September 14th, 2009 by Emergiblog in Better Health Network, Opinion
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Emergency has something in common with Labor & Delivery.
Neither department has control over their census.
Medical/surgical, telemetry units and ICUs have a finite number of beds. When they are full, they are full; they cannot physically expand to more beds.
ED patients and laboring women are never turned away no matter how full the department may be. Oh, the ED may triage and L&D may send a patient in early labor home, but in both cases, eventually, all will be seen.
Labor and delivery has one advantage over the ED.
They can have someone on call.
I’ve never worked in an ED that has had an “on-call” nurse.
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I will never understand the logic behind staffing an ED based on the previous 24 hour census.
If the ED does not meet a pre-determined number of patients on one day, the break nurse for the next day is canceled and there is much wailing and gnashing of teeth as the department goes over budget.
Never mind that the acuity level of the patients who were seen was through the roof. Or that 50% of them were admitted. Or that the next day, acuity again sky high, the nurses go without meals/breaks and the department is required to give penalty pay. Again, there is much wailing and gnashing of teeth for having to pay this penalty, a penalty that would never have been required had the break nurse not been canceled.
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Now if the ED is slow, staff can always go home early. But not too early, because you never know what is coming in through the doors. So maybe an hour, 90 minutes early, knowing that the remaining staff can handle whatever they need to handle until the next shift comes in.
But what happens when the patients overwhelm the staff, both in acuity and numbers? Ambulance diversion doesn’t stop the walk-in critical patients. The MIs and the possible CVAs. The GI bleeders. The potentially septic. Trying to get patients out of the department and up to the floor doesn’t work when the floor won’t take the patient for four hours because it would put them “out of ratio”.
This is a huge issue on the night shift. When there is only one unit clerk/registrar, two nurses and an ED tech after 0300.
Of course, at night it is feast or famine.
Either the feces hits the proverbial fan or…it doesn’t.
Which is exactly why we need a nurse on-call.
The ED needs flexible staffing that accounts for those times when the acuity level/census is overwhelming. Not canceling the extra break nurse is one way of doing that on days and evenings; using the on-call system is another way that could be utilized at night. If it can be done in L&D, why can’t it be done in the ED? Surely the money saved in penalty pay for missed breaks and meals would make it budget neutral.
All I know is that trying to drop staff in an ED based on what happened the previous 24 hours makes zero sense.
(And don’t even get me started on why nurse-patient ratios are treated like unbreakable rules on the floors, but it’s okay for the ED to be waaaaay out of ratio and nobody blinks….that’s another whole post!)
*This blog post was originally published at Emergiblog*
September 11th, 2009 by Emergiblog in Better Health Network, Opinion
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I’ve received some emails from nurses who would like to start a blog. Some are a bit nervous about starting, others are not sure how to begin. There are a million sites out there on how to start a blog; in fact, I wrote a post specifically on how to be a “nurse blogtitioner”.
But their emails got me thinking about the blogosphere in general and the most important considerations in starting/maintaining a blog.
1. The blogsosphere can never be saturated.
Think you have nothing to add to the dialog? Think that everything about your topic has been said? Think again. If you aren’t blogging there is still a voice that needs to be heard. What exactly do you bring to the discussion? You! No one has had your experiences or can express your opinions. More importantly, no one else can bring your voice. And unlike a meeting or an email, there are no time limits or physical boundaries to the blogosphere. There is room for everybody, and that means you!
2. The heart of the blogosphere is interactivity.
If you read blogs, you probably leave comments. Comments are the soul of the blogosphere. With them, the blogosphere is a conversation. Without them, the blogosphere is simply a virtual collection of “articles”. By starting a blog, you bring the dialog to your “home turf”, so-to-speak. You are the host/hostess of a virtual “salon”, providing information on your sphere of expertise, initiating the debate and most importantly, learning from those who comment on your posts.
3. The blogosphere is the great equalizer.
There is no hierarchy of blogs. Don’t confuse size with importance. Some blogs may have a million readers a day and some may have ten, but in the blogosphere, no one is “better” than anyone else. Your blog, with that first post, is just as important and just as relevant as anything you see on “Instapundit” or the “Huffington Post”. It’s unique and cannot be replicated, because it is based on your outlook and experiences.
Here are some things to keep in mind as you start your blog:
1. Content is King
Maybe you look at the blogs with the sidebars and the graphics and the ads and the widgets and think, “Man, I don’t know how to do all that!”. You don’t have to do all that! All you have to do is start posting. One post. Later, if you want, you can add a blogroll or a few widgets. But the way to start is to begin writing, and keep writing. People will come for your content. Everything else takes a back seat to that.
2. Promotion, Ur Doin’ it Right
You’ve just put up your first post. A few folks might stumble on your site by accident, but you need to get out the word that you’re on the web. This is where you start promoting your blog. The best way to do this is find a carnival for your niche and submit a post. For those of us in the medblogging community, examples would be Grand Rounds, Change of Shift, Patients for a Moment and The Handover. Make your url part of every email signature and blog comment you send. Write it, and they will come…but they need to know you’re there.
3. Prolific Perfection…Not
Blogging can be addicting, and in a good way. It can be challenging, therapeutic, frustrating, and energizing – all in one post! But…you do not have to be the “perfect” writer. Just find your style and run with it. And while consistent posting makes it easier for readers to find your blog, you control your posting schedule. “Prolific” is what you say it is, be it once a week or once a day. But know this: the more you write, the easier it becomes to write; the more you are interacting with the blogosphere, the more inspiration you will find and the more you will want to write. It’s the blogosphere “circle of life”!
So…if you ask me, should I blog?
I’ll say YES!!!!
Been there, still doing that, and if I can do it, you can do it.
It will clarify your outlook.
It will recharge your batteries.
It will change your life.
Really, the bottom line?
You’ll never know unless you write…
That first post.
*This blog post was originally published at Emergiblog*
August 30th, 2009 by Emergiblog in Announcements, Better Health Network
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Okay, I know this photo has nothing to do with BlogWorld/New Media Expo 09, but it is so cute I had to use it.
Besides there is no Nascar this week, so I had to get my fix somehow.
And I was up all yesterday blogging “fast and furryest”, emailing right and left, Tweeting the Good Tweet and generally spreading the the word about the Medblogger track.
Just in case someone missed the message! : )
Time has just flown by and what once was nine months out, then six months out and then four months out has come down to less than seven weeks.
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I am now blogging over at the BWE blog, as are all the panelists for the Medblogger track. My first post is here. Comments welcome!
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There is the official logo.
If you have been on the fence about attending, it is not too late. The majority of those who register for BlogWord do so by the third week in September. Details are here, with links to registration.
The discount codes are still in effect. The discounted rooms at the Venetian are still available.
Come for the day or stay for the weekend. You can basically choose what you want, smorgasbord-style. I would suggest the whole weekend, though. While the first day is all medblogger, the rest of the weekend will take you through the meat-and-potatoes of the art of blogging.
And, chances are, if you have a favorite non-med blogger that you follow, they will be there.
Any questions, any problems – email me. I will either answer them or hook you up with someone who can.
This will be informative, educational….and a downright blast!
Hope to see you there!
*This blog post was originally published at Emergiblog*
August 18th, 2009 by Emergiblog in Better Health Network, Health Policy, True Stories
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She didn’t eat her dinner Friday night.
By 4: 30 am Saturday, the previously healthy 65-year-old female had a fever and lower extremity weakness. A family member heard her repetitive moaning. The patient got up to void, but could barely negotiate the one step up to the hallway. As she negotiated the hallway, she staggered.
By 5:00 am she was in the ER.
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The patient was taken to an exam room. Vital signs were taken and it was noted that the patient’s fever was “extremely high”. The doctor came into the room and the temp was re-taken. Extremely high. The patient had no insurance and was not verbal; the doctor discussed options with the family member.
The goal: find the source of the fever and begin treatment. A CBC, Chem 14, a urinalysis, an IV and hydration would be started. No lactate level would be done; the doctor stated it would be pointless to run a test that she already knew would be elevated based on clinical presentation. Blood cultures would be drawn, but not sent immediately. As the doctor explained, they are expensive and it would take days before the test results would be back.
In this facility, payment was expected at the time of treatment and a detailed estimate was provided to the family. The low end of the estimate was the deposit.
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By 8:30 am Saturday, the fever was still raging; the lab tests were normal. The patient was in ice packs with a fan in an attempt to lower the fever. An IV antibiotic was initiated; hydration was on-going. An internist and a neurosurgeon were consulted as the patient was experiencing lower back pain in addition to the profound weakness. The patient was admitted.
Further tests were proposed: lumbar x-ray to rule out spondylitis and, given the patient’s age, a chest x-ray to rule out occult pneumonia. The pros and cons of each test were fully explained along with rationale and the cost.
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The radiographic exams were normal. A loose bowel movement that morning had been blood-tinged. The patient had been medicated for pain. A second antibiotic was started. The next step would be an abdominal ultrasound, as no obvious source for the fever had been found. The rationale for the test and the cost were discussed and the family gave the go-ahead.
The spleen. Enlarged and mottled on ultrasound. A call was made to the family to discuss needle aspiration to rule out lymphoma.
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Monday morning the patient’s fever was down. She was eating. She was voiding. She was still weak, still moved slowly and awkwardly. She would be discharged home on oral antibiotics with the results of her spleen aspirate pending.
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It’s been a week now and the patient is acting 100% normally.
The patient was my dog, a 10-year-old, 70 pound Shepherd mix. We still don’t know what nearly killed her last weekend. The spleen aspirate was abnormal, but not lymphoma. The fact that the fever responded to antibiotics (as did the weakness) leaves us with the feeling that it was an infection in such an early stage that the source was not obvious.
I realize veterinary medicine is not human medicine, and a million holes can be found in my attempt to draw a parallel between them. But a few things crossed my mind during this experience:
(a) Tests were not done just for the sake of testing or because a printed standard said they should be. This was not template medicine dictated by any outside organization or government regulations.
(b) The doctor/patient relationship was unencumbered by insurance company approvals, government regulations, billing, coding or the number of patients that had to be seen in a certain time frame.
(c) there was full transparency regarding what each test would cost.
Maybe the human health care system can take a few pointers from what the veterinary world has been doing all along.
(P.S. I just realized you can read this story from the vantage point of ME being the third-party payer standing between the vet and my dog, deciding what would be “covered” – i.e. paid for. Interesting either way….)
*This blog post was originally published at Emergiblog*
August 7th, 2009 by Emergiblog in Better Health Network, True Stories
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I hope you can read the print on this.
It’s a hoot!
Apparently, the Vacuum Tympan cures the most “desperate causes” of hoarseness and sore throat, massages vocal cords and gives immediate flexibility (to what?). Oh, and after it brings relief, “a permanent cure soon follows”.
Maybe it sucks out the phlegm. (Ewww…just writing that made me gag.)
It sort of looks like the old incentive spirometers we’d use for post-op patients.
Or maybe it’s a type of nebulizer.
Frankly, it looks like a bong.
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I’m at that age where certain tests involving scopes and colons are recommended, so I did my duty as the good custodian of my health and scheduled the pre-test appointment.
(Don’t worry, this will not be a case of “TMI”.)
I’m sitting there with the GI doc going over my health history, when he notices I’m on Protonix. Based on this fact (and the fact that my upper abdomen is sore on palpation – well, duh, you’re pushing on it!) he says “Well, you are going to be out anyway, I might as well take a look down there, too!”.
Say what? I’m here for a tube up one end and you want to put a tube down the other end, too?
I swear to (insert-your-own-deity-here), my first thought was “dude, you’re just trying to add a procedure to crank up the income.”
I’m not proud that was my first thought, but I’m being honest here. “Sure!” he said. It might be a structural problem, we can make sure you don’t have Barrett’s Esophagus (note to self: look that up) and basically just know what we are dealing with.
Well, okay. But I don’t have indigestion/heartburn when I’m on Protonix; I’m rather asymtomatic, actually.
“What kind of anesthesia would you prefer? We can use Versed/Fentanyl or if you want, we can use proprofol.
Propofol? Dude, you can stick a tube anywhere you want. Go for it!
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Easiest thing I’ve ever done. I have no idea why I waited so long. When I fell asleep Shania Twain was feeling like a woman and when I woke up, the Eagles were takin’ it easy and I wondered when the hell they were going to start!
I was done.
The procedure went well, the biopsies were taken (routine) and I would get my results by mail within two weeks.
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My colon rocks. No problems except divertiulosis and I can live without nuts and seeds.
It was the endoscopy that I almost refused that showed the problem.
The biopsies showed acid-induced esophageal and gastric inflammation.
What??? How??? I thought the Protonix was taking care of that!
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And then came the “treatment” boxes checked off.
“Keep taking your medicine for the next three months, then stop.”
Okay…if I have this inflammation now, why would I stop the medication? Won’t it get worse if I do?
“Please avoid Aspirin, Naprosyn, and Motrin. Tylenol is okay.”
Aw man, Motrin is my best friend, my right hand! It’s gotten me through many a rough shift; 12 hours in the ER can make you ache. Tylenol isn’t worth the powder it is printed on.
I took a swig of my Diet Pepsi.
“Avoid fatty foods…”
Okay, doing that already with ol’ Richard Simmons’ plan.
“…chocolate, peppermint, spearmint and smoking”
Bah – I don’t smoke and I can live without chocolate and who wants spearmint anyway?
Took another swig of Diet Pepsi.
“…alcohol…”
No biggie, I only have two Bud Lights a month, during Nascar races, and that’s only to support Kasey Kahne’s sponsor (and I know you all just doubled that to four per month…).
“Avoid caffeinated beverages…”
Uh oh.
Took a tiny swig of Diet Pepsi.
“Decaffeinated coffee…”
That…means…ohh nooooo…
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Oh HELL no.
I will NOT give up Starbucks.
Damn it!
I don’t smoke, I barely drink, I don’t do drugs, my diet has more fiber that corrugated cardboard, I’ve lost close to 30 pounds and I’m working on the other 25.
My only “vice” is a total addiction to Starbucks and the goal of someday mainlining Diet Pepsi.
It will be a cold day in hell before I give those up.
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I’m giving them up.
I know the effects of chronic esophageal and gastric inflammation can lead to bigger problems.
And in the scheme of things, given the impact a diagnosis can make on a life, this borders on laughable.
But we all talk about how the patient has to take responsibility for their health. I could keep on downing Starbucks twice a day and Diet Pepsi in my sleep and then whine because my Protonix isn’t working.
Or I can make the changes suggested and see if they will make a difference.
But how ironic that the main problem was found in a test I didn’t even know I needed; and how scary that I was essentially asymptomatic, but the inflammation was still there!
Kudos to the doc for being interested enough to find out why I had needed to be on Protonix to begin with.
I shudder to think what things would have looked like had I been on no medication.
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Who knows?
Maybe I can go off Protonix if these changes work.
And I can still go to Starbucks, only my new drink will be a Grande Skinny Vanilla Steamed Milk.
With a little cinammon on top.
Hey, a girl’s gotta have something to look forward to…
*This blog post was originally published at Emergiblog*
