Saturday, April 28, 2007

Rules of Nursing, Revised and Updated!

1. All together now: If you have to jack with it, it's wrong.

2. The amount of time it takes a patient to announce "I'm not a junkie!" is inversely proportional to the probability that the patient is indeed a junkie.

3. The amount of irritation a particular order, procedure, patient, or request will produce is directly proportional to the number of sleepless nights the ordering resident has had.

4. The messiness of handwriting is directly proportional to the difficulty in getting hold of the person who wrote the order.

5. The amount of feces a patient produces during a shift is inversely proportional to his level of consciousness.

6. The difficulty level of a drug calculation is directly proportional to the drug's dangerousness.

7. Benzoin never washes out.

8. Bile will always land on whatever is white.

9. The patient on several different interacting medications will always have a general practitioner who does not do blood levels of those medications.

10. Everything happens after 0400/1600.

11. The probability that a patient will survive a code is inversely proportional to the likelihood that they will be declared DNR.

12. Any attempt at efficiency will, sooner rather than later, be met with Three-Stooges-like complications.

13. The lift is never on the floor when you need it.

14. The high-risk profile for terminal illness includes a happy family, a good job helping others, and a cadre of devoted friends and relatives.

15. Elevators fail to work during codes.

Friday, April 27, 2007

Say the word and be like me.

It's so fine; it's sunshine. It's the word "no."

A meditation on saying "no."

I had one of Those patients today. You know the sort; they come in with poorly defined abdominal pain that stays poorly defined and resists all efforts to diagnose it. The only thing that calms the pain is a patient-controlled pain pump with X number of milligrams every Y minutes (determined by the patient) with a Z bolus of A milligrams every B minutes.

You know the sort.

This one wanted to go smoke. Then she wanted to go to the gift shop. Then she wanted just to walk around outside. I told her she could do none of those things; that leaving the floor with that much narcotic was not allowed.

So she put an aide on the spot by asking *him* to take her out to smoke.

Which I called her on. Then she called the aide a liar, which I called her on. Then it became a huge joke, which I did not find funny.

The last straw, for That patient, was when I told her that, regardless of what she *wanted* to eat, she'd be getting a particular diet. Period. No argument.

Whereupon she, being an old hand at this hospital business, called the Big Boss and poured out her tale of woe. Oh, the cruel nurse! Oh, the inhumanity!

Immediate Boss dealt with it and came back with this ultimatum: either give up That patient and offer a "half-assed apology" or offer a "half-assed apology" (and I'm quoting, here) and go on for the rest of the shift.

I said "no."

As in, No, I will not apologize to the patient who will not follow the rules. As in, I was not rude or condescending or nasty; I simply stated how things would be. As in, No, That patient won't get an apology, and further, *you* get to handle her for the next four hours.

As in, No, I will not be abused in the name of customer service.

Because, you see, my job is not customer service. My job is to provide the safest and most therapeutic environment possible for my patients. If that means that they don't get to smoke their usual two packs a day while they're being evaluated for a duodenal perforation, so be it. I'm happy to offer nicotine replacement; it's their loss if they refuse.

My job is also to protect the people who have less power than me. If you call my aide a liar while trying to get him to do something he knows he can't, I'll call you on it. And if you continue to screw around, I will not tire of telling you "no."

The surgeon, thank God, is on my side.

The other nurses I work with are shocked. And admiring, that I had the huevos to say "no" to something that we'd all normally go along with in order to keep the peace.

I've had enough of saying "yes." It's time we, as a profession, got rid of this imagine of being pushovers who only want to please. I'm sure the first twenty-dozen nurses who refused to stand when the doctors entered the station got hell, as did the first twenty-dozen who refused to carry the MDs charts for them during rounds.

I'll take hell for saying "no." I've already defined my job; my bosses' job is to make sure I can do *my* job safely and without untoward interference.

I have the feeling I'll hear about this once Biggest Boss Of All gets back from vacation. In the meantime, I'll savor the feeling of "no."

Wednesday, April 25, 2007

*smack* *munch* nurses.

That's a joke, people.

John (for whom I have immense respect and liking) has a post up on "lateral violence", aka "nurses eat their young with sprouts and bleu cheese." He posts some sobering stats on how many new nurses (defined here as nurses within the first couple of years of licensure) leave the profession entirely or change jobs.

Not to disagree entirely with John's point, but I have a thought on a couple of other issues that face new nurses. I thought I'd expound. Of course I did.

Issue Number One: Nobody Really Knows What The Hell It Is We Do.

We dare to care, yes. We dare to cry. We dare to work out BSA and dosages for neonates in a code. We dare to keep up with changes in legislation. We dare to influence that legislation. We dare to advocate for abused patients. We dare to work in a profession that is historically undervalued. We dare to protect our patients from doctors' errors. We dare to report our own.

In short, we do a whole lot more than caring and crying.

Yet, when I started nursing school, I was the only person in a class of forty who said something other than "I want to help people."

Nursing students are no less clueless than the rest of society. I would estimate that ninety percent of the folks I went to school with thought that a person's warm-fuzzosity was the primary determinant of how they'd do as a nurse. And all of those people got whacked upside the head with the reality of how tricky the job is--not just from the standpoint of interacting with sick people, but from the standpoint of having to be a scientist.

Aside from the one woman who went into school "to meet doctors" and the other who wanted her husband to stop bugging her about getting a job, *all* of the people who wanted to "help others" have left the profession.

All of them. That's fifteen nurses (of the ones that finished school) who have gone back to accounting, or bank tellering, or whatever they were doing before. I am one of six (SIX!) students from my graduating class who is still a nurse. Nobody, apparently, knew that it would be as hard and as intellectually demanding as it is.

At the same time, I'm watching smart young feminists of my acquaintance not enter nursing because of the helpmeet stereotype. Frankly, what this profession needs more of is smart young feminists. Yet we're not attracting them, because nursing is still seen as a pink-collar, nearly-service-industry, "helping" profession. When I talk to women who are working toward their premed degrees about what I do for a living, they're gobsmacked to discover that modern nursing is a hell of a lot more like their concept of being a doctor than they thought.

Solution? We need to be realistic about what we do. We need to tell people, every chance we get, that we are intelligent, trained, scientific professionals who are also able to steer a family through a health crisis or advocate for a rape victim. I am eternally grateful for Pal Angie, who will be getting a newly-minted RN this summer (hooray, Angie!) and who is one of the smartest, toughest, feminist, most realistic people I know. If more people could see nurses like her, we'd have no problem with a shortage.

And if more nurse-wanna-bes understood that it ain't all hugs, we'd have fewer people who ought to be somewhere else.

Harsh, but true.

Issue Number Two: It's About The Stupid Management

Sometimes I feel like a cross between Joe Hill and Emma Goldman, with the Pinkertons about to bust down my door, but it's true: Hospital management is hostile to nurses. Period.

A friend of mine who's also an RN got offered a fantastic bonus for signing on with a particular hospital which shall remain nameless. She showed up on the floor the first day after two weeks of orientation to find herself in charge of one practical nurse and twelve patients. Twelve. All of whom were in varying states of circling the drain because of nursing shortages at that hospital. She walked out after that first day and came to our facility, which (at the time) still cared about staffing rather than the latest technological widget.

We as nurses need to do two things to fix this problem: First, we need to stop signing up for extra work. When I see a nurse who's working ten days in a row without a day off, I don't see a dedicated professional. I see a person with serious issues about saying "No."

Quite frankly, the world will not end if we all start saying "No." The hospital will hire agency nurses or more full-timers, or start paying attention, at least, to staffing levels. Management might actually have to come in and work--and that, my friends, is a truly marvelous feeling, to watch your manager wipe ass for twelve hours because he hasn't had the huevos to hire new people.

Second, and more importantly, we need to agitate for safe staffing levels. When I say "agitate", I mean everything from my own technique (which involves yelling if necessary) to the technique of calmer colleagues (who speak in front of the state legislature). Every nurse can make a difference at some level in this fight. If you're crazy about writing letters and emailing representatives, you can do that. If you're nuts for making middle management uncomfortable, you can do that. And if you get a warm, fuzzy glow from saying "No" to extra shifts, you can do that.

We as nurses do need to shut the hell up and stop putting new nurses through a gauntlet. Nobody's going to be tougher, or faster, or smarter for being abused. There are, however, *systemic problems* that I think are a larger threat to the profession as a whole. We need to spend the breath we'd use debating how, exactly, we eat our young fixing those.

Tuesday, April 24, 2007

How not to be impressive.

It does not impress me if a nurse routinely complains at 1430 that she hasn't had a chance to open her charts. It makes me wonder where she learned her time-management skills.

It does not impress me if a nurse tells me he's never made a medication error. It makes me wonder how many of those medications he's taken himself.

It does not impress me if a nurse on our floor tells me she never has time for lunch. I qualify that with "on our floor" because we are very serious about food. See time-management skills, above.

It does not impress me if a nurse complains constantly about the fact that one of these days, he's gonna get sued and lose his license and isn't the culture of lawsuit-happiness awful. If that's his main focus, I wonder what and how he's charting and what the hell he's doing in the room.

It does not impress me to hear a nurse deny that she's wrong.

It does not impress me to learn of a nurse's difficult relations with doctors. There's no reason not to get along with doctors, with the possible exception of the occasional total nutcase. Even if you get off on the wrong foot with each other, careful negotiation can make a good working relationship possible. If you can't get along with any of 'em, the problem is you.

It makes me sad and does not impress me when a nurse obviously hates everything about nursing. I don't care if you felt trapped ten years ago when you got your RN; you can certainly afford to change now. If you hate it that much, take accounting classes or learn to throw pots on the wheel.

Drama fails to impress me. Totally.

What does impress me, and what I'd like to be eventually, is the sort of nurse whose patients rarely end up in the ICU, because she's caught problems early. I'd like to end up as one of those nurses whose gut feelings get taken seriously by residents and attendings alike, because he's been so careful in his assessment. I'd like to be one of those nurses whose charting is so complete and careful that you can tell, a week later, exactly what's been going on. I'd like to be the nurse who doesn't get flowery accolades from management, but whose patients always request her when they return after surgery.

I am very, very lucky to work with a passel of the latter sort of nurse and only a couple of the first sort.

But jiminy cricket, I need to work on my charting.

Thursday, April 19, 2007

"what i don't know outweighs so much of what i do know, sometimes it's hard to believe"...

I have to, *have* to address this.

New nurses are ignorant.

So are old nurses who are faced with something they've never dealt with before.

So are medium-aged nurses who have to keep up with new technology.

So are doctors, old and new, rusty and in-practice.

Part of the practice of nursing is scrunching out ignorance: your own and other people's. I would argue that the most important thing that a nurse does is scrunch out that ignorance by giving her* patients the tools and knowledge to deal with their conditions. The second-most important thing she does is squish her own ignorance flat under the weight of her own research, learning, and auto-didact-icism.

Do not ever let your ignorance paralyze you. Hell, if I dwelled every day on how little I actually know about neuroscience, I'd never get out of bed. (Or, at least, I'd have another good excuse for not getting out of bed.) What I do know, I know really well--and I can put it into language that a mentally-deficient turnip could understand. What I don't know I'm not afraid to admit, even to an anxious patient.

Where nursing students excel is in the almost eidetic recall of new stuff a lot of the rest of us have missed. Where they excel is in the energy they put into learning new stuff. They also kick ass at taking a look at The Way Things Have Always Been Done and asking "Why?"

Don't let the fear of your own ignorance paralyze you, whether you're a brand-new nurse, or a brand-new student, or an old-guard nurse trying something new. The absolute worst thing that will happen to you if you show your ignorance is that you'll feel like an idiot for a few minutes. Nobody's going to die. Nobody's even going to get hurt. More than likely, you'll make some pedantic nurse's or doctor's day by giving them the chance to explain something near and dear to them.

I once asked an endocrinologist a fairly simple (I thought) question about something endocriny. He treated me as though I had a much broader base of knowledge on the subject than I actually do and lectured me for three minutes on the ins and outs of that particular problem. (What the original question was has been burnt out of my head by the answer.) Even after he left the English language and started saying "Gleep! Waggado, florischepup mmm nnaaagh wazuuuuu weeeep, *click*!!" I sat there and looked interested and nodded. I learned more than I had in a week that day, even without taking into account the detours I took through Google and dictionaries as I looked up the words he'd used.

I am also now his very favorite nurse. He mostly speaks real human speech to me, even.

That's a good lesson on admitting your ignorance. Remember: if it's too humiliating, you can always get Freixenet Cordon Negro in those itty-bitty bottles for after work.

*Standard disclaimer on using female pronouns to label nurses goes here.

Wednesday, April 18, 2007

Gosh, look at the time.

It's spring, the loveliest time of the year!

Those of you who are about to graduate from nursing school will no doubt have noticed that it's staying light later in the day, although other details might've escaped your notice. Since it's spring, it's time for the periodic Tips From Nurse Jo For New Grads...

1. The first rule of nursing is (sing it, everybody!): "If You Have To Jack With It, It's Wrong." Remember that when you have to connect tab A to slot B through connector C and widget D. If something doesn't come together in an idiot-proof way, be it lab results or equipment, take another look at it and figure out what's wrong.

2. You will not kill anybody. I promise. You will still pray, as I did, every single day that you won't kill somebody, but you won't. There are people looking out for you.

Which brings me to

3. If you've somehow landed in a hospital where the nurses are horrible, you can always leave and find a new GN internship. Don't feel like you have to put up with abuse in order to pay your dues or make it as a nurse.

Mother Jones has a big discussion on the backbiting and cattiness in the nursing profession. Honestly? If nursing is the cattiest, bitchiest profession you've been in, you've obviously never spent even five minutes in community or college theater (but that's sort of beside the point).

The point is that there are plenty of nurses out there who aren't looking for a GN to chew on. There are lots of internship programs dedicated to educating you, making you a confident and competent practitioner, and plenty of folks like me who love to teach and are proud of you for what you've done.

If you end up in one of the other sorts of internships, don't take the abuse. You can always walk.

Speaking of walking, there's

4. Do not be afraid to leave a room or the nurse's station if somebody is abusing you. That goes for patients and double for doctors.

When you're a new nurse, everydamnthing is so overwhelming that, even if you've dealt successfully with crises before, you tend to cave. Remember that walking away is often the best way--and sometimes the only way--to deal with shouting nutjobs. Yes, I've turned on my heel and walked away from patients, family members, and doctors. As I've gained more experience, I've had to do so fewer and fewer times, but it's still a valuable skill to have.

5. Shoes, scrubs, and fiber are the three most important components of daily life for a new nurse. Make sure your shoes are good and sturdy, be certain your scrubs won't fall down if you have to book it down the hall, and eat your veggies. Taking care of your body and making sure that your clothing is worry-proof isn't selfish; it allows you to concentrate on your job.

6. Don't lend your stethoscope to a resident unless you're absolutely sure you'll see her in the next ten minutes.

7. The volume of shit a patient can produce in one shift is inversely proportional to their level of consciousness.

8. Other nurses and doctors (didja notice? I said "other nurses! You're a nurse! Hooray!) are there to have their brains picked. Ask questions. Ask for help. Don't turn down help if it's offered. Don't be afraid of looking silly; we all look silly on a daily basis (or oftener, if you're me). And don't underestimate the knowledge base of the transporters, patient care aides, radiology guys, and pharmacists. Pester everyone, absorb information like a sponge, and sort it out later.

9. Being a nurse is much, much easier than being a nursing student.

10. Eventually, I promise, you will feel like a nurse. It might take a couple of years, but it will happen. The flow won't come immediately; you'll feel completely at sea for the first several months. Someday, though, you'll be wandering down the hall and be hit with the realization that you actually saw a patient and planned her care and thought through her case in a second-nature sort of way. You will suddenly realize what all that studying was for. You'll understand how all the pieces of a problem come together and what to do about some of them. You'll feel a glow of accomplishment and a surge in confidence.

And then your patient will go into respiratory distress, or you'll realize you've made a whopping med error, or you'll spill spaghetti on your pants. But for one shining moment, you'll feel good about what you're doing.

Hold on to that. Spilling spaghetti on pants, tragically, does not get any less frequent with experience, but the feeling that you're doing good comes more often.

Monday, April 09, 2007

A delicate, feminine, lace-trimmed rant

When did a size 12 become "full-figured" and a 14 become "obese"?

What the hell is up with the BMI?

And where are the athletic-cut shirts for women?

I got into a little discussion the other day with some people at work. I'm closer to 200 lbs. these days than to 100, but I wear a (loosening) size 12. According to the BMI charts, I'm obese. According to magazines like "People" and "Vogue" (not like I'm saying they're bastions of intellectualism and feminist cred, but they are popular), I am "full figured". According to some of my coworkers, I am getting "too big" from weightlifting.

The only one of those three I can shut up immediately and effectively is the last, usually by simply picking the second-biggest person in the group and lifting them clean off the floor without visible effort. (The first-biggest person in the group is usually some general-surgery resident who was a nose tackle in high school. I don't need a hernia.)

But I'm still getting charged more by my insurance company because I fall into the obese category on the BMI charts. Never mind that my blood pressure is fine, that my cholesterol is normalizing, that I can and do run an eight-minute mile. Yeah, I could stand to lose 20 pounds, but that would still put me in the overweight-to-obese range for the government and in the holy-kamole-to-oh-shit range for insurance charts. To weigh what my doctor, my insurance purveyor, and the Gubmint would like me to, I would have to lose about sixty pounds. Which would mean that I would quit menstruating and probably breathing.

To give you an idea of the genetics behind my biceps, consider this: Beloved Sister "should" weigh somewhere around 125 pounds at her height.

She carries that much in lean mass *alone* on her frame. We're blessed.

Anyway, I'm getting bugged. My pants are getting looser at the same time my shirts get tighter, which means I can buy jeans (for now) at "normal person" stores, but have to spend the extra dough on "woman's" clothing in order to get something on top that will go around my chest. Or I have to buy men's large shirts and taper the waist down. If I want a dress, I have to order women's sizes in order to fit my chest and back, then alter them to be small enough for my waist and (sometimes) hips. Or I have to buy a "normal person" 16 or 18 and then alter the whole damned thing, because I'm short.

I want some women's shirts that are cut to allow for shoulders, boobs, and a back. I don't even care if they fit around my biceps; I just want to be able to go out in a T-shirt or button-down without looking like Sheena, Queen Professional Wrestling Slut From Hell.

I'd also like for the societal expectations for women's bodies to change enough that total strangers don't find it necessary to comment on my shape. It's nice when it's a compliment, but more and more often (especially if I wear a normal-person T-shirt) it's getting into "Good Heavens, what on earth do you *do* to get that big a back?" territory.

I'd also like for the coworkers who bug me about my muscles but love me to help them move heavy patients to shut up for a while.

Please note that I do not intend to quit lifting. There's something viscerally satisfying about putting on a shirt and having it strain across my back, even if I then get irritated about the fit. I love the fact that I now walk with that bouncy, tight weightlifter's walk, rather than with the tired-nurse tread that I see so often at work. I also love that I can do sixty reps on bicep curls with fifteen pounds and be just a little tired.

Plus, it's nice to be able to pick up people who bug me. I may, if I continue to make huge gains in strength and bulk, someday be able to shake them like a terrier would and then toss them over my (massive, rippling) shoulder.

Saturday, April 07, 2007

Not second-best.

It happened again: a raft of compliments from a patient and her husband, with the husband taking me aside and speaking seriously about what a pity and a waste it was that I didn't go to medical school. The implication is that I'm too smart, or too hard-working, or too marvelous overall to be a nurse; that I'd be doing the world more good as an MD.

This time I didn't scream. I didn't blow my top. I didn't even feel insulted. (Well, okay, I did. But I didn't let it affect my response.)

I went to nursing school not because I was too old or too tired to become a doctor, but because I wanted to be a nurse.

Doctors, by virtue of their training and specialization, focus on the disease process. Nurses focus on the person dealing with the disease process. (A lot of the narrow focus of doctors' work, unfortunately, is born of the medical system, with its emphasis on CYA shotgunning and rule-outs.) A nurse will view her* patients holistically, take the time to discover weird little underlying causes, and educate her patients about whatever's wrong with them and how to live with it. Because of the contraints under which doctors operate, if a doc does that, it gets him a book deal and a spot on NPR. Nurses do it every day.

Nursing and doctoring are equal professions. I predict a lot of flak from that, mostly coming from residents (grin), but listen up: I may not know the pharmacological profile of gentamycin like the back of my hand, but most doctors don't know how to deal with a clogged central line. I don't do as thorough a clinical neurological assessment as my neuro MD colleagues, but my neuro assessment will tell me (and them) more about how the patient is able/unable to operate in his or her daily life. I can't read an MRI reliably yet, but I have a gut feeling, honed through years of paid and volunteer work, that is pretty near infallible.

My two main foci as a nurse are assessment and education. It's because I'm a nurse that my assessment skills are more detail- and change-oriented than those of my medical colleagues: after all, they're in surgery or clinic all day, while I'm dealing with the same people for twelve hours at a stretch. When something minor changes, the nurse is often the first to notice--or the only one to notice--not just because she's there, but because she knows the patients better.

I also have time to educate. One of the biggest parts of nursing is translating what's just happen or what's about to happen into English. This can be worrying or reassuring, depending on the situation; it's up to me to deal with the patient's emotional and mental reactions. It's also my job to teach the patient how, for instance, not to rip the Harrington rods right out of his back immediately post-op. Doctors know the general outlines, like "do not lift anything heavier than ten pounds or do strenuous activity", but most can't translate that into "don't pick up anything heavier than a gallon of milk or vacuum your carpets." (It's worth mentioning that two-thirds of the education I do consists of putting instructions into fourth-grade reading-level form. This disturbs me on many levels.)

Doctors and nurses are two parts of a big symbiotic critter. Our skills are different, our education levels are different, our training is different--but we are equal despite those differences. I can't do what the folks on the neuro service do to brains, but they don't know how to mobilize their own patients, or prevent pressure ulcers, or treat the side effects of some medications without drugs. The healthiest nurse-doctor relationships (and I'm proud to say that, despite the current weirdness at L'Hospital Schwankienne, our professional relationships are top-notch) are those that recognize the inherent differences in skill and focus and give credit where credit is due.

I'm not a helpmate. I'm not a handmaiden. I'm certainly not a failed, frustrated doctor-wannabe. I'm a carefully-trained, careful-thinking, observant clinician with a wide range of disparate skills and some strange little tricks up her sleeve. You really can't compare the two professions; our tricks and skills are too different.

And my profession is certainly not second-best.

*Yes, I'm using "her" here, since most nurses are female.

Thursday, April 05, 2007

Change o' Shift!

Right here.

Tuesday, April 03, 2007

How to kill a hospital

It's best if you can pick a really good hospital to kill. Try to find one that was started by surgeons and physicians for their most complex patients. It helps if the hospital is known nationally for its quality of care and its research facilities. Merge it with another, larger hospital, one in persistent financial difficulties. This sets the stage for a nice, slow, painful death for the better-run hospital.

If you're a member of management, remember: small demoralizations add up over time to a poisonous environment. Try to start small, with something like the laundry service. Contract with a different service provider, one who can guarantee that about 20% of your linens will come back stained, ink-marked, torn, or with melted tape on them. The extra five minutes a day each nurse or aide will spend looking for usable linens really adds up.

Once your employees have gotten used to hoarding clean, untorn sheets, you can merge supply rooms. Be absolutely certain that the research hospital is a minimum of two miles away from the central supply area, and be sure that their stocks of necessities are always just about to run out. The nurses and aides are used to sorting and hoarding linens; hoarding lumbar puncture kits and needles is one easy step beyond.

Don't forget your support staff! It's best if you can plead "budgetary constraints" before you fire all but three or four of your longest-working support people. With the money you save, you can re-fill those positions with people earning just over minimum wage and with few if any benefits. That way, you'll guarantee that the people who keep the hospital clean, who transport the patients, and who cook and serve the food will think of your facility as just a place to come to work, rather than a job that they're proud of.

Try to hire managers who are completely ineffective. It's better if they can be actively harmful to their units, but ineffective is good enough. Encourage them to promote to management positions those who carry on flaming affairs with coworkers, backstab, or are simply too lazy to move from a chair. It might take a while, but you'll find your patience more than repaid in frustrated and demoralized employees. Train your unit managers to respond late if at all to concerns.

If you have employees who are chronically late or absent, or who falsify documentation or who are unsafe practitioners, do your best to keep those employees around. Try to hire and retain people who complain of bullying if their mistakes are pointed out to them. If one or more of those people is sexist or racist, fantastic. Be sure to discipline good employees at the same time you let the others slide--otherwise, your staff might think you're simply incompetent rather than malicious.

Play favorites. It goes *such* a long way toward establishing cliques and employee unhappiness. Remember: little actions count! Leaving one employee out of the annual holiday-candy dump will be noticed and remarked upon.

Don't neglect the small perks that make working at a formerly-good hospital so satisfying. I'd strongly recommend stopping all employee recognition except that which has to be approved by management. Be sure you appreciate hard work, but not too much. If you have a unit secretary who hasn't taken a sick day in fifteen years, a five-dollar gift certificate to a chain restaurant is about the right level of congratulations.

And be sure that you lower the quality and raise the price of the food in the cafeteria. Nothing says "We could give a flying fuck less about you" than a widespread outbreak of E. coli poisoning, especially when the prices for bacteria-laden sandwiches have almost doubled in a year. Sure, some of your employees might go next door for a decent meal, but remember: you can always discipline them for leaving the floor for lunch.

Investment in new technologies is always a fine idea. Before you invest, though, be sure whatever new widget you're rolling out will be several thousand dollars more expensive than you'd expected, be months late in implementation, and be difficult and tricky to use. If the widget is computerized and crashes routinely, so much the better. Bonus points for replacing a trouble-free system with one that dies on the average of twice a week. Triple bonus points if it has something to do with either patient safety or medication administration. Just think: with the money you've spent on this latest boondoggle, you could've hired another pharmacist. As it is, though, you're increasing the pressure on *that* part of the hospital while frustrating nearly everyone else. Good job!

Keep it up for eight to ten months and watch morale and job satisfaction slide! Don't neglect the tiny details, either, like imposing fines in particular parking areas, then changing the rules without notifying your employees. There can never be enough paperwork. There can never be too few people in critical positions.

Give yourself a raise, manager! You've successfully killed another hospital!

Monday, April 02, 2007

It's official: Mom and Dad adopted me from the aliens.

So I went to the happy shrink guy for my follow-up appointment and told him what happened when I tried to taper off Effexor. His response? "Boy, that's weird." "Weird" means more, somehow, coming from a psychiatrist.

And then I got the results back from my latest round of blood tests. When the last ones came in, my cholesterol was in the mid-180's, which, combined with my family history, made me a little nervous. So I cut back on booze, cut out junk except for a treat now and then, and upped the amount of lean protein and veggies and fruits I eat. I also incorporated more cardio into the workouts I have with Attilla, and started cardio on my own.

Whereupon my cholesterol went up twenty-four points.

I'm going back to a diet of burgers and beer. I may start breathing methane; it's probably the oxygen in the atmosphere that's causing my problems.