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Nurses And Policemen, Rapid Response Teams, Useful Apps, And Photography

So who hasn’t heard about The Policeman vs. Nurse? A nurse was pulled over for speeding, told the policeman that she hoped he would never end up as her patient, and was subsequently fired when the policeman complained to the hospital she worked at.

Really? I have the utmost respect for the police of course, but put on some big boy undies and get over it. Should the nurse have made that comment? No. Not in front of him, at least. That was pretty dumb. But being fired for saying it is ridiculous in my opinion. Does that cop go complain to the pimp when the hooker he’s arresting makes a sassy comment? Nurse and Lawyer had a pretty good discussion about the whole situation.

Next up: Rapid Response Teams Sign of Poor Bed Management. Really? I think GruntDoc summed it up best in his tweet about it. The article states that rapid response teams (RRTs) are utilized due to overcrowding because sometimes patients aren’t placed in a unit that is appropriate for their needs. Therefore, their condition worsens and they need help.

I suppose all hospitals are run differently, but at the one I work at patients admitted to the ICU are sometimes rock stable. Seriously — orders like, “Saline at 100cc/hr, Regular diet, Up ad lib.” No pressors, no oxygen requirements, no aggressive pain management. Why does the doc then order an ICU admission? I don’t know. Maybe they just have a feeling, although that’s not really a good enough reason to admit to ICU. Regardless, it’s unusual that a very sick patient is admitted to a regular nursing floor.  We actually tend to err on the side of caution. If a unit that provides a higher level of care has no beds, the patient stays in the ER until a bed opens up or until they stabilize and can safely be assigned to a room on a regular floor.

RRTs are an excellent resource. Basically, if a nurse on a regular floor is taking care of a patient that seems to be deteriorating, they call for the RRT to come help out. A nurse and a respiratory therapist (maybe others) respond to the code and help the patient’s nurse out. How could having MORE people assessing/treating you/notifying your doctor be a bad thing exactly? I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care. I think they are called because stable patients just stop being stable sometimes.

RRTs are a way of getting people to come help you before it becomes necessary to call a code blue. Personally, if I worked on a regular floor, knowing that I could call someone experienced to come assess a patient who was doing poorly would make me feel very secure. Like someone had my back. And the patient’s back, actually…there would be someone there helping the patient while I went to go call the doc.

Anyway, I know the article isn’t saying that RRTs are a bad thing. But I’m not sure the reasoning for their use is on target this time.

Last: Harvey MD sent me an app that he thought would be of use to nurses. It’s a “credential reminder” to help keep track of when our various certifications expire/time to do the TB test/keep track of our CV’s. I can’t say I’ve used it, but it does look fairly useful if your employer isn’t the sort to start hounding you about these sorts of things coming due MONTHS before they actually expire. Ahem.

Actually, that wasn’t last. I have a bit of a rant. I took a photography class this weekend. It was about how to use your digital camera…tips-n-tricks and all that. Very interesting class, but something the instructor said kind of offended me, and I don’t think I’m the type to truly get offended easily. She was talking about the “scene modes” and was telling us that the camera manufacturers decided to use the little icons in the menu (the party hat, the snowman for snow scenes, the lady for portrait pictures, etc) “in case you went to nursing school instead of taking photography classes” so we’d understand what each scene the icon represented.

I’m sorry, what?

I know what she meant, but good grief. What a crappy thing to say about any profession. Especially nursing! I know how to use an unbelievable amount of equipment (IV pumps, balloon pumps, CVVH/dialysis machines, cardiac output machines, monitors, etc. etc. etc.) — none of which have any icons except for the little button that has a slash through a bell.  That one is very important.

If she’d had an occasion to ask me what I did, I would have replied, “I’m a nurse. You know, one of those people that they dumb down the cameras for.” Alas, no opportunity presented itself for that ultra-witty comeback, so it’ll have to remain unsaid. Or blogged. Whichever.

*This blog post was originally published at code blog - tales of a nurse*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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