by obesity. That being said, in the event that you are vomiting or have a legitimate infection, your blood sugar and doses could actually be out of whack and qualify as an actual EMERGENCY. If this is the case, the ER staff won't necessarily roll their eyes at you when you aren't looking.

 6.  I have a headache

 Do you have a history of headaches? If not, proceed.  Have you taken medication for your headache and it hasn't helped? If so, proceed.  Is this the worst headache of your life and different than your usual headaches? If so, proceed.  HOWEVER, if the answer to the above questions is the opposite of those I have provided, GET THE HELL OUT OF THE EMERGENCY ROOM.  I also think it is simply adorable that most of our frequent flyers riddled with headaches are smokers.  NEWSFLASH- Smoking causes headaches.  Want to stop having frequent headaches? Drink plenty of water and stop putting poison into your body. YOU ARE CAUSING YOUR HEADACHES.  I AM NOT CAUSING YOUR HEADACHES.  Be prepared to sit in the waiting room because actual EMERGENCIES will be taken to a room before you. There is no need to holler and cry hysterically.  I realize you are in pain. I also realize that you are more than likely unwilling to hold yourself accountable for the cause of your pain.

 7. I am having a Sickle Cell Crisis

 My first question to you is why? Are you drinking enough water?  Did you stop smoking? Are you getting plenty of rest?  Are you making healthy choices with your diet?  If you answer NO to ANY of these questions, I need you to understand that IT IS YOUR FAULT THAT YOU ARE IN CRISIS.  You are in pain because your blood isn't carrying enough oxygen to the tissues in your body.  Do you know what a lack of oxygen does to the tissues in your body? IT CAUSES THE TISSUES TO DIE.  THIS IS PAINFUL. Proper diet, hydration and just taking the time to practice good, healthy, behaviors will not only save you time, pain, and money but will also extend your life by years.  Sickle Cell patients don't have long life expectancies.  Rarely do we see Sickle Cell patients that live past their forties.  I believe this could change if people would acknowledge their disease process, do the right thing and HOLD THEMSELVES ACCOUNTABLE.

 8. My back hurts

 Does it affect only one side of your lower back? If so, it might be a kidney stone which is a legitimate ER visit.  Did you injure it in the last 24 hours? Please, come in.  You might need to see a doctor.  However, if your back injury happened more than a year ago and you already have a pain management doctor GO SEE THEM.  Honestly, it is ridiculous for you to come to the ER.  The strongest medication we will prescribe in the ER is Ultram.  Deal with it.  I wish we would send everyone out with Lidoderm patches and stop feeding candy to chronic pain patients.  Have you ever dropped a Cheeto at the beach?  Every seagull within a mile can smell that thing and will be headed your way within seconds.  Lortab prescriptions are the ER equivalent to Cheetos at the beach.  Chronic pain patients can smell it before the ink is dry and will present wanting one of their very own.

 9. My fibromyalgia is acting up

 I literally have no words and am moving on.

 10. (Anything) that happened yesterday

 Chances are that if it happened yesterday and you are just now presenting to the ER this is NOT AN EMERGENCY.  Period.  Find an urgent care or a primary doctor to listen to your story.  I am so sorry that someone, somewhere, conveyed to you that you might be able to get some HUGE settlement from Wal-Mart because you failed to notice the bright red ketchup spilled on the white tile floor.  NEWSFLASH: It isn't Wal-Mart’s fault that you have the observation skills of a newborn kitten.  It is YOUR FAULT that you failed to use common sense.  Seriously.

 11. Can you get my prescriptions filled? I don't have any money

 NO. NO. NO.  NO.  NO.  NO.  NO. NO. NO.  You smell like smoke and told me to "Hold On" while you answered your iPhone 6.  Let me repeat- NO. NO. NO. NO.  NO.  NO.  NO.  NO. NO. NO.  It is not appropriate for you to save your last $30 for your manicure or your beer or your cigarettes.  You can afford a prescription. MAKE IT WORK.  Everyone else has to take care of themselves; I think you can also manage.

 12.  Can you call me a cab?

 No.  This is not the Ritz.  Call your own damn cab or call one of your friends that you just HAD to talk to during your triage assessment.  No.  I won't give you a bus pass.  How did you get to the ER? How do you get to the mall or the grocery store?  No.  No.  No.  FIGURE IT OUT.  YOU ARE NOT MY PROBLEM.  IT IS NOT MY FAULT THAT YOU CAN'T FIND A RIDE. Period. Also, it is crucial that you understand that I am not a waitress.  It is against hospital policy for me to accept tips.  Now I don't mind getting you the things that would make your stay better; For example, warm blankets or the occasional cup of ice water.  However, if I don't do this in a timely manner it is absolutely not because I am punishing you.  I AM BUSY.  I AM SAVING LIVES AND STAMPING OUT DISEASE.  Again, I am not a waitress.

 13. I have a rash

Seriously? Unless the rash is inside of your mouth and trachea, I DO NOT CARE.  THIS IS NOT AN EMERGENCY.  Find an urgent care clinic or go to your primary doctor.  Have you visited your local pharmacy? Tried Benadryl or Cortisone cream?  A small part of me dies every time someone checks in for a rash.  Literally DIES.

So it all boils down to this:  Use your brain.  Follow doctor's orders.  Take care of yourself. Save your emergency room visits for EMERGENCIES.  Please.  I absolutely LOVE my job.  I love being an ER nurse although I am sure you have questioned it a few times while reading this post.  I love EMERGENCIES.  E.M.E.R.G.E.N.C.I.E.S.  Emergencies.  Do me and every other ER nurse and patient with an EMERGENCY a favor:  Stay out of the ER if you don't have an emergency because no matter how many times you present with one of the above complaints we will take care of you and we will do so with a smile on our face and pretend to respect you while you are in our department. The problem is that more than likely, while we are doing all of that pretending, there is a patient with a real emergency that is waiting for the bed you are occupying.  Think of it as your own personal contribution to the health and well-being of the world.  Who knows? Maybe if everyone adhered to this train of thought and methodology things would improve.  Maybe the next time you present to the ER with an actual emergency you won't have to wait for the doctor to start the crucial steps needed to save your very own life.

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