masonRN

The nurse going off, who knew the patient, should have called the report. Verbal/written report is NO replacement for 4-12 hours of actual contact/interaction with the patient.

Not so much a funny one, but memorable: Medical cards floor, rarely getting surgical patients. A colleague got an order "Straight cath Q1hr." Straight cath without a bladder scan, palpated bladdder or patient complaint? Every hour?! Are you STONED? RN calls MD, who argues about how urine sitting in the bladder can lead to infection (Lap Chole, BTW). RN says "I don't follow your reasoning, neither do any other staff members here." MD says "Your orders are to straight cath. Do not scan, just do as you're told." RN says "I've discussed it with the patient and she is refusing." MD says "I'll go talk to her." It's 3am! Are you SURE you aren't stoned? MD sends a message 25 mins later saying (more or less) "Spoke with patient. Follow instruction as ordered. Patient will not refuse." RN thinks something smells fishy, goes to see patient, patient is scared, tells the RN "I don't want Cancer." Wait...what?! Did that doc share her weed with you? This goes round and round, MD threatening RN, RN shaky but standing firm. Charge finally calls a bigwig MD at home, thinking she (the bigwig) will be awake at 5am anyway to come to work. Bigwig was in bed, taking the day off for her anniversary. Charge apologizes, bigwig demands an explanation, charge gives it, bigwig is at the scene 20 minutes later, in sweatpants and parka, to chat with patient. I've never actually seen brimstone, but I think I smelled it that morning.

Interns sometimes need a good "breaking in." While I'd never advise someone to prank a new MD with a poor attitude, I'd have to plead the 5th if interrogated about my own past. It sounds like there's a good team of docs there trying to set her straight. May I suggest that you and your colleagues make an effort to thank them for their efforts?

This is a very good example of apathy. It is a primary component of self-fulfilling wage slavery. It is sad, but for some it is a facet of their existence they've chosen not to contest. Put another way: a person who refuses to be a doormat is much more difficult to walk all over. The conditions you (the OP) describe are a result of many factors, all of which can be changed; change is not easy. Complaining to your coworkers and chatting on the internet is NOT going to effect change. Filing complaints with the state department of labor, organizing labor, filing safety complaints with the state department of health, contacting the press and reporting Joint Commission are just the items that jump to mind. I used to work in a hospital that was similar to what's being described. There is a little joke about the place, that goes some like "Did you hear about the nurse who was found dead in her car? It was just a few miles from here. They knew right away that she worked here because her bladder was full and her stomach was empty." I left that place and went to an institution with much more favorable opinion towards its employees. The place I left has been laying people off; the one I work at now has laid off no one. That move brought a notable pay cut, but I made a concerted effort to see the big picture; and I feel like the decision I made for myself was an excellent one. That's a part of the discussion that bears repeating: the decision I made for myself. The next generation will not charge us for what we've done; they will charge and condemn us for what we've left undone.--Mother Jones

A program like this was piloted on my unit late last year. We are a telemetry floor/cardiac stepdown with 64 beds. On nights, we have 16-18 RNs and 2-4 techs. We were supposed to inquire about: pain environmental comfort (temp, lights, etc) hunger/thirst toileting and any other desires that the pt had. We objected STRONGLY to the instruction that we wake pts to ask these questions, and this was altered prior to implementation. The results were presented [internally] last week. Generally speaking, the results were: Staff thought it was annoying and generally ineffective. Pts knew they were being checked on frequently, but it had no appreciable effect on pt satisfaction. Call light use did not change. Fall frequency did not change. There has been no movement to make this a lasting policy, though several of us do make an effort to check on people at least once per hour. Often, that's just me tiptoeing in with my little flashlight, listening for breathing, checking the IV fluids and IV site, checking urinals and foleys, squirting some hand scrub and sneaking back out. See, this sounds like professional competence. A "policy" that requires q1 rounds impairs professional competence; it's what an ancient teacher of mine called "monkey medicine" where you just do what the paper (hospital policy) tells you to do, and try to remove the capacity for a professional to make individualized judgments.

The situation you're posing looks this way to me: if the patient is not only oriented, but fully understands the medication's purpose and the likely results of taking and refusing, and chooses to refuse, any person who administers against the patient's wishes is ASSAULTING them, both morally and legally (I am NOT giving a legal opinion, merely a personal opinion). The physician's belief that he/she (the MD) knows better than the patient, and can and should override the patients free choice, is a VERY dangerous opinion to have, and should be stomped out very aggressively. Does a person have a right to live and die on their own terms? I believe they do; even if I disagree with their choices, I support their rights.

When I was but a lowly (but very hardworking) butt scrubber, I had many opportunities to care for a street-walking prostitute. She occasionally (monthly) came in with mild to moderate trauma, and was almost always treated for STI during admission. One time she was admitted w/o trauma, because she had crippling abdominal pains during and after anal sex. It turns out she had 7 feet of ischemic bowel, and the bloated near-septic bowel was not happy with the rough treatment she was [frequently] getting from behind. She was DCed a few weeks later with a new colostomy, a surgically sealed rectum, and strict instructions not to let anyone or anything near her backside. She was admitted a week later with abdominal pain, and blood & purulent discharge from her stoma. The latest STI had inflamed her intestinal mucosa, and she was well on her way to losing the rest of her digestive tract. An adorable intern (likely from the suburbs) went in to discuss the prognosis with her, and turned white when the patient stated "Honey, I don't suck nothing. I kiss my babies with these lips. My mouth is clean." The entrance point for that STI is a piece of the lore of that place now.

At nearly every institution I know, the magic number to transfuse is HGB (hemoglobin) under 8.0; of course, this will vary per specific pt needs, but this is a common baseline. Given that a HCT (hematocrit) is usually in the ballpark of 3x to 3.5x the HGB, it isn't unheard of for a MD to order transfusions to maintain a HCT of 24 to 28. I was tempted, if only for a few seconds, to call blood bank and ask if there were any protocols I was unaware of for transfusing 16 units of PRBCs

I had a patient last year, who taught me in an absolutely clear manner, that removing your own foley by hanging the bag on the doorknob and simultaneously kicking the door shut and leaping away from the door, is a fast track to an enjoyable month in restraints.

A few orders I encountered this past July: Transfuse PRBC as necessary to maintain HGB > 24 PVR: ISC if > 25 Dilaudid 4mg IVP; per pt request, give over 5 seconds. MS Contin 45 mg TID. Instruct pt not to chew. May be crushed and mixed with food to aid swallowing. Kayexalate 30 mg PO. If pt is NPO, administer lady partslly. Instruct pt's caregiver on color, consistancy and taste of C-dif feces.

Let me offer a few opinions: Regarding the respiking of the blood...it's not ideal, but blood is not a plentiful commodity, and someone likely gave of their time and their body for the benefit of your patient, whom they would never meet. I would be cautious to be respectful for every last drop of the stuff, and would do my utmost to ensure effective use of all of it. Clinically speaking, the blood leaked OUT of the tubing, so an infectious agent would have a tough time traveling from the outside of the tubing (which was sterile prior to its removal from the packaging), against the current, into the infusing blood (the same way the human body works, flushing contaminants OUT). While there is obvious risk for contamination, I would judge it as low, and would have done similarly. Regarding a per-patient transfusion limit... I don't know of any institution that limits this, and I don't know if there is any reason to implement such a limit, for her or for him. I once gave 2x PRBC, 2x Platelets and 4x Cryo Plasma to pt #1, 4x PRBC to pt #2, and titrated NTG, MSO4, and Insulin on a 3rd. Thankfully, that's not a "normal" shift for me.

Regarding ER: While traumeas can be an awesome test to your knowledge and skills, keep in mind that a large number of your patients are likely to be: Narc seekers People with common ailments and no insurance Primadonnas who think waiting 3 days to see their PCP at the office is beneath them ****** off about the wait ****** off about the MDs ****** off about their pain ****** off in general Since you have CICU experience, please let me STRONGLY suggest you request an entire shift to shadow in the ER, to get a feel for the working environment.