jeffsher

Absolutely. I rarely get out "on time" these days. In fact, this was the week from hell. But I still love my job.

Absolutely! I've only been doing it for 7 months now, and it is a lot of work. But work isn't "work" when you love what you do.

Many times companies will post that they want experience, but that doesn't mean that they ONLY hire those with experience. Ignore the experience requirement and apply anyway. What do you have to lose?

It's called "entitlement attitude", and it's becoming more and more pervasive.

Baubo516, I've been out of commission for a while (surgery and a med problem that landed me in the hospital 3 weeks after the surgery) and missed your April post up until now. Glad everything is going well. Being a CNA will be an incredibly positive experience in many ways; you'll be able to get the basics down and better prepare you for clinicals. Your teaching experience will not be wasted, since a lot of being an RN is doing patient education. txsuzy-I don't think you'll regret your decision. There are so many opportunities available that your not stuck in one area. The NP field is exploding as there is an increasing shortage of physicians. And if you don't want to do that, there are so many areas of nursing to choose from; you're not locked into anything. Good luck to both of you.

I just started as a Telephonic CM back in January. I work for an HMO, and the position was newly created to cover the Medical Home and Community Case Managers in our system (over 100 CMs; there is also 1 other nurse hired as a coverage nurse). In this program, Medical Home CMs are embedded in offices so that they have access to the docs, yet most of the work is by telephone. The main goal is to manage specific diseases (Heart Failure and COPD) more closely, and reduce hospitalizations and ED visits. There is a skill involved in telephone work. You don't have the patient in front of you, so you oftentimes have to drag out information that might not be communicated by the patient. But like anything, you develop those skills over time, and it does get easier (I have 17 years of phone triage experience, so I'm well skilled in that aspect). If you have a decent clinical knowledge base, it's doable. I love the job, and as an added benefit, it works out well for me, as I have a hereditary neuropathy which limits me working on my feet all day. Feel free to message me or post a reply here if you have specific questions.

Just had an inservice on Pradaxa this week. It's not good for those with risk of GI bleed, but it carries lower risk of intracranial hemorrhage. Coumadin has a narrow therapeutic index, which is a definite disadvantage, but it's proven therapy. As mentioned, it's not good for those with creatinine clearance of below 30 (?), and it does not have an "antidote" like heparin and coumadin. There are studies that it possibly can be dialyzed out. However, it's duration of action is through the next daily dose, whereas coumadin exerts it's effects longer. If you miss 2-3 days of coumadin, no big deal; it is a big deal if you miss a dose of Pradaxa. Other disadvantages of Pradaxa: cost, it must be stored in it's original bottle or package, and if bottled, is only good for 60 days (although the directions currently indicate 30 days). I think that once it's indicated for more conditions, Coumadin will take a back seat to Pradaxa, but that isn't anytime soon.

Pradaxa is a direct thrombin inhibitor, while Coumadin/Wafarin prevents the activation of*4 clotting factors that depend on*Vitamin K. No need for monthly labs and frequent dose adjustments as with Coumadin. Of course, time will tell whether Pradaxa will replace Coumadin in A-fib patients....

One consideration: how long will coumarin clinics be needed, as the new drug Pradaxa doesn't require lab work?

I was giving multiple chemotherapy meds to a 2 year old for her ALL, mixed syringes up, and mistakenly gave a hep flush IM (was supposed to give L-Asparaginase). I was fortunate that I had already given the Vincristine IVP and not mixed up THAT syringe. I was just on the receiving end of a major med error last week. I am on Tacrolimus for a kidney transplant and had a recent foot infection leading to Orthopedic surgery. My foot ulcer grew out an opportunistic Candida, and after consulting with ID, the Ortho PA rx'd Fluconazole. When I had my monthly labs done, I was in acute renal failure and Tacrolimus toxicity. The PA surely had a warning of a major interaction between Flucoazole and Tacrolimus, but apparently ignored it, and never consulted with the Transplant doc who manages my Tacrolimus.

MRSA is widespread in the community. In our clinic, we wipe down exam rooms where there has been drainage from a MRSA wound; otherwise, standard precautions.

72 hour stool collection for fecal fat on a patient with cystic fibrosis. Also, I caught a gastroenteritis about 6 months after I finished nursing school. I had been vomiting all night, was dehydrated, and went to the ED. It turned out that I had a partial bowel obstruction, and while I was in the ED, started vomiting feces. THAT is gross.

As an aside, the "success" rate (meaning the patient eventually left the hospital alive) for CPR is 17% when performed in the hospital, 5% for those with chronic illness(es), and less than 3% in nursing homes.

Geisinger Medical Center in Danville PA. Low cost of living, decent salary, and still not a far drive to Philly and NYC. Downside- it's rural (although some may consider it an upside)

Do the physicians "buy in" to case management? That's the first thing that needs to happen. Instead of having the approach of having the patients "change their bad habits", take it one step at a time. Start simple. For the heart failure patients, have them weigh themselves daily, and when their weight goes up quickly, ask the doctor for a bump up in their diuretic for a few days, and follow up closely. When the patient sees concrete results, they will begin to trust you. For the diabetics, have them check their blood sugars every morning, and then when they are doing that, have them check before breakfast and 2 hours after. Get their blood sugars under tight control, and when their HbgA1C is improved, show them the correlation to controlling blood sugar and the drop in HgbA1C. When you introduce yourself, don't ask if they want a case manager. Instead, say I'm Joan Smith, the case manager in Dr. Jones' office, and I'm calling to see how you are doing". It's all about presentation. As you gain their trust, you can increase your management, and you will find that more and more will be open to having you call.

Press-Ganey is a powerful force!

Having worked outpatient for the past 17 years, I can tell you that there is a HUGE market for narcs. We would frequently get anonymous and caller-identified calls about a patient getting his/her 180 or 240 Percocets, and selling them in a bar, at a housing complex , etc. At a street value of $5 each, that's a HELL of a lot of money. And, it's fraud, because the insurance or Medicaid is paying for it. As far as inpatient, I don't hesitate to give a PRN narc if it's needed. And, as one poster said, if someone has chronic pain, it's time for Pain Clinic. I'm all for drug contracts as well.

Hard to say what the difference is, as it varies from company to company. I'm a Case Manager, and am strictly involved in disease management. In my company, the definition you use for Care Coordinator is called a Health Manager,and they have specific disease processes they handle. I deal with Heart Failure and COPD (Medical Home), with the main focus being keeping the patient stable (heading off problems before they mushroom), and preventing readmission to ED, Hospital, SNF within 30 days of last admission.

A strawberry/vanilla shake?

I also have a hereditary peripheral neuopathy (Charcot Marie Tooth), and my feet wouldn't withstand shifts working on a transplant floor (earlier in my career I worked in the hospital and just sucked up the pain). I did consider a position as a Transplant Coordinator, but I recently took a position as a Case Manager, which I love. As for getting sick, I worked in a Peds clinic before and after my transplant. I must be REALLY good at handwashing, because I've rarely been sick since my transplant in May 2008, and am CMV negative. I had "tolerogenic immunosuppression". The only steroids I had were 2 half-gram doses of IV solu medrol right after. I also had Campath intraoperatively, which wipes out (temporarily) B cells, thus allowing for minimum steroids. Maybe the fact that I'm not on Prednisone has minimized infections? I currently have BK virus, which is a virus dormant in the urinary tract that sometimes reactivates. It's fairly well controlled on Leflunomide, and my creatinine has been rock stable, so hopefully the damage is minimal (haven't had any biopsies). Don't feel bad if you've never heard of it, because I never did before I had my transplant. Even my PCP had never heard of it. Fortunately, my transplant center is awesome, and they screen for it routinely (more and more centers are starting to screen for it, but very few were when I had my transplant). BK probably has led to many people in the past losing transplanted kidneys. Docs intuitively gave massive steroid doses in the past when creatinine went up. If BK was responsible for the rise, this only caused it to proliferate and ruin the kidney. It's amazing how much has happened in the transplant field in just the past 5-10 years.

I signed on as a donor from when it first became available to do so with my driver's license. My personal irony is that I ended up RECEIVING a kidney 3 years ago (Polycystic Kidney Disease). I find it hard to believe that insurance status determines whether you can get on a list to receive an organ. Should you become ill with a catastrophic illness and need an organ, yet don't have insurance, you more than likely would get Medicaid. As for not being able to list at multiple centers, I was listed at only one-the one my insurance would cover that was "in network". I knew of people that list at multiple centers, but it's not necessary. Nobody but the workers for the organ procurement centers really know the exact "formula" for figuring who gets an organ or not, but generally, if it's a heart, lung, or liver, your clinical status is the most heavily weighed factor. For a kidney, it's time on the list and possibly how many antigens are a match (although with the new immunosuppressive regimens, that's less of a factor). The process does not seem to favor wealth (possible exception-Steve Jobs), and seems as fair as possible. I waited almost 3 years, but I live in a more rural area-urban areas typically have a much longer wait.

I just left a job after 17 years in a primary care clinic where I did mostly phone triage. The docs love having a good triage nurse; it takes a lot of work off of them. I leveraged that experience and am now a Case Management nurse (it was a job transfer) for a HMO, and I love it! I mainly deal with Heart Failure and COPD patients, although there are also a lot of other co morbid conditions these people have. The goal is to keep the patients stable, catch problems before they turn into much bigger problems. It helps the patient by keeping them out of the hospital, and helps the insurance company by saving big hospital and ED bills. This is where Medicare is going-reimbursement will become very tight, so most hospitals will need to go the route of having CM's.

Where to go? Case Management. As insurers (especially Medicare) look to cut costs, that will translate into managing high risk patients to keep them out of the hospital and ED.

Exactly! I find that this "entitlement attitude" is pervasive, and not limited to the nursing field. I just took a position as a RN Case Manager. No weekends or holidays, decent pay, great benefits, and autonomy. On the flip side, I am salaried, so no OT for the 9+ hour days I will be working. But for me, it's the dream job I've been wanting, and is an up and coming field, which hopefully = job security. (in the upcoming years, there will be even more of an effort towards keeping people out of the hospital) I started out working night shift, worked many holidays and weekends-I paid my dues. But I'm where I am at today because I PLANNED my career,focused on where things were headed in the system I work in, and made adjustments when needed. And yes, there were times when things didn't go according to plan, but with adjustments, everything is working out well. Woe is me will get you nowhere fast.

Cool! I didn't see anyone culturing the pus, though....