January, 2006 Archive

January 25, 2006, 7:41 pm

A Plethora of Paperwork

I am an addict.

It is true.

My drug has been available to the general public for five years now. I discovered it a year ago.

Most people can take it without becoming emotionally affected. I, however, am drawn to it as a moth to a flame.

I suffer emotional withdrawal symptoms when it is taken from me, as it invariably is.

I swore I would not become involved again, but my family is co-dependent and encourage my participation. I am often forced against my will to relapse.

At work, I have to sneak into the back room to get my fix. Some of my co-workers know. Others have never discovered my secret.

I’m so ashamed.

It’s cruel. It’s encouraging. Sometimes, it puts people in the “dawg pound”.

I am addicted…..to American Idol.

Please help me.

hhhhhhhhhhhhhh
Life used to be so simple in the ER.
If a patient needed to stay in the hospital, you obtained a room number from Admitting.
You then would take a final set of vital signs to verify that the patient was indeed stable for transport, bring your nursing notes up to date and double check the lab work to make sure that no one missed the potassium level of 9 or the hemoglobin of 1.
A call to the receiving nurse was then placed to give “report”, a verbal narrative of the history of the present illness and emergency department course, adding significant historical medical information as necessary: allergies, previous surgeries, etc.
After receiving a litany of 15 reasons why the receiving nurse can’t take the patient right then, a negotiation ensues. A time for transport is agreed upon and the patient goes up with his chart.
Oh, how I long for the good old days.
Approximately one year ago, some agency (JACHO?) decides that things must change for the good of the patient! Here is what now must be done before the patient goes up:
  • Report must be faxed.
    • This entails writing the entire report. So, everything that you have just spent hours writing on the nursing notes must be summarized and rewritten on the fax report form. Even I, with my passion for charting, think this is asinine. It is also mandatory.
    • It takes longer to fill out the fax report than it does to verbally report.
    • The only advantage is the nurse can’t give you 15 reasons for not taking the patient any longer.
      • In my facility, the policy is the patient comes up 30 minutes after the fax. Oh, and we call to confirm that the fax is on the way. In the beginning they mysteriously weren’t received.
        • Okay, in the interest of fairness, sometimes faxes are sent to the wrong floor or a bed number is changed after report has been faxed.
        • And the floor/unit nurses get a 30 minute “heads-up” after the fax and before the patient arrives so they can prioritize prior to getting the patient. Which I know I would greatly appreciate if I worked up on the floors.
    • We tried faxing the nursing notes instead for a brief period, thinking that would cover all the bases, but how shall I put this, not all nurses are thorough “charters” and/or it was difficult to read through to get the pertinent information.
  • We need to practice “medication reconciliation”.
    • This means that, when a patient is going to be admitted, an exact list of what medications the patient is taking, including vitamins and herbal supplements must be listed, along with the dosage, frequency and the last time the patient took the medicine. Allergies and adverse reactions are also noted for a second time (first on the nursing notes).
    • The goal is a noble one: to make sure the patient is discharged with the medications “matching” the ones they came in taking, with or without changes.
    • This is all done on a new form that acts as a physician’s order sheet for meds (ie they can check to order the drug as written or to not order it.
    • Guess who gets to get all this information ready for admission – yep, the ER nurse. They say the family can fill out the form and sometimes the patients come in with beautiful computerized lists that bring tears of joy to my eyes. But usually the family is anxious about doing that so it falls to the nurse to complete.
      • Oh, and by the way, those beautiful computerized lists? We can’t copy them. They must be re-copied, by hand, on the form.
  • Signature recognition
    • On a separate form, in addition to signing your name twice on the nursing notes, you must print your name, sign your name, and designate your work station.
    • Apparently illegible handwriting is making signature reading a lost art.
    • To my blessed delight, my facility no longer requires this form. But for many months this was also mandatory.

So, in one year, three new pieces of paperwork were added to the already hectic activity that accompanies a patient admission. Two of which require the nurse to sit, undisturbed, for a minimum of 20 minutes to complete in addition to all the regular paperwork. We have no recourse but to do as we are told.

I wish someone would tell these agencies off.

Where is Simon Cowell when you need him?

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January 24, 2006, 3:46 am

I’d Like To Place A Call To Grand Rounds!

It seems Miss Ames, RN has gotten a phone call!

Why, she’s been invited over to Grand Rounds !

Kevin,MD is hosting this week and the best of the medical blogosphere is overflowing with stories, information and once again, new blogs to get to know (at least for me).

Kevin has quite a wonderful blog. I can’t believe it has taken me this long to find it! I won’t be a stranger.

Speaking of stranger, it looks like Cherry’s co-worker is not happy about the call at all.

Could it be that Cherry takes too many personal phone calls at work?

Nah, Cherry Ames is the perfect nurse!

The other nurse is just upset that she wasn’t invited to Grand Rounds.

But you are invited!

Do come!

hhhhhhhhhhhh

I also forgot to mention that Emergiblog has a post in the latest “Carnival of the Mundane”, this time hosted by Kaply over at her blog. It’s my post on using the nursing process to assess your boxes of candy. Truly a skill that all should possess.
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January 23, 2006, 12:46 am

Is Your Spleen Squeaky Clean?

Okay. I thought by now I had seen it all, but this…..this is really bad.

Be a nurse and make good money….why gosh it never occurred to me to be a nurse until I picked up these matches!

Granted, this is for “practical nursing”, as opposed to what? Impractical nursing? Maybe they mean LPN. It’s still insulting. And the nurse is wearing the coveted cap.

Learn from home in your spare time? What is this, an old Sally Struthers TV commercial? Who are your clinical patients supposed to be? Family? Neighbors? Your animals? Where do you get your equipment? How do you know if you’re doing things right or not?

The course is endorsed by physicians. Well then, it must be A-OK! Not! But I betcha they don’t hire the “graduates”.

But wait! High school is not required! Whew! I bet that was a load off some folk’s minds. ‘Specially since you can be anywhere from 18 to 60!

Send for the free booklet! No salesman will call! Nobody will oversee your education! What more could you want?

One minute you have nurses beseeching you to join their ranks for the good of the country and the next thing you know they’re soliciting from matchbooks.

I just hope they close their cover before striking……

hhhhhhhhhhhhh

I hate spleens. I really do. I mean, I’m glad I still have mine, and I fully intend to keep it. But spleens aren’t very forgiving and sometimes they are downright sneaky.

Young girl, early teens, unrestrained front seat passenger of a car driven approximately 25 mph head first into a wall. Old car, long ago, no airbags to deploy.

Patient is ambulatory on scene without c/o neck, back or head pain. Slight pain to lower left ribs but nothing more. Mother arrives on scene and signs patient out AMA, stating she will transport patient to the ER. And she does.

My ER. My non-trauma center ER. As triage nurse for the day, I began taking the history. Slight pain on palpation when left lower ribs are softly touched. Pain increasing slightly with inspiration. Lungs clear. Denies SOB. I’m thinking pulmonary contusion, maybe rib fracture. The mechanism of injury was not great, but the patient was walking and looking good on scene and when he got to the triage station. Then, suddenly the patient begins to look rather, uh, sick. Icky. Pale. Nauseated. Shocky. Bad.

This is not good.

Mom gets sent out to registration and patient comes with me, in a wheelchair for obvious reasons but now she can’t stand up straight anyway. I grab the ER doc on the way in. He examines the patient only to discover within about one-half second that it is not the ribs, it’s left upper abdominal pain and we are goin’ to the OR. Mom returns within minutes and gets the scoop. Two large bore IVs with a bolus (BP falling)while the OR gets ready and off we go.

Ruptured spleen.

I hate it when they do that.

hhhhhhhhhhhhh

It had been a helacious shift.

Everyone was very sick in some fashion or another, almost all requiring IVs and medications for pain or nausea (or both). Lots of respiratory distress and a couple of in-house codes to top it all off. (We lose the ER doc and an ER nurse for what is hopefully a short period of time when someone in the hospital has a cardiac arrest).

We had people sitting in the waiting room that I desperately wanted in rooms; they were miserable.

Finally we get one bed open. I’m about to call in the next patient. This guy walks up being supported by friends. “Hey, like, he has the flu, man. Been vomiting all night. He even passed out twice at home!” Sounds like he’s dehydrated from gastroenteritis just like the rest of the county. But passing out twice kind of gives you priority for a bed. We don’t take kindly to syncope (fainting).

I asked the patient to gown and lay down on the bed. He said it hurt to lay down. Well geeze, dude, if you don’t lay down and you’re dehydrated you’re gonna pass out again! I said it a wee bit more professionally than that. Nope, he wasn’t gonna lay down. Okay.

“Look,” I told the friends. “Sit next to him on the side of the bed. If he feels dizzy lay him down.”

He needed an IV, like yesterday. But….. three more patients walked in and I ran out to have them sign in for triage and make sure none of them was having a heart attack, stroke, etc. And someone had to take report from the medics who had brought in a possible stroke victim.

Did I mention that at this particular facility there were only 2 nurses after 2300? It was after 2300.

I heard loud cries for help from the friends of our vomiting, fainting guy. I rush in to find him, essentially unconscious, sitting between them. They hadn’t laid him down. So I did. He woke up.

Blood pressure of 70 systolic when flat. And in pain.

I still thought he was a severe case of dehydration but a little voice inside my head made me act like a trauma nurse and put in two large bore IVs. One of them was a 14 Gauge. A freakin’ hose. Had the ER doc at the bedside by that time and he did his exam. The patient’s abdomen was rock-hard. It was so tender that even touching the hairs on his upper abdomen was excruciating.

No fever. Sudden onset. Denied trauma. Normal BMs. Weird.

The IVs kept flowing so that I could get his blood pressure up and try to address the pain issue. And the pain kept getting worse and the blood pressure would not respond. It seemed like it took forever to get my patient to the CT.

Ruptured spleen.

Massive hemoperitoneum.

Say what?

We didn’t believe it. We had one “ruptured spleen” in surgery already. We thought they had faxed us the earlier report.

Then the truth came out. Three weeks earlier, a large tool had fallen onto the patients left side. It was sore, nothing major. He did notice he could no longer jog without pain, which he thought was weird, but nothing to see a doctor about. He had a hematoma on his spleen. It started bleeding that night, giving him the “flu” symptoms he presented with.

He made it. So did the first patient. I, however needed a weeks worth of Ativan after that shift.

So don’t be surprised if you are ever in an ER for a sprained ankle and the nurse asks how your spleen is feeling.

It will be me.

I hate spleens.

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About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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