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RobbiRN

RobbiRN RN

ER RN
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Content by RobbiRN

  1. RobbiRN

    Ripe for Exploitation

    The Most Trusted Profession Nursing ranks as the most trusted profession in Gallup’s annual poll for the seventeenth year in a row with a score of 84. Doctors and pharmacists come in a distant second and third with scores of 67 and 66, and the list fades from there. Politicians are tied with car salesmen, continuing their grip on last place with a score of 8. The honor of being part of the most trusted profession should not be taken lightly. Patients are keenly aware that we spend the most time with them, our motives are not tainted by financial gain, we usually care, and we’re positioned to share an honest, enlightened opinion. In theory, nurses are really cool people–great for relationships, good with confidences, least likely to inflict unnecessary pain, and excellent for decorating hospital marketing brochures with bright scrubs and big smiles. (And we usually pose for free, you know, because they asked.) We may be all these things. In a cruel twist of irony, some of the same qualities that consistently win us first place on the most trusted chart also make us ripe for exploitation: We’re eighty-five percent female, programmed to please, and unlikely to fight back. Risk for Exploitation - Why?? 85% Female Profession First, just being an eighty-five percent female profession still makes us vulnerable to inequality. "On the Basis of Sex," a recent movie about Supreme Court Justice Ruth Bader Ginsburg, stages a brilliant moment. Felicity Jones, who plays Ginsburg, is arguing a sexual discrimination case before an all-male panel of judges. One of them looks down on her and declares in a voice laced with condescension, “The word 'woman' does not appear even once in the U.S. Constitution." She stares him down and quips, “Neither does the word ‘freedom,’ your honor.” It’s a moving moment of assertive confrontation on her pathway to becoming the first female Supreme Court Justice. It’s a reminder of how far we’ve come. Women have made major strides. We just finished Women’s History Month. We even have a Women’s Equality Day. There’s a myriad of opportunities open to us, but we still glaringly lag male counterparts in easily measured areas like equal pay for equal work and representation in government office. A friend of mine in Spokane, WA, works at a major hospital where the nurses are threatening to strike. One item of contention is the $41 million in salary paid to the fourteen executives at the top while the workers are facing eroding benefits. A breakdown of the executives’ salaries posted on social media shows an equal number of men and women, but the women make half of what the men get. Statistics vary, but females employed in the U.S. make about twenty percent less than males. The discrepancy is still about five percent for doing the same work. The number of females elected to government office continues to increase, but women still only hold about one in five elected positions. If money and power are any indication, an essentially female profession is still inherently vulnerable. A Desire to Fix Things Second, our innate desire to rescue, fix things, and make people happy increases our risk of exploitation. There’s a profoundly odd inverse relationship between love (caring) and power in human relationships. As power increases, love decreases, or, as love increases, power decreases. Most of us learned this lesson the hard way during our early teen years when we first fell in love. After a few weeks or months of infatuated bliss, we were slammed with the devastating realization that the other person no longer cared. We may have found ourselves desperate to save the relationship, willing to do anything to try to please the one who had stopped caring, making us vulnerable to manipulation and various forms of abuse. The one who cares the least obviously has the most power. Nurses are correctly described as caregivers. We don’t need a lot of concocted programs or checklists to push us to improve patient satisfaction. We’re usually programmed to please. It’s in our genes. Most often, it’s why we signed up. So, what happens when we’re short-staffed, equipment isn’t working, supplies are missing, and patients become demanding or even belligerent? Our first response is to skip breaks, work with full bladders, walk faster, and try harder, often postponing or neglecting our own needs to make sure others–patients, visitors, and our bosses–have what they need or even what they just want. Many of us work while sick or injured ourselves, giving for the sake of others. As sensitive people who care, we’re inherently vulnerable to “takers” who don’t care beyond their commitment to their own welfare. Nurses - Not Fighters Finally, nurses are generally not fighters. While this is an obvious corollary to our basic instinct to fix things, there are other constraints firmly entrenched. New nurses are increasingly entering the profession deeply in debt. The push for increasingly higher levels of education has a hidden benefit for employers–a submissive workforce. Student loan debt averaged about $33,000 in 2018. More than ever before, new RNs just need the job. A young, smart coworker was venting to me in the breakroom a few weeks ago about a new policy removing our ability to override several frequently used medications. Her observations were valid, and her rationale had merit. When I suggested that she send an email to management, she quickly backed down. “Are you kidding me? I can’t afford to rock the boat. I’m a single mom with $48,000 in student loans. My kids come first. I’m bought and paid for.” A lot of great ideas never get past venting in the breakroom. The ultimate restraints are the legitimate needs of the patients entrusted to our care. Even when the workload is grossly unrealistic because we had a couple of call-offs, we still imagine that the people in those rooms are like our own family. Some of them really need us, and we don’t want to fail the ones who do. In the ER, we have no control over how fast patients pour in. As EMS stretchers line up in the hallway and patients back up in the lobby, we’re forced into working dangerously–again, and we shift into a nearly frantic survival mode of putting out fires. We just try harder, work faster, and, yes, cut corners (putting ourselves at risk) when survival depends on it. At times our productivity is super-humanly-amazing, off the charts–and simultaneously enabling. Those who profit from the accepted inequities in our system bank heavily on our dedication to our patients. If bus drivers, teachers, IT specialists, or professional athletes strike, it’s an irritation or an inconvenience. If we strike, even if enough temporary replacements are pulled in, patients could die. If enough of us went on strike at once, a lot of people would die. There are some significant pockets of resistance, and a few major battles have been won, but generally, our profession of non-fighters has demonstrated remarkable restraint. Those in power expect that we’ll continue the established path of pacifism. Bargaining Power Paradoxically, the greatest constriction of standing up for ourselves, the welfare of our patients, is also our best bargaining chip when we do take on the powers propagating the exploitative system. I sometimes think of our current nursing profession like a wife in an abusive relationship, fearing for our own safety and that of our children, those entrusted to our care. The battered wife knows there may be casualties if she resists, but at some point, she chooses to take the risk. As a profession, we cannot condone harm to innocent, needy people. At some point, honor demands we take a stand. The core problems plaguing our profession run much deeper than staffing levels. This year, there are massive rumblings about fixing our national disgrace. The U.S. remains the only industrialized country on the planet that does not provide some form of universal access to healthcare. We are the only system enabling rampant profiteering at the cost of human lives, pretending that healthcare is a commodity like a new car or pearl necklace. Storm clouds are gathering, and two serious questions for the rest of our Nation are looming large on the horizon. Who causes the greatest harm to our patients? And who will step up to rescue them?
  2. RobbiRN

    Ripe for Exploitation

    You're right that healthcare is primarily a human rights issue, and the rest of the industrialized world treats it as such. Only the U.S. makes healthcare a commodity, a business issue, with rampant profiteering enabled by immoral politicians. Conservatively, 50,000 people die annually here because they can't buy what they need. A compliant nursing profession is an integral part of leading the lambs to the slaughter.
  3. RobbiRN

    How would Medicare for all affect nursing?

    Check the numbers here. Another myth supporting profiteering is that US drug companies need years of exclusivity to recover their large investment in developing new drugs. Most R&D is funded by taxpayers and the drug companies are allowed to profit anyway. According to this article: "A recent study found that all 210 drugs approved in the U.S. between 2010 and 2016 benefitted from publicly-funded research, either directly or indirectly." https://thehill.com/opinion/healthcare/376574-pharmaceutical-corporations-need-to-stop-free-riding-on-publicly-funded
  4. RobbiRN

    How would Medicare for all affect nursing?

    First, I'd like to second the financial breakdown and arguments well-stated by MunoRN in this thread. I've researched this subject extensively (five books and hundreds of articles) over the past two years and talked with many people while traveling outside the US. I firmly believe private insurance tied to employment is the root cause of our exploitative, inequitable system. Consider or reconsider the following: 1. The majority of bankruptcies in the US are due to healthcare bills, and about 75% of those bank bankruptcies are people who were "insured." 2. About 30% of all healthcare dollars spent in the US are spent on employees hired by providers to argue with employees hired by insurance over denials, coverage, and payments. 3. Government should be the single payer, but providers should remain private, and regulation should be a joint effort. 4. We are drowning in clutter and complexity. 5. Those profiteering form our system spend heavily to promote the arrogant notion that we are superior to the rest of the world and we have nothing to learn from them. 6. The US is spending about 18 % of our GDP while lagging countries who spend a third of what we do in broad measures like life expectancy (we're number 31 on the list) and infant mortality. The next most expensive country is Switzerland at about 12% of GDP. 7. Most countries that get better health for less money spend more than we do on social services and solve problems before they become medical problems. They promote health instead of enabling a few extremely wealthy people to profit from illness. 8. No matter how we do this, those who pay will always pay for themselves and everyone who doesn't pay. 9. Quoting myself (and I won't sue me for doing it): “We are the only industrialized country held hostage by fear of a medical crises. Everyone else has a backstop, but not the U.S. You lose your job? You just lost your health insurance, and you better not have a serious problem until you get more. Financially, you could retire at sixty-two, but you can’t afford private health insurance, so you’re forced to work longer. You want to have a party for your twelve-year-old, but you’re afraid some kid might get hurt at your house. If he does, you’ll have to pay a big deductible and fight with your homeowner’s insurance because that kid’s health insurance will deny the claim and tell his parents to sue you for his ER visit. We live scared in the U.S. In countries with universal coverage, you can retire, move, change jobs, and party when you want to without the overhang of being wiped out by one catastrophic medical event.” And to answer the original question, could nurses get paid less under some form of Medicare for All? Yes. It's a sacrifice I would make for the sake of honor. Those enriching themselves at the cost of human lives here would make billions less, and many would be out of a job.
  5. RobbiRN

    Ripe for Exploitation

    Thank you for a noble effort and your kind affirmation. As you found, I believe strong individual efforts leave us vulnerable. I know several doctors who were punished severely as well for individual efforts to practice reasonable medicine. Our best chance to rein in the lunacy is resistance on a large scale, like the apparent union victory in NYC this month. As a profession, the mere threat of a massive strike should bring the Nation to its knees. After all, we do have their lives in our hands.
  6. RobbiRN

    Ripe for Exploitation

    I believe it was one of your comments in another thread that inspired the line about how super human productivity which is off the charts is simultaneously enabling. Your point is well taken. My generalized, impressionistic portrayal of nursing is intended to help sharpen the focus on the challenges we face and rally our collective resolve to demand a better system at every level.
  7. RobbiRN

    Latest on RaDonda Vaught case

    I'm late to the party -- again. Maybe this was covered in a previous thread, but what can we learn from the actual incident? To me, the biggest mistake was after all the others discussed in this thread. A paralytic (vecuronium) doesn't kill a patient. Failure to to bag or vent a paralyzed patient will result in death within a few minutes. Supposedly, after the vecuronium was given, the patient was put into the scanning machine, and left alone for thirty minutes. Didn't anyone watch for a minute or two to see what the drug would do before shoving the patient into the MRI tube? Paralytics usually hit in a matter of seconds. Versed also can require mechanical support in some patients. Was the need for speed so important that we couldn't wait a couple of minutes to observe a med effect?
  8. RobbiRN

    I was slapped by a patient

    I've seen signs like this in airports all over Europe and in Australia, especially in the immigration areas. Several of us have forwarded examples of signs from other hospitals to management and security at our facility, but so far our administration hasn't seen fit to trouble the public with the notion that they are to to treat staff and other patients with respect. Here's one from a hospital in Sidney:
  9. Yes, but they are only a small part of a lineup of "soul-sucking despots that truly only care about the bottom line." Some suck souls indirectly through the art of profiteering. I believe the correct order based on profit margins is: 1) pharma, 2) equipment makers, 3) health insurance companies, 4) for-profit hospitals, 5) bought and paid for legislators who enable the abuse, 6) lawyers who are having a good day, and 7) non-profit hospitals which rank last because their average CEO salary is only about $4 million. All profiteering at the cost of human lives is pathetic, immoral, and unsustainable at current levels. The beam will cry out from the woodwork.
  10. RobbiRN

    Curiosity Killed the Cat and Got 50 Hospital Employees Fired

    What am I missing? Every staff member in our ER can see the name of every patient in our department, their presenting complaints, orders pending and completed, along with a lot of other information, whenever we access our main dashboard screen. The list balloons up to fifty patients at a time, and we work as a team. If I'm caught up on my patients, the first thing I do is scroll the dashboard looking for who may need help. I may click on several patients to determine who is most at risk and highest priority even though I may not care for several of them whose records I access. Any patient in the department is a potential recipient of care from any staff member at any given time. It is ridiculous to imagine we are to myopically focus on our own patients and sacrifice our ability to quickly reallocate our resources to where they are most needed. If teamwork within a department is a HIPAA violation, we've thrown the baby out with the bathwater.
  11. RobbiRN

    Your Third Act

    Thank you for a great article. I find it interesting how several strong voices on this site just confessed to being 60ish. Me too, as of two weeks ago. I pictured many of you as being a little younger, but I should have known that such wisdom and the ability to share it articulately grows over time. The Third Act designation is excellent. I'm proudly adopting it as the new description of my station in life as I continue ER nursing indefinitely while speaking out against the profiteering and exploitation plaguing healthcare delivery in the U.S.
  12. RobbiRN

    Pit Bull Service Dogs

    You are assigned a patient who brings two pit bulls with him to the ER claiming that they are service dogs. While it is illegal to falsely claim that a dog is a service dog, we are not allowed to challenge the claim or ask for proof. The patients complains of abdominal pain, but he has wounds on his hands he states are from separating the dogs when they got in a fight. He has no one else with him to help with the dogs, and they are on long leashes which allow them free access to the majority of his room. When you prepare to draw his blood they jump onto the stretcher, standing on either side of him. What would you do?
  13. RobbiRN

    Thoughts on vegetarian/ vegan diet

    Being vegetarian doesn't make a person healthy, but it can contribute to a healthy lifestyle. I was raised vegetarian and never found a good reason to change. 25 years into ER nursing, I can still do four 12's in a row and 2 hours of non-stop dance fitness with kids half my age. I have no ongoing medical problems and take no meds. My co-workers regularly come into the break room and tell me my food smells great--then moan when I tell them it's a garden burger. I just laugh and say, "Hey, you want to race across the parking lot?"
  14. RobbiRN

    Charge Nurse in 6 months?

    Several trends contribute to the toxic situation you described. 1.) Experience is valued less; a nurse is a nurse and one straight out of college costs less. 2.) Profits are more important that quality care. 3.) Policies protect the institution while insuring the nurse can be blamed when things go wrong. 4.) Charge nurses are no longer the most capable person on a team, just someone who will do it. 5.) Charge nurses spend a huge amount of time distracted fro the flow of the department because they are doing clerical tasks, compiling QA reports, doing call backs, etc. I've worked in the same ER for 20 years. On some shifts I can add the years of experience in the department and the grand total of the other 6 RN's will still not equal 20. We do put young, new grads in as charge and some do well, as long as the rest of the team does what we are supposed to do. The toxic environment you describe goes way beyond a charge nurse assignment. If you stay, you could be the miracle worker to take a pathetic place and make it work like it is supposed to. The challenge appears to be massive. Anything is possible. (By the way, I do take charge for limited periods on rare occasions because I work 11am-11pm. I prefer patient care, and a strong core of nurses each holding down their assigned area leaves a CCN little to do.)
  15. Last night, my MSN homepage bannered a slide-show article by Peter Giffen entitled, "20 ways artificial intelligence is changing our lives." The slide-show opens with an adorable little robot looking submissive and inquisitive. He, she, or it, looks safe, friendly, clever, and, well, almost lovable. I want one. Giffen asserts: "From chess-playing computers to self-driving cars, artificial intelligence involves machines learning from experience and performing tasks like people, only better." (Geffin, 2018, para 1). In the arena of healthcare, he intones, "AI has the potential to make medicine more precise and personalized." (Geffin, 2018, para 4). Or, more robotic. I wonder which it will be? AI's presence has blossomed in my world over the past few years, but it's learning curve has introduced new forms of danger. I research a trip to Australia. Within minutes, a bunch of adds for travel to Australia pop up in my FB newsfeed. Targeted advertising is cool, and a little creepy. Do I want to be spied on? Apple really wants my fingerprint to keep my phone safe. But, if I give it to Apple, my fingerprint becomes a new member of the AI community, making it available to anyone, or anything, clever enough to find and use it. Apple also suggested using facial recognition for security. Hey, why not? God knows, my face is already out there- except a photograph can pass the recognition hurdle. A few numbers in my head might be safer. My opinion, for what it's worth, is that privacy and autonomy are the commodities at stake in our courtship, or struggle, with AI. Whatever we give to AI comes out of our own pockets. When AI gets more, we have less. There are subtle levels of vulnerability in our surrender to AI, and our work environment is not immune. About a year ago, we adopted mandatory bedside scanning of patient armbands and medications prior to administration. In theory, scanning a patient's ID bracelet and every medication prior to administration removes risks of errors. We may have gained some safety, but we slowed the process. Giving AI a big voice has introduced several arguments I'd rather do without. For example, I need to give a child 240 mgs or 7.5 mls of children's Tylenol. When I scan the first 5-ml container, my KBMA warns me that I've only got a partial dose. When I scan the scan the next container, the KBMA hits me with a stop which I must justify. After scrolling through a drop-down menu, I choose the "physician's order" option to inform the KBMA that I won't be giving the full 320-ml dose which has been scanned. AI has the doctor's order too, and, hopefully the next upgrade will simply ask, "Since the Dr. ordered 240 mls and you scanned 320 mls, you're going to waste 80 mls, right?" That would allow me to confirm that we are all in agreement. Now, our AI simply knows I've got more than the doctor ordered. After our conversation, the KBMA signs off without knowing how much I'm planning to waste. And, it still has no idea how much volume is going in the syringe or in the child's mouth. AI may confirm the patient, the dose, and the route to its satisfaction. But, after making the computer happy, nurses still have full control over how much is pulled up, where it goes, and how fast it gets there. The same vial of Decadron can be given IM, IV, or PO (despite the "for IM or IV only" warning on the label), and the patient will probably have a similar outcome despite a route error. But, giving Bentyl IV (trust the warning) instead of IM will cause multiple adverse reactions including pain, edema, thrombosis, thrombophlebitis, or reflux sympathetic dystrophy syndrome. A 0.3 mg dose of Epi IM will stop an allergic reaction but giving the same dose IV will destroy even a young, healthy heart. Sometimes, I choose to override my KBMA for practical reasons. Our PO potassium order defaults to two 20 MEQ tabs. Most patients can't swallow them, but I have to override AI to substitute four 10 MEQs. In life-threatening situations in the ER, we still routinely work off verbal orders and create a record later. Despite the appearance of AI control, the autonomy in medication administration is still largely ours. The responsibility is definitely ours. Our wireless communication Vocera units are a mix of AI. They're getting better at voice recognition and taking more initiative in conversation: "Jason is not logged in. Would you like to leave a message?" But, they're still learning. If you have any doubt, crank up two of them and set them next to each other on the counter. The artificial conversation is entertaining. Their lack of intelligence shows up by the second or third sentence. They're very polite though, and they apologize to each other a lot. "I'm sorry, I didn't understand. Could you repeat that message?" "I'm sorry. I didn't hear you. Did you say to call to call Martha Johnson?" When two consecutive sentences start with "I'm sorry," the AI meltdown is well underway. One evolving pitfall of AI is the notion that simple clicks equal completed tasks. Recently, I had one patient waiting for transfer to another hospital when my shift ended at 11:30 p.m. I told my coworker assuming care that I'd called report to the receiving faciality. My coworker asked me to put in a disposition note. I said that I couldn't do it yet because the patient was still in our department. "It would be falsifying the record for me to chart that she's gone when she may still be here two hours from now." The oddity of the encounter was that my coworker was clearly not impressed with my explanation. I can understand her confusion though. New management instituted a plan where a receiving unit "pulls" the patient to the floor in their computer as soon as a room is assigned, creating a digital record that the patient has been moved. While this makes their times look great, the report has not been called or charted, transport may not come for fifteen to twenty minutes, and the patient is physically in my room. In a glaring AI failure, our ER charting system and floor systems are separate. After a patient is "pulled," I can no longer see him in our ER system. I can only chart by adding an append note, and vitals and other pertinent data are displaced. As reverence for virtual reality evolves, there's a growing acceptance that clicking creates reality. If it's clicked, it's done, end of story. The real world can catch up later. The greatest danger of AI in our environment is the ease of wrong orders entering the system. Doctors can order multiple order sets and sweeping protocols with single clicks. The configuration of our dashboard gives them a margin for error about the size of a cursor between patients. AI is not yet equipped to ask if it's sensible to order a psych consult on a two-week-old or question the fluid bolus ordered on the CHF patient. Instead of making medicine more precise and personal, AI is making it more cookie cutter. Extremely diverse complaints are evaluated with the same "might be septic" battery of tests. The evolution of AI protocols has made doctors more obsolete while passing more of the ongoing assessment, treatment, risk, and responsibility to bedside nurses. Ironically, even when AI seems innocuous and safe, it may be the most dangerous. We recently got bedside scanners to print lab labels. They've been great. Within seconds of an order going into the computer, I can scan an armband, print a label for a specimen I've already drawn, and have it in the tube system in about one minute. After more than two decades without a labeling error, last week I had an "ah ha" moment. I realized that I'd come to trust the seemingly infallible new system and let my career practice of carefully checking the name and birth date slide. Scanning an armband is only infallible if the person who put the armband on got it right. Geffin makes an interesting observation. In autonomous car crashes, there was a human on board. "The human 'safety driver' in the car, who was supposed to provide emergency backup in cases like this, was apparently looking down at the fateful moment." (Geffin, 2018, para 9). Our fragile love-hate relationship with AI will evolve, and we will surrender more autonomy. Until AI becomes like us, "only better," nurses will remain the safety drivers, the patient's last line of defense. Someone still has to pay attention. For now, we're it. Peter Giffen. "20 ways artificial intelligence is changing our lives." 2018. Web. November 3 2018.
  16. RobbiRN

    Holding Hands with AI (Artificial Intelligence)

    Ouch. Our Pyxis clocks often run a few minutes out of sync with our charting system. The sad part of your story is that someone was getting paid to come along later and make an issue out of your situation. The morphine was pulled, it was given, and it was charted accurately according to the equipment supplied by your facility. AI is the new spy. It's cheaper, remote, supposedly accurate, and much easier than each level of management knowing their employees and actually paying attention in real time.
  17. RobbiRN

    "You're the Best Doctor."

    Doreen came from church. Before anyone says anything, I already know. It's 11:18 on a Sunday morning. Her dress is a striking blend of rich primary colors. Deep blue, bright yellow, candy apple red and dark leaf green jump off the stark black background of the thin chiffon knee-length dress. It will be hard to get this one off her without tearing it as she reclines with the head of the ER stretcher raised about thirty degrees. Her friend helps me get her into a gown before I hook her up to the monitor. Doreen seems accurate, but she speaks slowly and searches for words as the story evolves. She had coffee but no breakfast. While standing at the door to the church as a greeter, she started feeling lightheaded and walked toward her friend at a nearby table. The friend takes over, telling the story from her point of view. "She wasn't walking right and seemed confused. We helped her sit down, and I gave her some orange juice. She didn't pass out or fall, but something wasn't right. She's better now, but she's still not normal. Are you the doctor?" "No. I'm just a nurse. Someone higher on the food chain will be here soon, but I'll get things started." Most people laugh at my "higher on the food chain" notion. The truth is, it's getting complicated trying to list all the possibilities. She may see a doctor or a PA or a NP. I won't know which until one of them walks in the room. Doreen is in a sinus rhythm, has normal vital signs, and moves all extremities without guarding. I page for an EKG and do a complete NIH stroke evaluation. Aside from the friend's observation that "she's still not one-hundred percent," she has no obvious neuro deficits. An IV catheter slides smoothly into a large vein in her upper forearm, and I'm drawing labs to cover a possible stroke alert when Jason walks in. I introduce him as the Physician's Assistant and give him a short synopsis of Doreen's history. He asks the same questions we've already covered, and Doreen is sharp enough to tell him so. He shrugs, "Well, sometimes we double check to make sure you stick to your story. I'll go get your workup started. Again, my name's Jason. I'll be the provider taking care of you today. Let me know if you need anything." Doreen looks at the blood tubes in my gloved hand: "Did you just take that from me? I didn't even notice you were drawing blood. You're a really good doctor." I correct her one more time. "Honey, I'm just a nurse. Jason, the young man who just left, is a Physician's Assistant. He's essentially the doctor taking care of you. He reviews your case with the ER doctor who may or may not see you while you're here." Doreen's observation is matter-of fact. "I don't know why he says he'll be taking care of me when you're the one doing everything." Her brain seems to be working just fine. Despite the normal NIH scale and resolving symptoms, Jason and the attending designate the patient a stroke alert. A few minutes later we're back from CT. Even the friend who has been with her since the onset agrees that her recovery is complete. Doreen laughs and waves when a large posse of beautifully dressed women from church show up. If you want a massive group of visitors, make sure you're at church, preferably Jamaican, a Hispanic party, or a kid's sporting event when you go down. I coax the visitors back to the lobby for a few more minutes and drag in the neuro-tele unit with a monitor and video camera facing the patient and a monitor and keyboard on the opposite side for the nurse. It looks like it could get us to the international space station if we could figure out how to fly it. Our neuro-tele-doc halfway across the country "examines" Doreen, walking her through the same questions we asked previously. Once or twice she looks at me shaking her head when he has her do a few of the function tests from the NIH scale. Doreen finally tells the neuro-tele doc that she'd already passed this test before she went to CT scan. Mercifully, he cuts her test short, declaring that he doesn't see any evidence of an acute stroke and doesn't believe she's a candidate for TPA. The beautiful ladies from church pour into the room, fawning over the patient and laughing together for about half an hour before Jason comes back to discuss her results. He tells Doreen that everything has come back okay, and it's up to her whether she'd like to stay in the hospital for observation or go home and follow up with her doctor sometime in the next few days. She chooses to be discharged, have lunch with the church group, and head home from there. The friends help her back into her colorful dress. She walks well and feels like she's completely back to normal. She asks me if she's making a mistake by going home and wonders what I think might have caused her symptoms. "I think you're good for another lap. I would choose to go home if I were in your situation. There are a lot of sick people here; you might catch something. My best guess is that you should have eaten some breakfast this morning. Your blood sugar may have been a little low, and you were probably a little dehydrated since the orange juice seemed to turn things around. Standing in the heat for too long might have made everything worse. It's not impossible that there's more to it though, so listen to your body and come back right away if anything else happens." She gives me a hug and a beautiful smile. Her closing words are no surprise. In spite of several corrections, some people just don't get it. But there's no point in correcting Doreen's designation again as she says goodbye. "Thank so much. You were the best doctor I've ever had." I don't know what causes so many patients to fall back to the doctor title when expressing their appreciation at the end. Maybe it's because they are forgetful. Maybe it's because they are subconsciously elevating us to what they perceive to be the highest level of care and expertise. It really doesn't matter. After correcting them two or three times, I just let it go. The title doesn't matter. Their sincere gratitude is everything. Sometimes, I gaze into the not too distant future, imagining myself on the stretcher as the frail and possibly forgetful patient. I'm hopeful that we won't completely deteriorate into cold dark environment of apps and bots by then. I'm hoping that there will be someone there who is competent and dedicated to help me when my time comes. I'm hoping that nurse will not scorn my weakness, that he or she will take enough time to hear my real complaints and make sure legitimate symptoms are addressed and unnecessary testing is avoided. Mostly, I hope that nurse will value me and treat me with dignity and respect. When that day comes, and it's my turn to say goodbye, I sometimes imagine myself saying, "Thank you so much, you were the best doctor ever."
  18. RobbiRN

    Mandatory Hurricane Evacuation - Can I be Forced to Work?

    On the coast of Florida, I've worked before, during, and after several hurricanes. We are required to sign an annual agreement that we will work as assigned during storms. One of the hospitals in our network is routinely evacuated due to its location. Mine stays open. If I have a choice, I take "during." EMS doesn't run through the heart of the storm; no one is coming in and the hospital has a generator. Before and after are crazy. Best of luck to all in the path.
  19. Nursing Intuition, Part 1: "The Visitor is . . . Dying!" "How much damage to the car?" We're in the ER. EMS has just dropped off a young female driver following a motor vehicle crash. "I'd say moderate. It was partly head-on, but more left front to left front. No airbags went off. Everybody was ambulatory at the scene. They all denied any injuries. Even this one originally refused transport, but she decided to get checked out because she's eight-months pregnant. Her cousin here was a front seat passenger, but she just came to be with her. She's not a patient." Tom is nonchalant. He's a good medic, generally concise and accurate in his assessment. "Any other questions?" "No, thank you. We'll take it from here." I turn to assess the young girl strapped to the backboard. She confirms Tom's story. She's 21, in good health, denies any pain, and states she feels the baby moving normally. Her vital signs are good. "I'll get some help in here and we'll get you off this hard backboard." "Can I get some water? I'm really thirsty." I glance across the protruding abdomen at the patient's nineteen-year-old cousin sitting in a visitor's chair on the far side of the stretcher. She smiles and shakes her head. "I don't know why I'm so thirsty." This is where the big intuitive moment begins. All nurses have intuition; it's a hallmark of healers. Subconsciously, we listen beyond the words, pulling in nonverbal clues and relevant tidbits from previous experiences and a broad knowledge base. Sometimes, there may even be shades of clairvoyance, and our intuition acts more like faith or an energy that takes us to the right answer well beyond reason. Maybe it was the way she shook her head or her stated surprise at the sudden onset of her intense thirst. Maybe it was knowing that moderate front damage can cause serious injuries. Inexplicably, I flash to a single line from a story I'd heard years ago: "The cry of the dying is for water." Three teenage boys were drinking when their car careened out of control, slamming into an old gumtree in the front yard of the person who told the story. He rushed out to find that all three of the boys had been thrown from the car. Two were not moving, but one was writhing slowing in the middle of the street. He ran to the boy and listened as he moaned one word over and over with his dying breath. "Water." The storyteller shared this experience to make point out that in the face of death there is a realignment of our values. He observed that the bottle of vodka was lying in the street beside the dying teenager, but the boy wasn't asking for that now. "The cry of the dying is for water. Just water." I look at the young girl simply asking for a drink of water. She's clearly unconcerned about injury, but I can't ignore the "water" words flooding my consciousness now. "Are you sure you are okay? Does anything hurt?" "I'm fine." She pats herself down and lifts her arms as turns her head side to side. "Nothing hurts. I'm just super thirsty. I don't need soda or anything--just water." "Even though you feel like you're okay, do you mind if I check a few things really quick before I get you a drink?" I motion to an empty stretcher on the opposite side of the trauma bay. She agrees and lies on her back on the stretcher so I can check her abdomen. I pull the curtain, slide her shirt up, and see that her abdomen is smooth and flat. There's no seat-belt abrasion or discoloration. "Were you wearing a seat-belt?" "Yes, but it was bothering my neck so I had it tucked under my armpit. I'm really okay." I'm tempted to let this quest go, but "the cry of the dying is for water" words won't go away. I apply moderate pressure, palpating the lower quadrants. She denies any tenderness. When we get to the right upper quadrant, she winces. "Does that hurt?" I ask, adjusting the position and pushing a little deeper. "Oh. Okay. That's a little sore there. Um, I guess it really does hurt right there." She suddenly looks worried for the first time since she casually walked into the department. Her radial pulse is thready, and the rate is about 120. Her BP is 96/48. Her palms are sweaty, and there's a hint of perspiration on her face. She looks a little pale now. Objective findings are piling on in support of my gut feeling. The next few hours turn into a blur of lifesaving interventions. I physically drag the attending ER doc to the bedside where he supports my suspicion. We start two large bore IVs, draw labs, band her for a type and screen, and hang normal saline. We have her in CT in less than ten minutes, confirming a large intra-abdominal bleed from a lacerated liver, likely from her improperly placed seatbelt sliding under her ribcage on impact. Only one OR is available, and they ask me to scrub in because they don't have enough staff to handle the emergent surgery. For nearly forty-five minutes, I function as a human rapid infuser, standing at the head of the table to the right of the anesthesiologist, hanging unit after unit of blood and manually squeezing in several of them when her pressure drops precipitously. Additional OR staff finally replace me, and the surgery drags on for several hours. I come to work early the next day to stop by ICU. She's on a vent, extremely edematous, looking like she is nearly twice the size of her slight build when she walked into the ER the day before. I'm told she received a total of 18 units of blood, but she is relatively stable now. Her puffy face looks peaceful. A tear rolls down my cheek as a surge of emotion reminds me just how close she came to dying. She eventually recovers and is discharged home. We never know how many lives we save. Our intuitive moments are not always profound or memorable, but, for me, this one was unforgettable. Even though it happened years ago, any complaints of thirst in potentially hypovolemic trauma patients still grab may attention. This girl was minutes from death, and no one knew until a flash of intuition intervened. "The cry of the dying is for water." EDITED BY ALLNURSES TO ADD This two-part series includes a giveaway as one of the contests allnurses.com will be having in celebration of Nurses Week coming up next week. You are invited to share your own intuitive "save" story as a response here. The story with the top 10 "Likes" shared by the readers will receive a paperback copy of "Anonymous Complaint: A Nurse's Story." Those who share a story in response to either article will be included. For Part 2 and details about a special Nurses Week Giveaway, see Nursing Intuition, Part 2: The Seizure Girl
  20. RobbiRN

    "You're the Best Doctor."

    Thank you your for finding the joy Libby. (Did you ever live in Walla Walla?)
  21. RobbiRN

    "You're the Best Doctor."

    Your suggested introduction is textbook perfect, safe, appropriate, and defensible. Mine is, well, clearly risky. Sometimes, I start your way (except it's 25 years), but sometimes I start just like I did in the story. I would have been disappointed if no one called me out on the "higher on the food chain" designation. "Just a nurse" was no accident. My purpose for using both in this somewhat artsy article was to highlight the ability of patients to see past traditional hierarchy, choosing to honor and respect caregivers who treat them well instead of arbitrarily ascribing honor to titles alone. As the use of artificial intelligence escalates and the practice of medicine becomes increasingly remote and robotic, nursing remains the warm point of human contact patients crave. Some doctors are great with patients. I wish they all were, all the time, so we wouldn't need to clean up after them. Some are terrible at taking time to explain and answer questions. When a doc fails to take time communicate well (so he can get back to the internet), I will not waste one word trying to build him up in the patient's eyes. When I do what the doctor should have done, the patient knows which one of us met his/her need for a "doctor."
  22. RobbiRN

    "You're the Best Doctor."

    "Just a nurse." Thank you for noticing. I'm old now too. When I was young, I sometimes felt defensive when people called me "just a nurse" derisively. When I became secure and assertive, I started taking the term out from under them before they got a chance to use it, redefining it as a term of endearment instead of an insult. Patients quickly learn who is caring, competent, and responsible, and they choose to put their trust and confidence in those caregivers, regardless of titles. So, if your are often confused with the doc for those reasons, beyond or in addition to being old and male, then you are seen as honorable.
  23. RobbiRN

    Oh, my aching feet!!!!

    I regularly do three 12's in a row in an ER which allows me very little sitting time, some days - none. My formula is to start with three different pairs of shoes that I love and rotate through them. I leave one pair in my locker and change my socks and shoes at my mid-shift break so I don't wear the same pair more than six hours straight. The pair I remove at break stays in the locker and goes back on 24 hours later at the next mid-shift break. I trade to a different pair at home every day.The fresh socks and change in angles and pressure points is a refreshing start on the second half of a shift. Throw in a little caffeine hit and you're good to go. I would massage your feet, but it would be a felony in Florida if you paid me. I'd just have to do it for free if that would work for you.
  24. RobbiRN

    It Never Occurred To Me.

    Excellent. That's that best ending to a touching nurse-patient story I've heard for a long time. Maybe write a book?
  25. It's 11:34 a.m. The triage complaint is listed as possible stroke, with dizziness and facial droop listed as secondary complaints. A fifty-six-year-old female still in her street clothes is partially curled up on her right side scrolling through her phone. Patti arrived six minutes ago via private vehicle, walked in from the parking lot, and was brought to the room in a wheelchair. She doesn't appear to be in any acute distress, moving freely while repositioning herself on the gurney, breathing easily, with good skin color, and strong fine motor skills going into the phone-work. Her husband is leaning back in his chair at the bedside with his left ankle crossed over his right knee, reading a magazine. Nothing in this room conveys a sense of urgency. "The triage note says, 'possible stroke.' Can you tell me what happened today that brought you to the hospital?" I slide on a blood pressure cuff and a pulse oximetry clip as we talk. "I've been having headaches for a couple of months. But they've been worse for maybe two weeks now. And I've had some dizziness too." Her facial movements are symmetrical. She speaks clearly, without difficulty. Her vital signs are all within normal limits. "The note also says, 'facial droop'. Can you tell me about that?" The husband takes over. "She was just sitting at the table after breakfast this morning about nine o'clock. The left side of her face kind of pulled to the left, and she was having a hard time talking. It happened twice, about ten minutes apart, and it only lasted for a minute or two both times. She's had seizures so we didn't know if it was a seizure or what? Her face just pulled to the left." His description of pulling to the left doesn't sound like the "facial droop" described in the triage note. "Can you demonstrate how it looked to you?" The husband uses the muscles in his left cheek to pull the left side of his mouth laterally toward his ear." The patient adds, "I was having a hard time swallowing and I couldn't talk." "Any new or different medications recently?" "No," they say in unison, shaking their heads. About an hour later, we have normal findings on her EKG, chest x-ray, CBC, CMP and coagulation labs. Her repeated vital signs are also normal, and she's in a sinus rhythm with no ectopy on the monitor. She breezed through her NIH stroke scale with no neuro deficits. I'm headed to the room to let them know her CT has been read as "no acute intracranial findings." Intuitively, the husband's recreation of her face pulling to the side is still dogging me when he suddenly bursts through the privacy curtain, running toward me. "She's doing it again." Patti's sitting up at a ninety-degree angle, gripping both side rails. She's clearly anxious now; her eyes are wide, and she rocks rapidly back and forth. She's still in a sinus rhythm, but her heartrate is up to 110, and she's breathing fast. Her lower jaw is pulled laterally as far to the left as it can go, confirming the husband's choice of words in his description that "her face just pulled to the left." Somewhat relieved, I feel her tight muscles displacing her lower jaw radically to the left. "Can you move your jaw?" She shakes her head and tries to talk, but her voice is throaty, and her articulation is predictably muddled. "Is there anything else that feels wrong to you right now, other than your jaw being locked off to the side like this, making it hard for you to talk?" She looks at me and shakes her head, mumbling a garbled "no." "Patti, I can see you're really anxious. This doesn't look like a stroke or a seizure. I think it's a much lesser evil. Try to relax while I get the doctor in here to look at you." Dr. Spicer agrees that her presentation is consistent with a dystonic reaction causing a spasm of her jaw, lips, and tongue muscles. She's allergic to Benadryl, and, after considering Cogentin, he gives me a verbal order for 0.5 mg of IV Ativan. Her symptoms resolve rapidly, and, instead of being sleepy, she's just loopy enough to be happy and fun as we process her admission and move her to the observation unit. Patti's case is interesting for a couple of reasons. In looking for a potential cause, the most likely culprit appears to be her carbamazepine. They said 'no' when I asked about any new medications, but it turns out that her husband had changed jobs two months ago, forcing a change in insurance and doctors. The new doctor took her off Dilantin, which she had taken for years without incident, and put her on carbamazepine. The headaches had started a few days later, but they hadn't made the connection between the medication change and the headaches until we explored the timing together. Usually, a dystonic reaction happens after the first dose of a new medication or after an increase in dosage, neither of which applied in Patti's case, unless she had accidentally taken extra medication. We add a carbamazepine level to her labs, and the result comes back a little over the high end of the therapeutic range. Acute dystonic reactions are relatively rare in our flow of ER patients. Acute dystonic reactions to carbamazepine are also rare. Carbamazepine is sometimes prescribed to treat dystonia from other causes. The real key to the story was the husband's description that "her face pulled to the left." More specifically, just her jaw pulled to the left, but he was accurate in describing something that didn't sound like facial droop. (Try looking in the mirror and alternate between using your facial muscles to pull only your cheek or your jaw laterally. It's easy to see how he got his description.) It's unfortunate for Patti that she became one more causality of a system which forces changes in medical care because of a change in employment. The good news: there's no facial droop, no stroke, and no seizure. The simple longer-term fix for drug induced acute dystonic reactions is to discontinue the offending agent.
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