LilPeanut

"I didn't have diabetes before I was here, I'll need teaching." "Uh, you should be fine, it'll just be temporary." "But temporarily, I'll need to understand how to deal with this." "You just check your sugar, based on the number you get, you inject how much insulin it says." They basically still did nothing and I got no teaching. I did file a complaint.

I loved the resident who, when rounding, stated confidently that despite the high dose steroids, I've not had blood sugar issues, so should be fine to discharge without any. "Uh, I've been getting insulin twice a day and I still haven't been eating. I'm pretty sure my blood sugar is going to go up more when I'm eating." Later in the same hospitalization, still trying to get discharged, have never been diabetic before, but because of said steroids, have a touch of diabetes LOL Anyway, the discharge home instructions from the doc "Just follow a sliding scale, check your sugars as normal and you'll be fine." 1. I am an NP, but for neonates. I deal with babies on insulin drips, I've not used a sliding scale, you're going to have to teach me. I was not diabetic prior to this. 2. How am I supposed to check my sugars without a glucometer? Checking my sugars as normal would mean not at all, since I wasn't diabetic. 3. when I finally did get discharged home and we picked up all my supplies, they forgot to prescribe the needles that go with the insulin pen. I couldn't figure out what I was doing wrong! (I hadn't ever used an insulin pen before) 4. and obviously no diabetes teaching. Shoddy discharge planning.

You can know what EMR they use without saying you work there. I know what EMR several hospitals use that I don't work at. And I know how to figure out if they use Epic.

I definitely agree - anyone the staff spoke to should also be charged and arrested. Yes, the RNs had more knowledge presumably about the patients and medical situation, but unless the RNs were outright lying about conditions ("It's 68 degrees inside and not humid at all") which I highly highly doubt they did, anyone would have known that it was dangerous. The fact they were so close to a hospital though for evacuation does though make it harder to justify any reason the nurses didn't get help. The whole chain is responsible. edited to add: That even includes administrative staff who were there (secretaries and the like) because it does not take any sort of medical training to know that was dangerous. Those adults were vulnerable. They deserve protection.

neonatal nurse practitioners are in short supply all around. There are not enough of us.

Really, the houses here are more like >700k, but buying is not the best option for everyone. It's a lie we've been sold. Just have to keep repeating this.

That is not the same as every illegal alien with no ssn can get free community college tuition, which is what you implied. It is intended for children who have lived in this country for their whole lives to still be able to attend college.

Because it was on the MAR for more than one shift. Not being able to get an order in immediately, that's understandable. But many hours later isn't. I'm a provider and when stuff is crazy, some orders will get missed, but within a few hours, nurses will remind me that x and y still need ordered or discontinued. Example: our orderset for methadone automatically includes narcan, because it was designed for outpatient use. Neonates on methadone are all being weaned off narcotics and should never be given narcan ever. If they have respiratory depression, we will support them, but not give narcan. It could cause seizures. Forgetting to discontinue narcan is very easy to do. But it is an accident waiting to happen. All it takes is a float nurse who isn't as familiar with our withdrawal protocols and is used to older children or adults. So as providers, our responsibility to prevent that mistake is to keep the MAR up to date as far as orders. You can put in comments that a provider needs to be spoken with prior to administration. The nurse was wrong, but the provider could have helped prevent the error from occurring.

Citation please.

In San Francisco it is!

Yes, the doc should have discontinued the order, or placed in the comments that they needed to be contacted prior to administration. Especially since it has been on the MAR for more than one shift as an inappropriate PRN. You also could document a "not given" with the reason "per provider, should not be given" at the beginning of the shift, to document for anyone to look at the MAR that it shouldn't be given, and then it will fall back on the provider that they didn't keep their orders accurate. Honestly, the whole thing is just crazy. This is exactly how the stuff in vanderbilt happens. Nurses who don't look at MARs, don't talk to others, don't document in a timely fashion. There are some systems issues that can be addressed to protect from the incompetent nurse, but part of the systems fixes are also to get rid of the incompetent nurse. It's totally unacceptable.

I know how to use public transport and used it while I was in Cleveland. To get home from the airport, I had to take the train, then get the bus. I needed to budget two hours for travel to the airport. In a car, it would take 30 min. https://www.google.com/maps/dir/13800+Fairhill+Rd,+Shaker+Heights,+OH+44120/Cleveland+Airport,+Riverside+Dr,+Cleveland,+OH/@41.452368,-81.7908589,12z/data=!3m1!4b1!4m14!4m13!1m5!1m1!1s0x8830fc89769dc2f9:0xad96864c9ff5d428!2m2!1d-81.5880192!2d41.4899226!1m5!1m1!1s0x8830eced544890cd:0xbbaf031e9364e392!2m2!1d-81.8538669!2d41.4057985!3e3 To get to my son's allergist, which was the closest allergist our insurance would accept (because I was not thrilled about going to twinsburg.) it would take >2 hours while driving was 30 min. https://www.google.com/maps/dir/13800+Fairhill+Rd,+Shaker+Heights,+OH+44120/Twinsburg,+OH/@41.2833081,-81.8498518,10z/data=!3m1!4b1!4m14!4m13!1m5!1m1!1s0x8830fc89769dc2f9:0xad96864c9ff5d428!2m2!1d-81.5880192!2d41.4899226!1m5!1m1!1s0x88311ee1cdf4800f:0x717e21af3de8996e!2m2!1d-81.4401129!2d41.3125552!3e3 To get to Aldi's, it would take over 45 min by RTA, 8 min by car. https://www.google.com/maps/dir/13800+Fairhill+Road,+Shaker+Heights,+OH/ALDI,+10815+Kinsman+Rd,+Cleveland,+OH+44104/@41.477754,-81.6280388,14z/data=!3m1!4b1!4m14!4m13!1m5!1m1!1s0x8830fc89769dc2f9:0xad96864c9ff5d428!2m2!1d-81.5880192!2d41.4899226!1m5!1m1!1s0x8830fb5ea8de4a77:0x23ec995ca5835e2b!2m2!1d-81.6083969!2d41.4697878!3e3 It's possible to get to places, sometimes with more walking than others, in often inclement weather, but you are going to spend way more time doing it, to the point where it is not worth it to do anything. It's possible to not have a car, I know not everyone has a car. But living in a dense city vs spread out city is a no brainer when it comes to cars. Everyone who lives in the city travels out of town. I'm probably the only person who doesn't regularly go to Tahoe or the Russian River or some other place when they have a couple days off. I can even get to Monterey for under 5 bucks, only take 30 min longer if I go by bus than car. It's often *faster* for me to go by bus or muni train or bike than by car. The vast majority of people living in Cleveland would say a car is necessary. The vast majority of people living in SF would say a isn't necessary, and might be a hindrance.

To be clear, I love Ohio (O H I O) I am a two-time Buckeye and grew up in Columbus. But I remember needing to get my driver's license ASAP because I needed friends and parents to drive me places.

The buses and RTA are more expensive and less extensive than public transportation here. Getting to a grocery store in Cleveland was not possible without a car. I lived in Shaker - the buses and trains are not nearly enough to be functional. Add on to that, in the winter and the summer, it becomes difficult to conduct the same activities outside. I can't ride my bike comfortably year round. Maybe some people bike in the snow, but they're crazy. You can find places to go using buses and RTA, but trying to actually live without a car? I dare you to try it for a month or two. Preferably in the worst of winter. Downtown C-land does not have the vibrancy nor the availability of services as a city like SF or NYC has. Riding a bike to work is possible in the summer in C-land, if you have the ability to shower at work. Otherwise it's not actually feasible, unless you don't sweat. Our lows in the summer/winter at at worst mid 40s, it never gets freezing here. I live in a high rise and like cooler temps. In the coldest times, I close my windows. But thanks to global warming, we´re having more hot days ? In general though, our temperature here is between low fifties and high sixties. I don't think there's been a day that hasn't reached the mid fifties, even during July. You wear layers and just adjust PRN ? Fun facts about that quote: https://www.anchorbrewing.com/blog/the-coldest-winter-i-ever-spent-was-a-summer-in-san-francisco-say-what-says-who/ https://www.sftravel.com/article/san-francisco-weather For the micro-climaters - I live in the so-called "east cut" (self named that no one likes) but most consider us either Rincon Hill or the border between SOMA and South Beach. Personally, I'd prefer to live in Pacifica, the Presidio or the Sunset, but I can't beat the convenience to Mission Bay where I work. ? It is technically possible, but very difficult to not have a car in Cleveland. In SF it's difficult to have a car. That's a luxury. The city is far more friendly to walkers and bikers. There's bike shares, scooter shares, buses, muni, bart, caltrain, ac trans, etc. I can get to the IKEA in Oakland in less time by taking the bus than by driving. I can go to San Jose by train in almost the same amount of time it would take driving (faster if there's traffic). It takes nearly three times the amount of time it would take to drive to take the bus from Shaker to Kent. My son goes to Kent and has had to take the bus before - but it takes far longer and far more limited as to when you can use it. Again, ask most Cleveland and its suburbs residents to give up their car, they would say it wouldn't be possible. Especially if you ask them in winter when there's a few feet of snow on the ground.

I don't even have roommates (apart from my kids LOL)

I would suggest some therapy also to help deal with unreasonable anxiety.

I have lived and worked in Cleveland Ohio, Houston Texas, and San Francisco CA as an NP since 2011. My pay didn't vary much between Cleveland and Houston. It skyrocketed with SF. My standard of living was also essentially unchanged between all places, except in SF I can save more, even when I pay an obscene amount in rent. In Houston, you can expect to pay 2-3k for a 3 bedroom place, if you want to live inside the loop (ie, keep your commute <1 hour). You get around 100k/year (a little less). You have to have at least one car for your family. Utilities are a constant cost that is high because of all the air conditioning. In Cleveland, the prices for a three bedroom can vary more, depending on area, but I would expect 1.5-2k for a 3 bedroom apartment without a huge commute. You have to have a car for the family. Utilities are still heavy, with air conditioning in the summer, heating in the winter. I was making about the same, and the costs were overall about the same. In SF, I am making ~200k or more, my apartment is 4k/month, which is a 1 bedroom. (I live in a fancy brand new high rise) The biggest buy in cost is at a one bedroom. Adding more bedrooms is often much cheaper in a per bedroom comparison. I sleep in my bedroom. When the kids are here, the living room is converted to a bedroom (common here). My costs are lower - I don't use heating ever and rarely use cooling. I don't need a car. I live downtown so my commute is less than 10 min on a bad day. I can walk to work in 30 min if I wanted. My overall quality of life is better though. I am growing my nest egg (in addition to my pension) and I live in an amazing city where I can go outside nearly every day of the year and it will be pleasant. My rent is more than 50% of my income I think, but because that number is so high, I still have plenty to live on and save with. I travel regularly, buy everything I need, eat as much as I want, etc. I don't know if I could ever move, because I'm not willing to take the quality of life cut. Houston had no state taxes, but no one would drink the tap water because it was gross. But community college is free here and our tap water is delicious from the sierras. I have more activities here, open minded people, and plenty of disposable income. It's easy to knee jerk about CA, but you have to actually plan out your budget to be able to truly compare.

Can you please cite that case? Often cases are cited as excuses to not intervene, but when you actually read the case, it is not how it was presented.

My sarcasm meter is not functioning well tonight; I hope that was a joke, right? This is an issue for NP providers too. At night, I am often carrying 20-30 patients, the vast majority of them have nothing active going on, I'm there to put out fires that might happen, but otherwise, I'm just babysitting those kiddos. There are often a few that are actually actively sick and needing intervention. Focus on those kids, "nothing to do" is enough for the others. Maybe let me know if they have labs you want me to look at (often the labs obtained are more for the benefit of the day shift NPs, and they don't want the night shift to go chasing down every lab if it is not urgent.) For us, what drives me nuts is "feed check" and "resp check", with nothing further said. Ok. You want me to make sure the baby is breathing and feeding. I do that with every patient. You don't have to tell me that. If you are considered about feed toleration "Big belly, concerned about tolerance, had bowel US 4 hours ago that didn't find pneumatosis, We continued feeds, but if there is another emesis, please stop feeds." Or "extubated this morning. Doing well and we're tolerating a CO2 up to 80 and an FiO2 up to 60% right now before we want to consider reintubation. In 4 hours, if they are still working hard and have FiO2>40 and their CO2 hasn't come down to the 60s, the team would like to intubate." I will care for all the patients on my team to the best of my medical ability, along with the fellow and attending. BUT if the primary team has a specific concern and/or a specific reaction they want us to have, especially, if it is outside "standard", let me know that. But I don't need to hear the play by play of how many stools or have them read the daily progress note to me. Very frustrating. Especially when certain people will take 45 min to an hour on the minutiae.

Dude, if it were a big deal to forget to notify the board about an address change, there would be a ton of nurses losing their licenses. It's more that it is a liability to you. If there is a problem with you or your license, they will attempt to contact you with the info on file, which if you can't receive it, you can't rebut or fix the problem.

I choose that because most ICU RNs have had little to no experience with women's health I would think. I guess I would take the age into account too. ?

Going back to the original questions: I would always offer on a plane. IMO, the best case scenario is that everyone with medical training will offer and you can discuss amongst yourselves about who is most qualified for this - and who to perhaps confer with if needed. Similar to what was mentioned in the linked article, it can get complicated as to which is the most appropriate/qualified. an ICU RN, a cardiologist, an NNP, and a radiologist all respond to the emergency call. What is the issue? The cardiologist has had a drink or two, doesn't feel drunk. The ICU RN is a new grad just out of orientation. The NNP is experienced, but that experience is exceptionally narrow. The radiologist is not used to dealing with patients like this - she looks at a computer screen all day. Chest pains? ICU RN for front line care with the altered cardiologist to give verbal backup and support, as long as they've disclosed their drinking and have stopped (which is why they shouldn't be hands on). Woman delivering a baby? Radiologist and NNP. The radiologist can take care of the mom, the NNP will take care of the baby. (cardiologist and radiologist both have distant training how to do it, and the radiologist hasn't been drinking). Seizures? ICU RN with other professionals as backup/extra hands. Coding? Everyone except the cardiologist can help - but the ICU RN and NNP have more code experience than the radiologist (NNP's codes might be with babies, but you are in a good habit of being in that situation, less likelihood of panic/freezing) I am not worried about being sued or getting into trouble for offering help. No jury will convict assistance offered in good faith even if someone did sue. In a situation when I am the only person available and I may have had a drink? If I am literally the only person that can help, I will offer and tell everyone, patient, family, staff, that I have had a drink and I cannot accurately guarantee my level of impairment, but if I'm the only thing you got, I might be better than nothing. In the latter situation, my preferred situation would be to be able to give my observations to another provider who is on a phone (again, disclosing I've had a drink). There are even situations where someone could be totally sloshed and if there is no one else to help, they might still be better than inaction. (for example, if a woman delivered a mildly premature baby, the NNP could make sure they know to do kangaroo care until they can land. That she would know in her sleep. Obviously that would be incredibly terrible as a situation, but the chances of it happening are so extremely rare. The flight attendants wouldn't automatically know who is most suited, and often if most people won't say they can help, there's no chance to know who could best help. I do transport as an NNP and even if I was the only person available on a flight, I could at least talk to ground support to give accurate assessments and carry out recommendations. I know there is always ground support somewhere. I also think back to the case where the woman died on a flight back from Hawaii when they didn't divert when recommended by the doc who responded. That doc made a mistake, IMO, because the first time she lost consciousness (which was written off as syncope due to anxiety, without ever having a history of syncope), the flight should have landed ASAP. It was over an hour later when she had the loss of consciousness with loss of bowel control/seizure. But no one is getting upset at him (likely helped by the fact they were over water with nowhere to land anyway). Even with the mistake, it was given in good faith, and there weren't other people giving other options or disagreeing. Lots of rambling to say, legal consequences be damned, the moral and ethical thing to do IMO is to offer aid.

And patients who are getting serious or life altering lab results should not have to wait once those results are back. The provider should be there promptly to give them. The a reasonable delay would be to notify the patient that the provider is making a care conference for discussion of the results - if that is what needs to happen before sharing.

@Jory Stop. You've acted poorly. You aren't representing NPs well.

That's a whole different situation. I would not give info like that on a patient I was no longer caring for, as an NP or RN. And patients can misunderstand and misconstrue what we say no matter what. Patients have a right to their health information. When I was hospitalized, I would see my liver panel every morning, because I was in for liver failure. A nurse telling me she couldn't tell me the result would have sent me into a panic most likely, because that's totally within their scope, and if they wouldn't tell me, perhaps something else was wrong. another possible review: "Bad nurses at city hospital, wouldn't even give me the results of basic tests because they are too dumb to understand them, was forced to wait unreasonable time to find out about my own health!"