Wednesday, December 31, 2008

The Few Times We Succeed

I don't remember who it was (ERP, maybe?) who linked over to Monkeygirl at Musings of a Highly Trained Monkey.

It is a very nice post about one of the few times that codes end right.  Any ER employee will tell you that most of the time, when we start a full-blown code, we go into it knowing that the person will likely not survive, and if they do, they will not make it through their hospital stay, and if they do, they will be a vegetable.  But we have to try.  It seems a fitting way to end the year to celebrate one of the successes.  As she concludes: "that, my friends, is why we do what we do."

Monday, December 29, 2008

Did I Say Mac and Cheese?

Random story:

I was standing in line at the hot food section of the deli in a large grocery store waiting to order a little something to tide me over until I could get home.

The person in front of me in line was ordering a little of everything for his family, and the person serving the food didn't appear to be the most customer-service oriented employee I've ever seen.  At one point the guy and his wife were discussing what else they wanted and I could see that the employee had noticed a little bit of old food that had become crusted to the counter.  The guy turned back and ordered some Mac and Cheese then resumed arguing with his wife.   The employee grabbed the serving spoon, still looking at the crusted grossness, then proceeded to scrape off the grossossity with the edge of the spoon.  When she was satisfied, she took the spoon and scooped out the Mac and Cheese.

I didn't order any Mac and Cheese that day.

Saturday, December 27, 2008

Who Are Three People Who Have Never Been In My Kitchen

Yeah, I'm a nerd.

I've learned to accept it.  You may as well learn to do the same.

I say this as a preface to my confession:  I love Jeopardy.

I hadn't watched it in a long long time, and had forgotten how much I love Jeopardy until a couple weeks ago when my wife recorded it on the DVR on a whim and so we watched it together.  I enjoyed it for years and years just watching by myself, but it is even better when you have someone there by you to challenge you for who can get the answer first and congratulate you when you pull one out of your rump and it turns out to be correct.

Did I mention that I'm a nerd?

By the way, I'll give a thousand points to whoever can get the reference from the title.  Another thousand for whoever gets the other TV reference.

Saw Gah earlier today, my wife made a funny face by using her tongue to make it look like she had a giant lip.  I thought it would be funny to try to kiss her like that so I went in for the smoocharoo and... let's just say that this is a less-than-romantic way to kiss someone, so I turned away and said, "oh, so gross!"

My 20 month old daughter was right there the whole time and now every time I go for a kiss, she says "saw gah!"

You gotta be careful what you say around the kiddos.

* Editor's Note: my wife is a lot cuter than George Bush.  Just in case you were wondering.

Friday, December 26, 2008

Whatever You Do... Don't. Blow. Your. Nose.

The Nurse Resource has a link to an article about a woman who may have charges pressed against her for spitting on an ER nurse.  The article contained this gem:

"The saliva in question had already been cleaned off the nurse’s face prior to the deputy’s arrival."

Was this fact actually in question?

"Yes, officer, I have the spit right here dangling from my nose.  I've had to hold my neck back like so for the last 20 minutes while I wated because the darn stuff just wants to slide right off.  Would you like to take a picture?"

Anyway, we had a similar event in our ER a few weeks ago, and the officer said that they were going to charge the guy with felony assault.  Rock on.

Thursday, December 25, 2008

Christmas Music don't like to listen to too much Christmas Music.  In fact I try to avoid it starting in late October when businesses start inundating us with it, and all the way up until just a few days before Christmas.  Its not that I don't like to get into the Christmas Spirit and all, it is just that I get sick of the same songs repeatedly being beaten and tortured by greedy singers.  Growing up, my Dad liked to listen to Neil Diamond and Barbara Streisand sing the Christmas standards.  Both Jews.  Fine, but I'm going to make a Rosh Hashanah album.

Anyway, I've always loved the Carpenter's Christmas album (really pretty much anything by the Carpenters) and my wife also grew up listening to them on Christmas morning, so that is a tradition that we have now.  It is amazing, though, that every single artist out there seems to have a Christmas album nowadays.  This morning I went on Groovegshark (try it, you'll like it) to set up a playlist, and looked for my all-time favorite Christmas songs: Sleigh Ride and O Holy Night.

O Holy Night is a big song.  A really big song.  I don't think that some singers realize how bad it makes you look when you try to sing a big song and fail.  And yet it seems like everyone has to try it.  Very few can do it.  I discovered today that Josh Groban has a version of O Holy Night.  Perfection.  He sings it big and beautiful but does not fall prey to the temptation to overdo it.  Josh Groban could sing the ingredients on processed cheese and I would enjoy it.  In fact, if I weren't already married, and happened to be gay, and had a thing for geeky guys with ugly hair and was only judging based on voice, then I might just marry Josh.  Fortunately for me, I'm already married, not gay, and have a thing for geeky women with nice hair and judge mates based on a few additional criteria (like how will they look hanging on my arm at fancy restaurants).

I also discovered that David Hasselhoff, Jessica Simpson, Big Atomic, Go Fish and too many others all think that they can sing O Holy Night.  Yes, and I can repair the fuselage on a jumbo jet, but you probably wouldn't want to fly on that plane.

And if you want to be disrespectful and irreverent, go listen to the Southpark version of O Holy Night.  I have to walk a lot of stairs on my knees after listening to it, but I always laugh.  Repeatedly.  "Jesus was born and so I get presents.  Thank you, Jesus, for being born."  Also, enjoy how the choir in the background keeps correcting him.  When you are done, a couple of hours of self-flagellation should wipe the stains away and you can get back to the real spirit of Christmas.

Anyway, I've enjoyed my couple days of Christmas music, and now I'm looking forward to shelving it for another year.

Merry Christmas everybody!  Enjoy the presents and the food and the fun, but please do take a few minutes on this day to remember the Christ in Christmas and do something kind and loving for someone around you.  One day it'll come back to you when you need it most.

Pass Me Now, See You Later

I've heard of ER Nurses having license plate frames that say "Pass me now, see you later."

Tonight while driving home from my parents house, I was doing my usual routine for driving with low traffic volumes when I am in no particular hurry: set the cruise control to the speed limit and sing along with the radio.


A stretch limo goes flying past me at 15 or more miles over the limit.  I watched it go by and thought, "do people really think that they are above the law just because they are rich?*  Boy, would I love to see that guy get pulled over just to teach them a little lesson!"


State Patrol.  1 mile later I passed the limo.  I wonder how much the ticket will be for.

* I know, I know, the limo driver probably gets paid piddle and the rich snob in the back doesn't really have much to do with the speed that the car is going, but the symbolism is too great to resist.

Peripheral Vascular Disease

The aorta looked great with no notable problems.  Some mild wall thickening showed up along the iliacs and into the femoral arteries with turbulance more notable as we reached the popliteal artery, but flow at the dorsalis pedis was almost completely blocked.  In fact, I had to have my Dad come out and give me a push to get moving as I tried to turn around on his side street.

I hate snow.

Tuesday, December 23, 2008

Chief Complaint of the Day

This one actually hails back from a few years ago, but in the spirit of poor linguistics, I remember this complaint as entered in the computer by an ER registrar:

head lack

Sadly, I think that far too many of our patients and staff alike suffer from this terrible disease.

Then there was this final diagnosis by a Nurse Practitioner in the same ER (it may have even been the same day):



Monday, December 22, 2008

I'll Take Gameshows for 2000, Alex

10 out of 10 (does that make him half the man I am?) has a very funny post up about topics he recently saw on the 25,000 dollar pyramid.  Check it out.

Linguistic Pet Peeves

Nurse K has a post up from a week ago about linguistic pet peeves.  Specifically, she complains about people using worser when they mean worse.  This started a small firestorm in the comment section of people mentioning some other word usage that annoys them.  Here are a few of my big pet peeves:

Din for didn't
Irregardless for regardless
Aks for ask
Jewllery for jewelry
nucular for nuclear
Atenonol for Atenolol

What are some of yours?

Sunday, December 21, 2008

Dear Radiology Tech my dear friends over in diagnostic imaging:

I love you guys.  You are usually very quick to come and get the patients, are willing to wait a minute or two when I'm in the middle of something or when I'm coming in to give some pain meds, and never complain about having to unhook the patient from the monitor or having to put them back on the monitor when they are back.

That said, I have two questions for you:

1.  Why is it that not a single one of y'all is capable of parking the stretcher straight.  At first I just thought that maybe I happened to get the drunk DI tech, but no: it seems like every single time a patient comes back from DI, the stretcher is parked at some kind of diagonal angle.  What gives?

2.  Okay, so this isn't so much a question as just a complaint:  some DI techs are okay at this, but others will bring the patient back, get them all hooked back up, maybe even park the stretcher straight, and then walk out without giving the patient their call light.  This happens all the time.  Often I catch it quickly, because I always try to go in the room when a patient comes back just to make sure they are doing well and vitals are stable and all that jazz, but sometimes I'm swamped with things to do and can't get in for a while and only find out that the patient doesn't have a call light until someone hears the patient calling out and then yells at me about not giving my patient a call light.

The first point is just a humorous observation.  I don't really care if a stretcher is parked straight or not.  But the second point is a genuine safety concern.

So to all you thousands - nay, millions - of DI techs that read my blog on a daily basis (okay, maybe there are 2 of you...), what can I do without stepping out of bounds to help the DI techs remember to give the patient a call light when they come back?  I don't want to become the DI police, and I'm not much for confrontation, but I do get concerned about patient safety issues.  I think DI is great for the most part and I really love the techs I work with, so I don't want to alienate anybody.

So, Dear Abby, what do I do?

Saturday, December 20, 2008

Villainous Bacteria

These killer bugs are getting worse and worse!

Said one nurse, who was obviously fighting a whopper of a URI, when asked what was wrong:

"Streptococcus are ravaging my bronchioles."

And there you have it: your nursing diagnosis of the day.

Favorite Medical Word of the Day

Someone once told me that the reason Doctors use fancy words is because people will pay a lot more if you treat pharyngitis than if you treat a sore throat.

Whatever the reason, medicine has some pretty outlandish words.

In this new series of blog posts, Braden highlights some of the more interesting medical words that make him happy and help life continue in its sunny course of awesomeness.  All this because he likes you (and because it is a really easy way to pad his post count).

Today's word:
Ischemic Penumbra

an area peripheral to one of ischemia where metabolism is active but blood flow is diminished.

This is really what we are fighting to save when we talk about the golden hour in stroke care.  Also when we talk about door to balloon time for an acute MI.  This is not to be confused with the famous "balloon to anaphylaxis due to latex allergy" time commonly talked about in pediatric wards.

To understand the penumbra, you need to understand what happens with ischemia.  When blood flow is interrupted to an area of the brain or heart, there is an area that is dead and aint coming back.  This is referred to as "screwed tissue."  Then there is the ischemic penumbra, which is still salvagable, but is a lot like any show that Bob Saget has ever participated in: right on the edge of being worthless.  Hope this helps.

So now, huddled masses, go to and find an excuse to use the term Ischemic Penumbra today.  Share your experiences in the comments.

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Friday, December 19, 2008

Yeah I Want A Break, But Not From You

I'm sure I'm not alone in rarely getting more than my 30 minute lunch break and maybe one of my 15 minute breaks.  We are supposed to get three 15 minute breaks and two 30 minute lunch breaks according to the union contract, but I've never done it and I don't know anyone who has.

That said, I love it when the float nurse comes up to me and says, "hey Braden, do you want a break?".

At least, most of the time I love it.

There are some float nurses that I really don't want covering me for a break.  One time in particular, I was swamped with things to do.  It seemed like each patient had a perpetual list of three tasks needing to be done and no matter how hard I worked I couldn't catch up.  I had been going nonstop for several hours and was starving of starvatious starvation.  The charge nurse came up to me and said "I'll give you a break if you want."  Boy did I want.

30 minutes later I came back out, hoping that I would at least find myself no further behind.  But this was a charge nurse with many years of experience and skill under her belt.  Maybe I'd find that she had made real progress on my patients.

I went to the nurses' station, but she was nowhere to be found, so I grabbed the first chart to see what was done.  Nothing.  Oh well, she's probably been busy on the second room.  Here's the rack, there's the chart... and: nothing.  Third chart: nothing.  That's right, I left for thirty minutes and put my faith in this nurse to cover me and more importantly to cover my patients, and I come back to find that absolutely nothing at all has been done.  No meds, no procedures, no vital signs, no walk by the room and wave.  Nothing.

If I wanted to abandon my patients for 30 minutes, I could have just left a couple hours ago and enjoyed lunch back when I was hungry rather than waiting until the ravenous bugblatter beasts of traal invaded my stomach and commenced an internal devouring.

I know that 30 minutes isn't a lot of time to do everything that needs doing, and I expect to come back from break to find that there are still things to do, but please, if you go through the motions of listening to report and what needs to be done for each patient, at least try to tackle a couple of those things.

Thursday, December 18, 2008

Electronic Medical Records

One thing that Mr. Obama and I agree on regarding healthcare is that it is very important that our records go digital.  We are never going to maintain the best healthcare in the world (yes, we have the best healthcare in the world... access may be limited, but technology, skill, and delivery are still in our corner) if we can't come up with some way to maintain consistant, accurate patient histories and medication records.

From that point on, we disagree about almost everything else, including how to implement the system and who should pay for it.  But it is always nice to see areas where you agree.

Anyway, this isn't a political post, but rather a chance to spout off a few random thoughts about EMR systems.  There are a lot of systems out there, and many of them I've never used, so I'm not exactly an expert in the field, but here are a few that I have played with:

Where I am working now, we use the FirstNet program from the Cerner Millenium suite.  It is alternately called ACIS, which I think refers to the whole hospital group of programs where FirstNet is the ER part or some such drivel.  I can't speak on the nurse charting or physician order entry aspects of this software, as we only use it for the tracking board, secondary assessment capability, and lab interface.  I suppose this is not the worst software out there, but I'm not overwhelmed by it.  I appreciate how it interfaces with the rest of the hospital, and the medication reconciliation, while frustratingly slow, is actually fairly decent.  But beyond that there are literally dozens of madening aspects to it, ranging from small to homicidal-ideation-inciting points that seem like they would be such no-brainer fixes (like why do we have to have a character limit in the free-text box for each system - so when I'm talking about abdominal tenderness and last oral intake and bowel tones and which shade of green that vomit was, I run out of room and have to start cutting things out or abbreviating or eliminating spaces after periods.  Seriously, people, what's up with that?).  Another thing that really frustrates me is trying to chart pain.  When I chart on a paper chart, I can write

O - sudden
P - movement, pressure.  no palliation.
Q - throbbing, burning
R - L arm
S - 8/10
T - 3 hours, intermittent pain

This takes me about 30 seconds to do, if that.  But in Cerner, each field brings up its own individual pop-up window with checkboxes that rarely satisfy what I want to say (probably 80 percent of patients descibe their pain with throbbing or stabbing but neither of them are in the "quality" checkbox, for instance).  Why I can't type in where the pain is located and then have 1 box pop up where I can simply enter the details all at the same time is beyond me.  I know that this only takes an extra couple of minutes, but when I'm seeing anywhere from 5 to 30 patients in a shift, and stupid stuff like this takes an extra 5 or 10 minutes for each patient, it really adds up - especially when I have the doctor who writes for Dilaudid "every 15 minutes" on every patient who walks in the door (praise be for carpujects).

I have used a couple other EMRs as well, including EPIC from Epic Systems, which has a number of really great features, and no huge drawbacks that I can remember, although I do remember being frustrated from time to time at a few things.  I used it mainly in Peds and Family Practice as an LPN at a huge (40 or so doctors) comprehensive health clinic, and I really liked the way that everything was integrated into one fairly easy to use system with lots of automation and patient-friendly graphs.  Patients could send e-mail messages through the system and doctors could reply and have the whole exchange automatically entered as part of the medical record.  Messages could be sent electronically to different staff members.  Medication refills could be sent straight to the doctor for approval and then sent back electronically.  And a whole host of other really nifty features.  I also spent a good amount of time in the same organization working in the Urgent Care Center.  I found this system to be a little less intuitive for this use.  Mainly, I think, because the triage entry seemed less intelligent and the nurses' notes came out in a reader-unfriendly format.  although because physician order entry was electronic, to chart giving a medication involved checking a box for PO meds, and for IM or IV meds you just had to fill in a couple details.  Also, you could see the tracking board either as a standard list, or as a layout of the department with rooms colored based on status, which made it easy to see at a glance what was going on.

Far and away the best feature, though - and the one that I miss sorely - is the "dot phrase" that Epic allows you to use.  In medicine, we are constantly using the same or very similar phrases over and over, whether it be in charting or patient instructions or whatever.  With Epic's dot phrases, you can enter a phrase one time (or choose from a large library of pre-entered phrases) and save it with a keyword.  Then whenever you type a dot and then the keyword, such as .sleep the computer replaces that with your pre-determined phrase, such as:

patient resting quietly with eyes closed and even unlabored breathing

because everybody knows that nurses aren't qualified to determine if a patient is actually sleeping or not.  Even cooler, is that if you include three asterixes in your original phrase, then this becomes an easily-editable part of the phrase.  For instance, I could put *** after resting quietly, and then when it pops up in the charting, I can quickly go through the text and any time there is a *** it will highlight it and ask me what to replace it with, so I could put "on his back" or "on his right side" or "in the sink" and then move on.  Even cooler, is that a lot of data from the patient's medical record can be called up in a similar fashion, so if I made a phrase such as:

.name is a .age .gender who complains of .cc for *** days.  .he has allergies to .allergies and regularly takes .meds.

and saved it under the keyword .triage, then when I type that keyword, I will get something like this:

Braden is a 72 year old male who complains of nausea and vomitting for *** days.  He (this phrase calls up the gender and puts the appropriate pronoun in place) has allergies to aspirin, ibuprofen, tylenol, and tramadol and regularly takes vitamin b12.

At that point, I hit the tab key (if I remember correctly) and it highlights my free text spot (the ***) and I can type what I want.  And of course the whole thing can be edited, so if anything doesn't apply I can delete it or add what I want.

Needless to say (but I'm saying it anyway), this saves immense amounts of time, and makes it so that you can write all the lawyer friendly stuff (patient tolerate procedure well, for instance) without having to wear out your hands and take the time to write the same thing over and over again.  I could chart a very thorough summary of crutch teaching, for instance, including documenting return demonstration, height of crutches and everything else, by just typing .crutch and then editing a detail or two.  Boom, 15 seconds spent on what would otherwise take a minute.  Multiply that times every patient encounter of the day, and perhaps you can understand why I miss this feature so much.

Okay, enough free advertisement for EPIC.  Are you still reading?  Good.

The other system that I have used is Ibex PulseCheck from Picis.  I remember being impressed with it because it was so simple and straightforward.  That said, there are very few specifics that I can remember to either praise or denegrate the program.  One thing that I do remember liking, however, was that the background color of the screen could be modified based on conditions, so when there was a blue screen, that meant that things were going well and you could bring your own patients back, but when there was a red screen it meant that we were getting busy or had a lot of ambulances on the way, so only the charge nurse could assign patients to rooms.  At the time I used this, I was an ER Tech, so most of my documentation consisted of charting blood draws, splints, EKGs and patient transports, so I really can't speak too much for how easy it is to do nursing assessments or med documentation on this system, though it seems that most of the nurses seemed to like it once they got used to it.

Another hospital I did clinical rotations at in nursing school used a DOS based system from the 1600s.  I would rather engrave the medical record in stone tablets than go back to that hospital.

Anyway, each of these systems has really nice features and each has features that just make me scratch my head and wonder if anybody is really thinking this through.  This gave me the crazy idea that I could come up with a good EMR, and since my brother is a computer programmer (who brings in almost 2.5 times my salary), maybe we could get something started and strike it rich.  So I've been jotting down notes every time I think of something that I want in my EMR, and although I know deep down that it is an impossible dream, I keep getting excited at the idea of solving all of the worlds medical records woes.

So I told him about the idea the other day and he said that not only is it a bigger project than I realize, but it involves a school of programming that he is not interested in, and besides, a clause in his contract states that anything he works on while employed by Software Giant, Inc, becomes their property.

Oh well.  Nice dream anyway.

So for all you intrepid souls who have followed me this far, what EMR do you use and what do you think of it?

Monday, December 15, 2008

Flirting With Jay O Sanders

So I have a facebook account mainly just to be able to stay in contact with friends (and because my wife forced me to at gunpoint), but I have taken advantage of a couple of features, such as the book list and I joined a bunch of groups that I thought were funny.  One of the groups was fans of audiobooks (I loves me a good audiobook), and that got me wondering if there was a group for fans of Jay O Sanders, seeing as how he is far and away my favorite audiobook reader.  I stumbled accross him while listening to a book by an author that I really like, and since then, I have found myself going out of the way to find books read by him even if I wouldn't otherwise be interested in it.
Turns out there is no group for fans of Jay O Sanders, but he does have a facebook account, so I requested to add him to my friends list with a message that I really like his books blah blah blah.

Imagine my surprise when the next day I get a message back from him thanking me and telling me about some of the audiobooks he has enjoyed reading.  So I respond telling him about which books I liked (Dragon Tears by Dean Koontz is not only an excellent book, but Sanders knocks it out of the park), and politely offered to take good care of him should he ever get in a traffic accident.  He responded again telling me about the books I mentioned (turns out Dragon Tears was his first...) and politely declining the traffic accident offer.

By this time I'm delighted to see a real human behind a (semi) famous face, and not wanting to push my luck/look like a stalker, I told him that he rocks and wished him best of luck.  Then I quickly posted another message asking him why he was responding to my comment at an ungodly hour.  Turns out it was a time zone difference that made it look ungodly.

Anyway, the whole point is that I think it is great that he is willing to take the time to personally respond to a fan and show his human side.  It makes me even more desirous to go out and get more of his audiobooks.  And if you haven't ever heard of him (his acting career seems to be mainly smaller parts in movies and a few TV shows, but nothing that I remember seeing him in), please go check out one of the audiobooks that he has narrated.  Give yourself time to get used to his style, which is a little different than the average narrator, and I think you will agree that he rocks the hizouse.

"Thanks for getting in touch and for your kind words. It's great to hear directly from people who listen. It's time spent with all these people we rarely meet, despite the intimacy of having privately told them a story."

 - Jay O Sanders (personal correspondence to unidentified nobody schmuck - December 15, 2008)

Incidentally, he never did accept me as a friend, but that is understandable... I probably wouldn't accept a stranger as a friend on my facebook page either.

Saturday, December 13, 2008

Heartbeat Ring

COI Titanium Heartbeat Ring - JT493

This ring is actually pretty cool.  Hey Ker, if I ever lose my wedding ring, (and when I'm done sleeping on the couch and receiving my lashes) let's replace it with one of these.

Friday, December 12, 2008

I Can Name That Rhythm In 3 Complexes

ER Murse directed me over to the CNA website (am I the only one who has a hard time seeing the abbreviation CNA as anything other than certified nursing assistant?), and when I got there, I was greeted with their logo, which was conveniently placed next to three EKG tracings... or at least I 'm going to assume that these are three separate EKG tracings, because if this is the same patient, then not only does he have a rate of like 40, but he is experiencing several serious problems simultaneously.

Obviously, they have taken the P waves and the T waves out so as to avoid distracting us with anything other than the QRS complexes.  That's good, because I didn't want to try to figure out what kind of heart block these patients are in.

But we can still try to figure out just what we are looking at, right?

The first patient has significant ST segment depression which would make me be a little concerned about a possible heart attack.  I think I would have to confirm this on another lead.

The second patient has a good flat isoelectric line, but the marked RSR' would have me wondering about a Right Bundle Branch Block.

The third patient also has an RSR' but this one appears to be more in line with a Left Bundle Branch Block.

In any case, I think that all of these patients need cardiac enzymes, a cardiology consult, and a life-saving 81 milligram aspirin, STAT.

Also, is it just me or is that an innapropriate use of a tilde?  I think that they really wanted a semi-colon here, but somebody said, "hey, wouldn't that squiggly line look a lot better there?  Kinda trendy, doncha think?"

Is There a Right Union for RNs?

Change of Shift is up over at Marijke: Nurse Turned Writer and one of the interesting links is over to ER Murse's blog, where he opines on what union is right for RNs.  I hate unions, which makes me fall into the group that he considers "hopelessly naive".

If there must be a union then I agree with him that RNs should be in a separate union, but I hate unions.  Did I mention that I don't like being in a union?  Because I don't.

Anyway, in an effort to get mileage out of my comment on the blog, here it is, reproduced in it's unabridged beauty for your visual degustation: I am at, most hospitals are unionized and you really don't have a choice about which union because if you want to work for that hospital, you have to work for that hospital's union.

One hospital in my system is a non-union hospital. Their salary is a tiny bit higher as a base, but when you consider that they do not pay union dues, the salary jumps up a lot more. As far as I can tell there are no significant differences between the way their nurses are treated and the way that I am treated, with the exception of the fact that at their hospital nurses are treated as individuals and when individual circumstances come up they don't have to pretend that everybody is exactly the same with no exceptions.

My wife and I are considering the possibility of a move in the coming months and among the places we are looking is Arizona. In doing research, Arizona has no unions at all. But based on information I have gathered so far, salary is higher, benefits are better, staffing ratios are similar or better, and from the anecdotal evidence that I have collected in talking with a few nurses, general satisfaction is very high. Another hospital system about 100 miles away from me is also non-union, and the salary is significantly higher, and again, in talking with several RNs from that system, they are delighted to be non-union.

So I guess you can tell where I fall on your scale. Yep, I'm the hopelessly naive third group. I recognize that unions can do some important things, but I think that every major union I have run into (I have been a member of SEIU and my state branch of the ANA) has become bloated and impersonal and has lost focus of actually caring for the individual in favor of seeming to care for the individual. What they actually do is extract large sums of money from my paycheck and dictate to me what I can and can't do. They throw massive weight behind political causes that I do not agree with, though they use me as ammunition in doing so. They try to "protect" thier workers in such a way that my individuality is completely wiped out, and in such a way that I cannot be rewarded for good work or punished for sloppy or lazy work.

If I could be part of a very small local union consisting of a few dozen or maybe even a few hundred employees where I actually had access to leadership, and where individuals could still be individuals and where they weren't encouraging me to strike over a 1 percent raise so that they can get more money for their political ambitions, then maybe I would be interested.

But forcing me to be in a union, extorting me for union dues, misrepresenting me to the public, and not advocating for my individual needs makes me resent being a union member.

And yes, I know that I can join the union blah blah committee and get into nasty arguments and long and unneccessary unpaid meetings.  Maybe one day I will get frustrated enough to do that just to spite some union officials.  Unfortunately, unions don't generally appreciate the "loyal opposition" so much.  Don't believe me?  Go check out the Employee Free Choice Act.

Sunday, December 7, 2008


While reading a comment on Crusty Ambulance Driver's blog, I came across the term CAOx3.  I've never seen this term before, so a quick google search came up with conscious, alert and oriented times 3.

Of course I'm familiar with A&Ox3, but I've never seen conscious added to the equation.  Is this something that is commonly used and I just haven't seen it, or maybe is used frequently in other parts of the country?  It doesn't make sense to me, because to my concrete reasoning, if you are alert or oriented, then by definition, you are conscious.

So my question to anyone who uses this term:  Do you use it because it conveys something that I'm not understanding that is not already contained in A&O or do you use it because that is the way that you learned or the way that others around you do it?

And lest anyone think I'm being snarky here, I'm not.  I really want to know so I'm not caught flat-footed if I see this in the less-virtual world.

Also I have nothing else to post right now.

Saturday, December 6, 2008

All the Manipulation That's Fit To Print

Elizabeth Cohen needs to lose her "medical correspondent" status STAT.  Your ER Doc pointed to this article on CNN's website about how to manipulate your way in to see the doctor.

Starting with some heartstring tugging story - complete with photograph - of a woman who hit her head and was told by the ER to see her PCP, but she couldn't get in for a week, it goes on to list some ideas for getting in faster:

1. Harrassment is a great way to make your doctor slink further away from the community.  Because lawyers haven't done enough of that already.

2. It's not really a lie if it's sort of true.  Right?  Like, you remember that boy who cried wolf?  Well maybe there was sort of a wolf.  Right?

3. Make friends and influence people.

4. This one is actually good advice... as long as you are considerate with how you use cancellations.

5. Are you kidding me?  Are you freaking kidding me?  No, seriously, are you kidding me?  Please see number 3... multiplied times 50.

I love it when our illustrious news media tries to help out by encouraging deception, manipulation and harrassment.

Here are a few random thoughts:
  • If your throat really does feel like it is closing, then please get to the nearest phone and call 911.  That is a true emergency and you shouldn't be seeing your doctor anyway.
  • Your manipulation may get you in to be seen sooner, but at what cost to your future credibility?
  • Note that the woman in the article is bemoaning not being able to get in to see an internist.  Perhaps she could have tried to see a general practitioner.  I don't know about where she lives, but the family practice clinic I go to has several doctors in the office and almost without fail I can get an appointment to be seen within a day or sometimes two.
  • Group practices are great.  I used to work in a very large group practice as an LPN, and while it certainly had its flaws, I think we delivered good care, and as a patient in that practice, I received good and timely care.
  • As an ER nurse, believe me that I don't want all these patients spilling out the door of the doctor's office and into my back yard, but if your ailment is so serious that you need to be seen right away, then you may need an Urgent Care or ER visit.  If it is the result of not planning ahead on your part, then suck it up.
  • If your doctor really is that busy, then find another doctor.  Nobody is forcing you to go to that one.  This is the beauty of the free market system.
  • If you think this is bad, just wait until you are assigned to a doctor and that doctor is allotted a certain amount of money and no more.
A few gems from the comment section.  These are the ones who really get it - the people who have their finger on the proverbial pulse of true entitlement thinking:
  • "I am tired of hearing how "busy" the doctor's are. They should behave in a more professional manner and never make the consumer feel like a "bother" or a "nusiance"."
  • "When patients (an apt term) need to be their own advocates because a physician, hospital, or other healthcare provider can't be bothered, something is definitely wrong."  That's right.  How dare they make me advocate for myself! Something is seriously wrong when the doctor can't even care enough to squeeze me in on his lunch break.  What's he doing taking a lunch
    break, anyway?  How can he even think about food when there are sick people out there?
  • "there is no reason I have to walk around for weeks with coughs, pains, dizziness or other minor ailments, feeling miserable and troubling the people around me."
And finally the commenter that just doesn't seem to understand.  Hey guy, these patients are entitled, and how dare you suggest that they might need to accept that there are other people on the planet:
  • "If you 'exaggerate' and say your throat is closing when you have a regular sore throat and get in sooner, what happens to the people who really are having a true emergency?"
In the end, I understand that there really is a growing problem with access to doctors, and it is one that needs to be addressed, and I think is being addressed in many ways.  It can be frustrating when you are in pain and need to get in and are having a hard time finding an appointment.  My heart goes out to you, it really does (despite my sarcasm earlier in the post), but lying and manipulation and other dangerous and antisocial behaviors are not the solution, and shame on you, Ms Cohen, for being willing to spread such ideas.