Set up… To fail

So, the higher ups have decided to implement new changes in our department to make us more “efficient”.

😒🙄

Are the changes going to work?

No.

I say no, not because I am against change. I embrace change and fully believe medicine is an ever changing field.

I say no because the changes are rigid.

Our department is very fluid. We may not have a single patient one minute, and the next minute 6 outpatients are here and there is an vented ICU patient on the way down and a patient waiting to go back to their room. Our patient flow changes throughout the day and unfortunately the decision makers don’t recognize that. They see numbers. They see productivity. Pie charts and bar graphs.

Patient care just doesn’t work like that.

However, we are going to implement the changes. We will go along with what management wants. We will grumble and groan as we see how poorly the changes work. We aren’t afraid to speak up. The speaking has been done. At this point, we are going along so we can watch the changes fail and create more problems. We are doing this so that they can see how inefficient their decisions are.

Sometimes the only way to get through to someone is to stop talking.

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Drug dealers

Sometimes I feel like the health care industry are some of the biggest drug dealers around.

Case in point, the largest drug bust involving medical providers happened just this month. I first heard about it on the news while at work. Of course I had to look into it because I didn’t want to believe professionals in the very field I work in would stoop this low.

I was wrong.

This NPR article gave some numbers that were astonishing. There were almost 60 individuals caught in this bust. The Appalachia region of the US has been hard hit by the opioid epidemic. It was discovered that over 32 MILLION opioid pills had been prescribed in this region. If you don’t know, that’s more pills than there are people in most of the states in the Appalachian area! Doctors, NP’s, pharmacists, even a damn dentist was part of the drug problem. The Washington Post article tells a little bit more about how absolutely unbelievable these “professionals” were. Some traded opiates for sex. One doctor operated a pharmacy in his waiting room. The dentist apparently unnecessarily pulled teeth to justify writing prescriptions! However, the article goes even further with all kinds of things these people were doing in exchange for writing prescriptions. It’s shameful. So many people are dying of overdoses. So many are in our emergency rooms getting narcan to try and save their lives. So many people are on our units going through horrible withdrawal symptoms. Why would anyone in the medical field want to contribute to opioid epidemic?

It seems like the DEA (Drug Enforcement Administration) is starting to crack down on medical field when it comes to opioids. The New York branch of the DEA just charged a pharmaceutical distributor with unlawful distribution. This case is one of the first of its kind in the country. If this works out as planned, I feel like we may start to see more companies held responsible as well as individuals.

It needs to happen. There needs to be some sort of accountability for the medical field. Some of us are a part of the problem, they need to be removed. We are here to save lives, not destroy them!

Unnecessary

I almost lost my temper.

One of the anesthesiologist does NOT know how to talk to people.

It feels like she is being condescending at all times. I get it, you’re a doctor. I respect that. However, it’s totally unnecessary to speak to people in that manner. I am a nurse. If you talk to me instead of at me you would know I have plenty of nursing experience. I know quite a bit more than you give me credit for. I am fully capable of the tasks that are required of me during this anesthesia case. I can do whatever you need if you just ask. Contrary to popular belief, nurses don’t read minds.

I’ll say this, she has one more time to speak in her condescending tone. One more. While I am going to be professional and respectful, I’m going to put her in her place. I’ve had to do it with plenty of residents and a few attendings. This isn’t new for me, I know how to get my point across. She needs to be knocked off the pedestal she placed herself on… I’m just the one to do it.

CIDP

In nursing, we are always learning something new. Sometimes we learn about a new med. Sometimes we learn about a new use for a med. Sometimes it’s a new side effect. Sometimes it’s a disease you weren’t aware of.

As I’m writing this, I just came across a disease I never knew existed: chronic inflammatory demyelinating polyneuropathy.

Say that five times fast!

I had a patient that had an MRI of the brain and complete spine ordered (that’s at least two hours) and the reason was “CIDP”. I have never come across this abbreviation before so I had to hit up good ol’ Google to find out what it is.

Turned out to be very interesting, at least to me.

What is it?

CIDP is rare. It’s a disorder where there is inflammation in the nerve roots and peripheral nerves. It also destroys the myelin sheath over the nerves. This inflammation and destruction interfere with signal transmission. Patients notice muscle weakness, impaired motor function, and it’s typically noticed on both sides of the body.

How is it diagnosed?

According to the rare disease database put together by NORD (National Organization for Rare Diseases), the symptoms of CIDP progress slowly. Patients notice “symmetric weakness of both muscles around the hip and shoulder as well as of the hands and feet”. These symptoms must continue for at least eight weeks without improvement to be considered CIDP. Patients may also undergo EMG’S, nerve conduction studies, lumbar punctures, and MRI’S to help lead physicians to the diagnosis.

Why do symptoms have to persist for so long, you ask? Great question.

Turns out, Guillain-Barré syndrome is kind of an acute form of inflammatory demyelinating polyneuropathy. With GBS there’s typically a preceding virus or illness. GBS progresses over three or four weeks. The symptoms plateau, get better, and don’t re-occur.

The extended period of time is to differentiate CIDP from the acute forms. With CIDP, the symptoms don’t get better without treatment. GBS is usually related to an illness while CIDP doesn’t really have a known cause yet.

How is it treated?

Corticosteroids and immunosuppresants are the standard treatments. According to the NORD article I linked to, IVIG has also been proven effective. It seems that plasma exchange has also been an effective form of treatment. However, both forms of therapy only last a few weeks and the patient may need intermittent treatments.

I spent about an hour reading about this disease because it was so new to me. That’s something I’m trying to make sure I do, read up and learn about the new things I come in contact with here in the hospital. I know I can’t learn everything. That isn’t going to stop me from trying though!

GFR

Now that I am in the radiology department I spend a lot of time focusing on GFR and kidney function. Why? Good question!

In MRI and CT we give contrast to a lot of patients. In CT the contrast is iodine based. In MRI the contrast is gadolinium (metal) based. Both types of contrasts are filtered out through the kidneys and thus the reason kidney function is so important in this department. The way we assess kidney function is by checking a patient’s creatinine level in their blood. Luckily for us we have machine called the i-Stat that can test the blood and give a result in two minutes. The result transfers into Cerner (our EMR) and the computer then uses that result to calculate the GFR. Great… except I didn’t really have an understanding of why we were checking the creatinine, what GFR really was, or why there is a GFR result for African Americans and non-African Americans. I decided to do a little reasearch and I figured, since this is a nursing blog and all, why don’t I share what I have learned?

What is “GFR”?

GFR stands for glomerular filtration rate. Basically, the GFR tells you the flow rate of fluids through the kidney. Your glomeruli are the capillaries in your nephrons inside the kidney. Blood is filtered across the capillary membranes helping to remove waste that can ultimately be excreted through the urine. Taking you back to anatomy and physiology in nursing school aren’t I? *shudders*

A simple google search will bring up lots of GFR calculators. Typically the GFR calculator takes into account serum creatinine, age, gender, and race (African American versus not) and then it will give you the estimated GFR. A GFR >60 indicates a generally healthy kidney. Less than 60 can indicate potential kidney disease. Less than 15 can indicate full on failure. Here is a little infographic that is patient centered.

Why creatinine?

Why does the GFR equation use creatinine? In the most basic terms, creatinine is a waste product of creatine. Creatine is used by the muscle cells for energy. Your kidneys help filter the creatinine out of the blood to be excreted in the urine. Low creatinine typically indicates good kidney function (which makes sense, healthy kidneys will filter out creatinine effectively). High creatinine indicates the opposite, kidney function is probably on the lower end because the kidneys are unable to filter out the waste product. Creatinine is primarily filtered out through the kidneys which is why it is a pretty good indicator of kidney function.

Why is the result different based on race?

Many, many times I have looked at my labs and wondered why the GFR had a result for African Americans and then essentially everyone else. It wasn’t until I started working here and paying attention to the GFR that I decided to look it up. Turns out studies show we have “higher than average” muscle mass so we generate higher levels of creatinine. Higher creatinine levels lead to higher filtration rates. The difference in results account for this.

Now I can actually explain to my patients why I am taking blood after I start an IV. I like to be able to asnwer my patient’s questions so of course I had to do a little learning on my end. Hopefully some of you will also find this information useful! (Also here is a great reference for frequently asked questions from the National Kidney Foundation because, why not!)

Look at me when I’m talking to you!

I am going to vent for a moment so bare with me okay?

I ABSOLUTELY HATE WHEN MY PATIENT DOES NOT LOOK AT ME EVEN ONCE WHEN I AM SPEAKING TO THEM!

This has nothing to do with eye contact. I know for some people, eye contact is uncomfortable or unusual in their culture. I get that. However, when I call someone into my IV chair and they can’t bother to put their  phone down long enough to raise their head and answer my questions it burns me up! I just feel like it is so disrespectful! Is that how they converse with everyone? No, I highly doubt it. I think *that* is what bothers me the most. I am simply trying to provide care within my environment. I didn’t force them to come to this hospital, nor did I force them to make an appointment for whatever reason they are here. I feel like the least someone can do is acknowledge that a human being is standing in front of them providing care.

There have been times when I am trying to go over information with a patient and they are so engrossed in whatever is happening on their phone that they have a hard time answering my questions. Typically this statement will get me the acknowledgment I prefer: “Let me know when you are done on your phone and then I I’ll continue.” After that I take a step back and wait. Patients will typically put the phone down and pay attention.

In all honesty, I don’t need their undivided attention the entire time they are in my care. Since I am the radiology nurse, I am going to be the one to go over the contrast questionnaire with the patient and then I will obtain vascular access. This isn’t dramatic stuff here. I really only need the patient to pay attention when I am asking them questions, after that I actually prefer they occupy themselves because most often it means they’ll focus on their phone and not on the 20g I am about to stab them with.

I don’t know, maybe I’m just getting old or something but a little acknowledgment wouldn’t hurt.

Uniform… Acceptance…

The hospital I work for has a uniform policy. As nurses we wear ceil blue and/or white. I hated the idea of uniforms… At first.

Now, I kind of like the fact that each department in our hospital has a uniform.

Yeah, it surprised the hell out of me too!

It helps me know who I’m talking to or who just walked into my patient’s room. I’ve often had patients say, “the doctor said I can have something to eat!”, however I haven’t seen the docs come onto the unit. Now I’m trying to figure out who my patient was actually talking to so I can find out what was actually said. With everyone being in uniform I can ask my patients “what color uniform were they in?” I cannot tell you how many times I’ve asked that question and then find out it was xray technician that came in to do the morning portable chest xray that the patient talked to! For a lot of our patients, anyone in scrubs is a doctor.

The fact that I can identify a department just by their scrubs is a real help and as much as I hate to admit it, uniforms made things a lot easier. I only have one big complaint, THESE COLORS!!!!

I despise the ceil blue/white combo. I would really prefer a darker color. Something like a hunter green or a navy blue would work for me but it is what it is.

So tell me, what policy did you initially hate that you’ve learned to accept and perhaps even like?

I’m a nurse, and the worst patient

I am a nurse. I am very proud of that, I mean, I have a whole blog dedicated to being a nurse!

However, I am the worst patient.

Lately I have had to be a patient far more than I want to be. (Here is a link to my blog post on why I have had to be a patient frequently.)

I don’t know how to stop being a nurse and sit back and be the patient. I don’t know how to shut up and listen. I want to talk. I want to tell the doctor what I know. I want to be in charge of my care. I want to be the nurse.

I don’t like not running the show when it comes to my own care. However, this situation is aggravated by the fact that I don’t even know what is going on with my health. I feel completely helpless… and humble. I now understand the fear my patients have when they are coming to get scanned. As you all know, I work in radiology and a majority of the patients I work up are there to get scans to either see if they have cancer or to see if their cancer has spread. They are coming in dealing with the unknown. The fear, the anger, the tears, the blank stares, I understand why my patients exhibit so many emotions. It’s the unknown. I am going through it now and I am pretty sure I have gone through a lot of those emotions. I am blessed to not have cancer but having to go from seeing a family doctor, to a pain specialist, and now to neurologist, all because I have spreading neuropathy is scary. I don’t know what is wrong with me and as a nurse that drives me nuts.

I am a nurse, I help people get as healthy as they can. My job is to literally fix people and yet here I sit unable to fix myself because I don’t even know what’s wrong. I feel so helpless. I want someone to say “This is what is wrong and this is how we fix it”. I want to fix myself like I fix everyone else. I want to nurse myself back to health.

I don’t even know where to begin so friends I ask: do you have any suggestions for not going crazy as I work through this?

Dear administration

Dear hospital administration,

Hi, I’m just a lowly nurse here in your hospital but may I make a suggestion?

Please, PLEASE include the staff that will be working in a new area in the design of that new area!

I know you think you, the architect, and the contractor know what’s best but you don’t. YOU DON’T. You all look at what looks good. I mean, everything looks great on paper. What you aren’t paying attention to is whether or not the area will function for staff.

I cannot tell you how many times I’ve walked into a new area and immediately started picking out what doesn’t work, what needs to be moved, and what needs to be completely redesigned. I’ve seen areas opened and then closed so it could be “remodeled”.

Stop it!

You could save money, time, and stress by doing it right the first time. Let us be a part of the planning process. Let us be a part of the “walk through”. Talk to us and find out what we do and don’t need in the new area. Talk to US! It will benefit everyone in the long run, I promise…

The kids are alright

This is my last week of shadowing in the PACU. I’m ending my week in pediatric pre and post op.

😒

I have been a grown up nurse my whole career. Med surg, small ICU, STICU, that’s what I know. I know how you fix an adult. I know nothing about children.

I am not good with kids. I’m uncomfortable around them. I’m not used to kids. I am out of my element.

I feel so freaking awkward!

I am so useless in here. It’s not because the nurses aren’t teaching me. The PACU nurses have been amazing. I just don’t know how to handle kids. I have none of my own. I don’t want any. I have no maternal instinct. I have little patience for crying. I’m just not good with kids and I’m well aware of that.

So here I sit, on my phone, typing up this blog while on lunch, hoping I survive a few more hours so I can go back to my adults in radiology on Monday…