I am a new grad RN and I feel I work in one of the best hospitals in my city. I have mostly seen equal tx of all pt's and a good majority of our pt's do not have insurance- I believe we were told about 40% of our pt's do not have insurance. Although, there have been a few situations that have really peeved me off. I would like your opinions on the following.
1) A homeless pt was subjected to a new med student putting in an IJ when a PICC was actually called for. The doc wanted her to get the experience. The student finally got it inserted on her FOURTH try and after causing a significant deal of pain for the pt and not to mention, a seizure during the third attempt.
2) Pt's that come in with illegal substances in their system do not get adequate pain control. We have many many of these pt's. We were taught over and over again in school that addicts may have built up tolerance to opiods and we should advocate for them appropriately. Doesn't seem to work with the doc's at all. I've had so many pt's that were writhing in pain and probably withrawling at the same time and only have prescriptions for a lortab or even one pt with a children's dose of pain relief. Grrrr.
3) Pt came in w/seizure and fell on rocks face first. He had a CT and urinalysis and once those were cleared he was let go with ABX and 10 tylenol 3's. This was his first seizure ever, he had a suspected broken nose, an injured shoulder from the fall... no xrays ordered, and the blood was not cleaned off his face enough before discharge to even see that a rock had pierced through his lip completely. Grrr.
So, if these pt's were known to have insurance and/or did not have illegal drugs in their systems... would they have recieved this same tx? I know I am new and don't know a lot, but come on, even I can see there is something wrong here. My offering of a warm blanket or an ice pack is not going be enough for any of these mistreated pt's.
Thanks for letting me vent and I look forward to any and all comments.
Specializes in Mostly: Occup Health; ER; Informatics.
... ER doctor, not a cardiologist mind you, said that it was "unlikely" that I really had a heart problem because statistically that would be unusual! ...
We say "Treat the patient, not the monitor."
Perhaps we should say "Treat the patient, not the statistics."
Perhaps we should say "Treat the patient, not the statistics."
:stone
Ah, yes, last month was "New Resident Time". When they start out, they always write for really weird stuff and say, "But the book says....." and they have to learn that the book isn't sick.
In California, we don't have access to the insurance info until after they have been treated. Then go back out to admitting and then show their insurance info . . or lack thereof.
I had the same reaction as the originial poster when I was in school -- they aren't treating this person's pain because they are poor/addicted/a minority/ whatever.
Now I know nursing students may say the same about me, when one of our "frequent fliers" is making his monthly trip, because he's run out off coke money before he's run out of month, and spends the last 10 days of the month at our hotel-- I mean, hospital. We've caught him in the room snorting the last of his coke -- he's got money for coke, but never for his bill. If he wanted to get off drugs, we'd bend over backwards to help him. But he doesn't. And we all try to talk to him, but it's useless.
Just this one guy has:
--called the CEO demanding to see him re: patient abuse. CEO comes, pt complains that we didn't carry Dr. Pepper.
--done jumping jacks to get his HR/BP up so he could get another dose of IV demerol for his "abdominal pain"
--Slapped a nurse who refused to do a fast push of narcotics, got arrested, taken to jail, then right back to us when he c/o chest pain.
--Refused his ADA 1800 calorie tray, and is calling for take out, all meals, and telling the delivery guy to "bill the hospital"
--Filing a complaint daily about his mistreatment -- sheets are scratchy, food's bad, room's too hot, room's too cold, nurses won't come, nurses always in his room, etc. I've seen him have the admin rep in his room 4 times in one shift.
Now, if a student is standing there and we see we're getting this patient as a new admit (again!) they are going to think we are cruel and heartless, as we stand around going "I had him last time...no, it's you're turn...well I'm not taking him unless I have to...I've got 2 expectant DNRs, and 3 PEGS, I don't have time for his BS..."
And of course, no insurance, so we are eating every bill. We're a non profit, and sometimes, just a few of those long stay high cost patients in a month can put us into the red. That's what ticks me to no end -- if my hospital goes bankrupt d/t people like this, who's going to be there for the rest of the community, who really do want and need help?
Clearly, none of the examples I posted, other than the first b/c I didn't explain why he was admitted, were not simply "frequent flyers." And I would have had no problem if the med student would have tried twice, or even three times to insert the IJ; however, after the third time when the pt had a seizure and was clearly extremely uncomfortable, IMO, it was time for the doc to say enough is enough and I will insert it.
I suppose I need some advice when it comes to advocating for the pt's in real pain, whether addicts, not frequent flyers, or not, need it. I am a bit timid at this point, as I am still in orientation technically, to say more than the situation at hand, when speaking with a doc. Many of the docs I talk to are new also, as we are a teaching hospital.
I don't know. I think the hardest part of the transition from student to nurse, so far, is that things are not as they should be according to school. I know an extra dose of such and such pain reliever is not going to cause detriment to my pt that is writhing in pain, but I cannot seem to do a darn thing about it. I want the ivory tower ideology when it comes to my pt's or anyone else's for that matter.
Keep the comments comming... I really appreciate all responses.
Hello there. I'm not a student or a new nurse. I have over 17 years of experience. I've worked in a variety of settings from rural hospital, border hospital in Texas, upscale hospital catering to rich and celebs, community teaching hospital and poor inner city hospitals. I tell you this to say that in my observation there is a difference in care based on setting, race and socioeconomic status. And have no fear, research has been done which supports my POV.
You should trust your instincts because for the most part you are right. I'm surprised that so many come on here claiming that in their place of businedd there is no difference. Many nurses on this board have admitted that they highly resent the poor, those on welfare, immigrants, etc. Do you honestly think those prejudices don't translate to their care? And physicians are certainly not immune, it's a no brainer that they might act similarly.
There are other factors which contribute to those differences. Like it or not, cost is a factor. If you don't have the money, you don't get all the bells and whistles and you might have to get a more conservative treatment. I don't disagree with that either after all where is the money supposed to come from to pay for someone with no money to get the latest and the best?
Finally let's not forget that the purpose of teaching hospitals is for the student to learn and YES they do often take the opportunity to learn when often there is a simpler way to get something done. I DO disagree with that.
I've had patients that everyone knows full well that they will never be able to pay their bill when they leave and they receive as much medical care as the next person. We don't turn people away because they are poor and have no insurance. I can honestly say that because that is part of the hospital's motto. The hospital eats a lot of cost because the population in the city is at or below poverty level or just homeless. I've never treated any patient any different just because they were black or hispanic and were on welfare or had no insurance. And if any nurse or doctor did treat a patient differently because of those factors, well, that's just plain wrong. So yes, I can honestly say that I've never seen any "poor" patients get poor treatment.
If you don't believe what I am saying, I don't care. I take pride in where I work because at my former job, if the patient had no insurance, they would just stabilize the patient and send them to the hospital where I work now. I get more satisfaction out of treating the patients at the hospital where I work now than at the uppity hospital where I used to work.
Clearly, none of the examples I posted, other than the first b/c I didn't explain why he was admitted, were not simply "frequent flyers." And I would have had no problem if the med student would have tried twice, or even three times to insert the IJ; however, after the third time when the pt had a seizure and was clearly extremely uncomfortable, IMO, it was time for the doc to say enough is enough and I will insert it.
I suppose I need some advice when it comes to advocating for the pt's in real pain, whether addicts, not frequent flyers, or not, need it. I am a bit timid at this point, as I am still in orientation technically, to say more than the situation at hand, when speaking with a doc. Many of the docs I talk to are new also, as we are a teaching hospital.
I don't know. I think the hardest part of the transition from student to nurse, so far, is that things are not as they should be according to school. I know an extra dose of such and such pain reliever is not going to cause detriment to my pt that is writhing in pain, but I cannot seem to do a darn thing about it. I want the ivory tower ideology when it comes to my pt's or anyone else's for that matter.
Keep the comments comming... I really appreciate all responses.
Speaking up is difficult at first. We were once intubating a patient and a PA was trying with the MD watching. She was going on her third attempt, and I was looking at everyone else in the room, hoping someone would speak up - because I didn't have the guts. Right before the PA went for the third try, the RT said "no, I think you've had enough tries...we need to intubate this guy now, and it won't be by you." I felt relieved that someone spoke up, but I felt guilty because I didn't speak up for the patient. The supervising MD didn't say anything, but neither did I...even though I wanted to scream "STOP!!!"
Just be firm and assertive. Discuss the procedure prior to begining it, especially if you aren't familiar with the clinician's skills. If you are assembling supplies for a med student and doc to put in a central line, firmly state "I've got two central line kits ready to go - which gives you two attempts." Chart like a madman. If someone's in pain and the medication isn't working, say "Hey doc, the patient recieved morphine 4mg IVP 15 minutes ago, and still looks uncomfortable and rates their pain as 8/10 - their vital signs are xyz...how about we try another dose of morphine for their pain, or could you suggest a different medication to provide pain relief?" And make sure to chart the conversation; "Dr. Smith notified of pt c/o pain as 8/10, no orders received." Its our job to monitor patients and their response to treatment, and despite what some docs/facilities may say, there is nothing wrong with charting that you reported the patients pain medication response to the ordering doc, and that no other interventions were ordered. JCAHO is cracking down on pain control, and if you don't chart that the doc was notified, it looks like you allowed the pt's pain of 8/10 continue without trying other interventions (although, a pt's pain of 8/10 may be fine without interventions if you document that they are on the telephone, laughing, eating pizza, and ambulating without difficulty; its the patients that are grimacing, guarding, sweating, and "truly" experiencing pain who suffer needlessly because of miscommunication.)
When you speak up, be firm. If you back down or envoke emotion, or come across as "wishy-washy", it may be hard to get what you want. And rules which apply to one patient may not apply to another - so you need to use your own judgement.
On a side note: I've been fine working with experienced docs who need to do multiple attempts at some procedures. When I know a doc and trust their skills, I factor in the patient's clinical situation as well - if we're coding a patient, I don't expect the doc to get a central line on the first attempt. I've seen experienced docs fail at certain procedures, not because they lack the skill, but because the patient isn't clinically "stable". I've found that experienced docs are confident, quick, and use logic when preforming skills - and inexperienced docs appear uncomfortable, are slow, and need guidance. When you notice that "nervous" energy, perhaps they are hoping that you will step in and say "stop", because they themselves are afraid to do so (especially if an attending doc is present).
Hello there. I'm not a student or a new nurse. I have over 17 years of experience. I've worked in a variety of settings from rural hospital, border hospital in Texas, upscale hospital catering to rich and celebs, community teaching hospital and poor inner city hospitals. I tell you this to say that in my observation there is a difference in care based on setting, race and socioeconomic status. And have no fear, research has been done which supports my POV.
You should trust your instincts because for the most part you are right. I'm surprised that so many come on here claiming that in their place of businedd there is no difference. Many nurses on this board have admitted that they highly resent the poor, those on welfare, immigrants, etc. Do you honestly think those prejudices don't translate to their care? And physicians are certainly not immune, it's a no brainer that they might act similarly.
There are other factors which contribute to those differences. Like it or not, cost is a factor. If you don't have the money, you don't get all the bells and whistles and you might have to get a more conservative treatment. I don't disagree with that either after all where is the money supposed to come from to pay for someone with no money to get the latest and the best?
Finally let's not forget that the purpose of teaching hospitals is for the student to learn and YES they do often take the opportunity to learn when often there is a simpler way to get something done. I DO disagree with that.
Hi Sharon -
I was speaking specifically about the insurance or no insurance issue. We really don't see any information in the ER about that. Of course, in our small town, we end up knowing just by experience.
I can say that I have seen different treatment based on a physician's bias against the frequent flyer drug seekers, not ability to pay. I myself have lost patience with one particular woman but it didn't make a difference in my care . . . I just needed to ask another nurse to give me a break and time out breather.
One of the things we were told to do in nursing school was identify our bias (one or more) . .. .so we could recognize where we might need extra patience. Mine is addicts, drug or alcohol.
Yesterday one of my hospice patients died. His daughter and I were talking about her physical ailments (she has many) and she mentioned how much she loved her doc. He recently moved to Texas (she didn't know that). So we talked about finding a new doc - her father's doc did a wonderful job with the family, very compassionate. However she had an experience with him in the ER when she came in for a spinal headache. He didn't give her any pain meds but did give a woman with a migraine a shot and she was angry about that. I don't know the details - I trust this doc - and she seemed a bit needy, whiny, etc. (I know - I'm judging).
Obviously some oversight was needed in medicine because a law was put in place not to put the insurance info on the ER paperwork.
I work in a hospital in Chicago and I understand your quesitons and concerns....but there are times when we see patients every few weeks....for complaints of pain (multiple reasons) and count hrs. for their pain meds.....get angry and irate when they dont get them....and refuse exams and tests....I hate to make my own prejudgements on why they are there....but when you add it all up....it seems as they are there just for the free highs.....This is something you see often in hospitals in big cities....it's sad...but it's true
I will always treat patients fairly and do my best to make them comfortable.....but when they start to act as though they are at a hotel and DEMAND things that are a lil silly to worry about when someone is truly ill or in pain....it makes me think!
Specializes in ER, ICU, Infusion, peds, informatics.
i don't see it so much as poor people getting poor care in-hospital, at least where i work.
i think, though, that this varies from hospital to hospital.
saying that, it is difficult to give excellent care with a smile on your face to obnoxious, rude, abusive patients. now, those patients might see their nurse less often.
i think the bigger issue is post-hospital care. that is where i see people without insurance having a hard time getting care. to the point where i've seen er docs admit patients just because they knew the patient would never be seen as an outpatient.
It's great Michigan that at your hospital care is no different for the poor as others. Of course to be accurate wouldn't you have to compare them to patients at a different hospital where everyone is insured? Also I wonder how long before your hospital has financial difficulties like at other charity hospitals around the country with that philosophy?
Also I'm curious how often are you in the room when the docs are discussing whether or not to order a certain test or medication due to cost and ability to pay? It happens believe me because I was in the room, sometimes it was my job to try to find alternatives for the poor/uninsured. Remember I didn't say they got substandard care just different.
As for being treated differently because of ethnicity/race/weight/citizenship status/income you need look further than the comments on this board to know it probably happens.
3rdcareerRN
163 Posts
We say "Treat the patient, not the monitor."
Perhaps we should say "Treat the patient, not the statistics."
:stone