Wednesday, April 25, 2012

A bit of a ramble here, but often, I just go where the good rhymes take me.

Secret of Excellence

All Managers desire
Conformity and compliance,
That's why they have the MBA
With their Bachelor's of Science,
And that's why I can not
Do that sort of thing,
I have acquired my education
Like a coffee-shop fling.

I dropped out of college
And then, attended seven more,
I didn't get scholarships
I chose the lower cost door,
But my secret of excellence
Lies in my ongoing search,
To consume vast stores of knowledge
Like some orthodox church.

I'm an incognito manager
A multitasking scholar,
I can clean up a problem
And take a disaster by the collar,
In the midst of a tempest
During an earthquake hurricane,
That is Nursing in a nutshell
Through hail, sleet and rain.


Yesterday, I received a 30 year old patient, transferred from an ICU at another hospital, for our Angiogram. This fellow was using his phone and texting almost continuously, while also stating that he had continuous chest pain. He was able to walk around without any difficulty, and truly exhibited no evidence of classic Cardiac disease. Sure enough, his heart-cath was normal, and what he needed to do, was drop one-hundred pounds.

Why the story? He shouldn't have been in an ICU, because that classified him as “critical”, and thus, needed an ICU nurse. It was a waste of resources.

Much later in the day, we received another patient from another hospital. She was a train-wreck. A classic, little-old-lady, previously very active, had fallen five days back and fractured her Humerus. She went to the Emergency Room of her hospital, whereupon they sent her home with an immobilizer sling, and told her, come back next week, and we'll fix that thing.

After being home for four days, where she probably slowly and unknowingly bled from her fracture, she had chest pain, and after quite a few hours, finally returned to her hospital. She had previously been diagnosed with stable cardiac disease, but never had undergone an angiogram. So, really it is no surprise to me, when her Troponin levels were quite high, and sure enough, she had suffered a heart attack, secondary to blood loss and the trauma associated with a little-old-lady falling down, and not being properly treated.

And did you know, that critical thinking, trumps protocols? Apparently, over at hospital -X, they follow protocols; in particular, the one where you place the person with a non-STEMI on a Heparin drip, Plavix and Aspirin. I know that sounds like a good idea, but not for the senior citizen with the broken arm, who is already anemic! This lady needed an emergency blood transfusion, before she could be rushed to the Cath Lab. She was clearly critical, needed an ICU, but had not been classified as such, at her home hospital. For us, this created a potential resource crisis, because now we needed two nurses to do the rapid-prep, to get her ready for her angiogram, and our staffing level was at its lowest point of the day. 

And to top it all off, a system-wide (as in multi-hospital and across several States), computer crash occurred. Nobody could chart a flippin' thing, or even check Labs or Diagnostic studies. Yessiree-Bob, how we love our EMR!

I saw this patient head out the door to the Cath-Lab, and soon after, I departed for home. If an ambulance crew ever tries to take me to hospital-X, I'll stun-gun the EMT driver.

Don't Go Back There

Hospital horror stories
Patient's will relate,
And we're the last in line
To invest in their fate.

A week spent elsewhere
Almost killed this fellow,
He's severely anemic
With skin bruised and yellow.

So we're documenting like crazy
To prove we didn't do it,
Taking pictures and tissue samples
Short fix?; we'll fish-glue it.

And casually, I'll suggest
If there is ever a future day,
Where you need to use a hospital
Don't go back there, no way.


Monday, April 23, 2012

For the past 30 years our Heparin infusions have been measured in "units per hour". Recently, this has been changed to a weight based method of prescribing, and it all seems to be tied to the "Anti-XA" method of measuring something, to quantify the anti-clotting effect. But really, the drug didn't change, the purpose of infusion did not change, the adjustment protocols changed a bit (and are far more convoluted and confusing, from a Nurses perspective), and to my simple attention, this is all bad.

Lab Scientists and probably the ISMP and JCAH, all think this has to be "simplifying"...........whereas, in our practice as "those who must follow the Protocol", this new methodology is totally FUBAR. It is mucked up, bucked up, totally frickin' crazy.

There was no good reason to switch the dosing from "units per hour" to this new-fangled stuff. And thus, I guarantee, there will be more mistakes.

The Felicity of Complexity

Listen to the Engineers
They ought to know,
Make a process more complicated
New problems will show,
It's the nature of those men
And the machines they will build,
They don't do simplicity
In the Complexity Guild.

When you're looking for safety
In the delivery of medication,
Don't increase the complexity
And then describe with obfuscation,
Because, you must surely consider
The audience you serve,
If you have 12 different lingo's
Complexity will throw a curve.

Take Heparin, for example
It was dosed units-per-hour,
Now there is a weight based formula
But it still has Heparin's power,
The drug didn't change
Only the method of defining,
It went from simple to complex
And that's why I'm whining.

The dosing nomagram
Is super confusing,
Preprinted for Nurses
By a Doctor's order, for infusing,
And although it's his duty
To deal with this stuff,
We are supposed to make adjustments
Which is more than enough.

While the recipient can't tell
That units-per-kilogram-per-hour,
Is like electricity from the wind
How it's different from solar power,
Which, forces the question
Why change the method, how we dose,
Complexity drives mistakes
Eureka!, I diagnose.


Thursday, April 19, 2012

The Joint Commission is at it again. Get a load of this new idea and  read the quote found in a “Pharmacy Communication” that was sent to all Nurses at our Facility.

“Effective Wednesday, April 18, pharmacy will dispense exact doses by splitting tablets and repacking them for each dose. It is required by TJC and recommended by ISMP that a patient specific unit dose should be prepared by the pharmacy and available for nurse for administration, negating any manipulation. “

As I read it, the Joint Commission is accusing we Nurses of  “manipulating” medication delivery. And of course, that means something like that would never be done in the Pharmacy. Actually, it probably means that Pharmacy Techs, will now become the Pill-Cutters. How’s that for a job title. “Dude,  tell me about your new job?” “Well, Bill, it’s like crazy, like I chop frickin’ pills all day!


They are dismissing our pill-cutters
Man, that’s hard to believe,
Now Pharmacists, will get the task
So, why do I grieve?
Because it’s just too damn stupid
The reasons they list,
A Joint Commission directive
I guess somebody’s pissed,
And they wanted to take-away
Something else, we Nurses do,
Chopping up pills
Was too risky for you,
The patient-consumer
Might get an improper dose,
And the Pharmacy chops pills
Statistically more close,
Than any Nurse could achieve
Even thirty years on the job,
Screw it, let them do it
Take it on, Pharmacy Bob!


_ _ _ _ _ _ _ _

My Editorial on the above topic:

I realize I represent a tiny voice in the shadows of mighty decisions, but hear me out on this concept of Pharmacy Pill cutting. I am aware that this idea comes from other big agency thinkers, but I believe it violates sensible Nursing practice We have both been Nurses a long time, yet I haven't forgotten the teachings of "The 5 Rights of Medication Administration", nor have you.

the right patient
the right drug
the right dose
the right route
the right time

One of my concerns is this: many pills look similar, but may have distinctive markings. Now, someone in Pharmacy is going to chop a pill in half, and I won't be there to see what pill they chose. And when that chopped pill comes to me, in its own little package, I may not be able to identify that pill, because I did not see it in its original shape, appearance, and perhaps some unique markings have now been obliterated. In fact, that was one of the purposes of Unit-Dosing, one pill, clearly marked, I open it, and I chop it.

Now, I am expected to administer a medication, that quite likely, I can not identify. How does this make for a more safe situation? We are taking away the "Right Drug" step of the process.

And if a patient has an adverse reaction (because, just maybe, the wrong pill was grabbed in Pharmacy), the Nurse will be blamed, because they administered it! This policy, although adding a "new and improved" layer of safety, is actually eliminating the step where the Nurse, can truly check the validity of what they are administering. This is not progress.

I think it would have been appropriate to address this issue, prior to having it "suddenly announced", and expecting us to incorporate it into our practice. 

Sunday, April 15, 2012

Why reprint old stuff? Just to prove that history keeps repeating over and over. The same old problems are just repackaged, and let’s see if anyone notices. It’s fun to say mercy and dignity, all in one breath, and then whoops and oops, you lost your job. Hmmph.

You Can’t See Your Victims

We’re not laying off
We’re just redistributing,
You can’t see your victims
In a drive-by shooting,
We have an abundance of projects
In a construction based facility;
Victimized by seniority
And not by ability.

Budgetary cuts
In lean fiscal years,
Administrative decisions
Fulfill common fears,
Hysterical restructuring
In an arena of fright,
Cut the ranks, save the salaries
Relinquish the light.

Apologies abound
In administrative meetings,
“We did what we could
Now, please take your beatings”,
A community leader?
Clearly setting the tone,
Denying the basic tenet
“Take care of your own”.


** See what I mean?...............nothing has changed. Of course, back then I was working at the big house, and now it's another ship in the storm.

Friday, April 13, 2012

I work in a great place, but a patient visit/encounter, can be quite taxing to that individual. We have them come in two to three hours in advance, so we can start the IV, send the Labs, sort the Documentation, verify the Doctors entries are up to date, and so on. But we have no way to predict how many drop in emergencies, or equipment breakdowns, or know-shows, or a procedure lasted three times as long as expected, and so on. These hungry, anxious, waiting people, get bored, and more, hungry, anxious, and then angry, when they find themselves in a seemingly perpetual holding pattern.
That's what I don't like.

We Are the Levers

The waiting
That’s the toughest part of this job,
We hurry up to get our clients ready,
And then we all stand around
Like an unemployed slob,
Looking for the Doctors; Tom, Dick and Freddy.

Here’s a typical dilemma

An over-rated disaster,
My patient got here on time
Why can’t you go faster?”
But we’re just pawns on the chessboard
Of Cardiac endeavors,
They are the fulcrums
And we are the levers.



Lately, almost every week, there have been Regulators, Dignitaries, Law-Enforcers, and other wandering eyeballs, that we need to impress, over at yonder healthcare system. Every department wants to look as neat as a pin, and then to top it off, all those wonderful visitors get the best of all meals, and what budget does that come out of, I wonder?

These two poems touch upon financial impact and all of that.

Sisters Charm

Sure, I realize
There’s a tough crunch,
Matching dollars to nursing time
But what about that lunch?

Where visiting dignitaries
Chew the fat and shoot the bull,
Who pays for all of that?
Waiting till all those suckers are full,
With our special gourmet
We catered for you, kind of dinner,
Now please, if you all would score us
As your favorite winner,
In the lottery of favorable comments
On the Who’s-Who list of Hospitals Best,
Come on; just give us a good score
This is not a quiz, exam or a test.

And it’s not about our Surgeries
Or Cancer-Care, or Robotic Arm,
No, it’s all about the catering
And Sister Euphemia’s charm.


Like Sheep

Writings twenty years old
Do they still have some funny?
If I publish them, what are the odds
That I’ll make any money,
Pretty low, I estimate
But that’s not the point,
I wrote then, about issues
That I needed to anoint.

Human habits change very little
Despite our technological advances,
I wrote about missed opportunities
And precarious chances.

Since that time, not much has changed
With ethics, morals and actions,
Although I’m inclined to believe
That the Hospital-as-a-business-model
Has led to an impaction,
Where good care and cost-cutting
Have nearly reached a critical-mass,
Where a gentle mercy and kind dignity
Won’t be allowed to pass………..

No matter how many feel-good, call-back
Phone calls are made
Cost-cutting will surely, bury those deep,
Even while our leaders and administrators
Chase Medicare dollars in their slumber…………..
Like runaway proverbial sheep.