September 14, 2009, 7:53 am

And Then There’s Fraud…

beforehand lotionWell, I lead a double life but it isn’t out dancing in formal wear!

“There is time for only fleeting thoughts about that dance you’ll attend during off duty hours.”

There isn’t even time for that.

Besides, who attends a dance during on duty hours?

Well, I guess the most important thing is that our hands are “soft, smooth and free from redness” because “your patients like it and your date expects it”.

Oh yeah?

The day they use a hand sanitizer thirty times in a shift and wash their hands another twenty, they can talk to me about soft hands.


OffwhitelogoDon’t forget Change of Shift is up this Thursday at Medic 999. Mark is awaiting your submissions.

Use Blog Carnival or send them to mglencorse at yahoo dot co dot uk”.

Many thanks to Mark for hosting the nurses this edition!


My husband won’t watch football with me because I tend to get hyped up and throw things at the TV when I get upset.

That explains why there were Notre Dame pom poms and a Cleveland Browns jersey at the base of the set this weekend.

I also like to talk back at the President when he is speaking on TV. Usually it’s things like “Say WHAT?” or “Give me a break!” “Get. A. Clue!” is usually a good one. This last speech, the one to Congress about health care, was no exception. My first comment came a bit into the speech when I noted a few times that “I haven’t heard a single thing I disagree with yet” and “he’s right on that point”.

I was afraid hubby was going to need smelling salts.

But I’m like, “let’s hear how he is going to pay for this…let’s hear him out”.

And then I heard it.

And then he lost me.


There were two comments that I could not let go. I looked them up in the text of the speech to make sure I had heard them correctly.

“…we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system – a system that is currently full of waste and abuse.”

“The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud…”

Hundreds of billions of dollars? Billions? With a capital “B”?

Waste. Abuse. Fraud.

This means that in order to pay to the proposed health care reform, we have to find enough waste, abuse and fraud to cover expenses.


But I have some questions.

What is the definition of “waste”? To the extent that “waste” means inefficient bureaucratic practices that use up monetary resources, I can get on board with that.

Abuse? What kind of abuse? Using the system inefficiently, like calling an ambulance for a stubbed toe? Remember, the President is using the term “abuse” to represent a potential income stream for the new system, so it would have to encompass behaviors that spend money that should not be spent. Money is spent on patient care, so is he talking about patients abusing the system?

And then there’s fraud…

That’s a crime, folks.

Hundreds of billions of dollars in waste and fraud?

The President must think that there are an awful lot of criminals in the health care system.

So what’s my point?


My point is this: funding for the new proposed health care system (see “most of this plan…”, above) is based on finding waste, abuse and fraud.

What happens when all the waste is taken out, all the abusers are stopped, the fraudsters jailed and the system needs more funding? Does that not make it imperative that we keep finding waste and abuse and fraud? Does that not mean that what constitutes waste, abuse and fraud must be constantly expanded to make up for rising costs?

This can’t be good.

I am in total agreement that our system can be streamlined, big time.

And maybe we could find enough money in waste, abuse and fraud to make it pay for itself, but I doubt it.

If we could do that, wouldn’t we have done it already with Medicaid and Medicare? The budgets for both are getting slashed on a regular basis. Drop the waste, abuse and fraud in those programs and then come back and tell me how much better their budgets are.

If we can’t do it in an existing government-provided system, how on earth do you expect us to believe it can be done on a larger scale?



September 11, 2009, 9:07 am

September 11, 2001: Never Forget

bradwtcsmI had a PALS class that morning.

The receptionist at the consortium could not reach her brother. In New York.

We were there, but we weren’t present.

By 1100, they ended the class. It could not be business as usual.



I never left the television.

Over and over, the images.

The horrific sanitized-for-our-protection American versions; the unimaginable reality of the European versions.

Shock. Disbelief. Anger.

Oh God, the anger.

But never acceptance.

Not then. Not now. Not ever.

September 9, 2009, 12:34 pm

Census and Sensibility

helpThat nurse better watch her back!


Baaaad body mechanics here.

I can’t figure out this little tableau; is she pulling him out of the ditch? Why is there a book on the edge of the fox hole?

I can sure appreciate the sentiment, though.

I’ve been hit with a virtual tsunami of activity now that school has started and could use a little “Help!”

But wait….

There is hope….


This could “Help!”

My son ordered the new Beatles Boxed Set (Stereo) for me! I’m….speechless….and thrilled!!!!

And right now I am listening to local radio station KFRC play the entire Beatles catalog in chronological order.

It’s like having an audio SSRI!

For 46 years the Beatles have been a huge part of my life. When this set comes, I’ll be incommunicado for at least two days. Just me and a set of Bose headphones.


In the spirit of collaboration, Change of Shift is occasionally hosted by our non-nursing colleagues and the next edition gets the EMS treatment! Medic 999 is doing the honors and he has proposed a theme! Information at Change of Shift Comes Visiting. Posts can be sent to “mglencorse at yahoo dot co dot uk”. Mark also hosted Grand Rounds this week and the latest edition of The Handover (the EMS carnival)! Wow!

About the only carnival Mark did not host is Patients for a Moment, and you can find that over at Leslie’s blog Getting Closer to Myself.


Emergency has something in common with Labor & Delivery.

Neither department has control over their census.

Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.

ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.

Labor and delivery has one advantage over the ED.

They can have someone on call.

I’ve never worked in an ED that has had an “on-call” nurse.


I will never understand the logic behind staffing an ED based on the previous 24 hour census.

If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.

Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.


Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.

But what happens when the patients overwhelm the staff, both in acuity and numbers?  Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.

This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.

Of course, at night it is feast or famine.

Either the feces hits the proverbial fan or…it doesn’t.

Which is exactly why we need a nurse on-call.

The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.

All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.

(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)

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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