Saturday, September 19, 2015

Here is why I love my town.

If you were to look at a map of Texas, you probably wouldn't notice Littleton at all. It's not one of those places where a river runs through downtown, free to everyone, or where huge concerts take place or where there's even a top-ranked university. It's just a small town, kind of stuck on the outskirts of a big city, but emphatically not a suburb. It's its own place.

That's why I love Littleton. The rents are cheap and there's a big airport nearby, yes, and the air is clean and coyotes and foxes and various other small animals roam through downtown (somebody found a litter of bobcat kittens behind a bar a few weeks ago and turned 'em into animal control, who is rehabbing them and re-wilding them), and it's peaceful and bucolic. And it's determinedly independent.

There are trains that run through the middle of town, just two blocks from the courthouse, every night. And every night, pretty much, you can hear the train horns blowing in some new and interesting signature way that the guys who drive them have developed. Yes, it's policy that they blow a short-short-long prior to reaching a level crossing, but the engineers have ditched the computer-programmed horns for Littleton and do their own thing. At Christmas, they blow "Jingle Bells" and "Rudolph The Red-Nosed Reindeer" rather than the usual signals.

The H.E.B. here (that's a local grocery chain) plays KISS and Ingrid Michaelson and the Bee-Gees over the speakers in the store. Rather than the usual boring "come get our chicken it's fresh between eleven and four and only a dollar ninety-nine" announcements, the staff say things over the PA like, "Is your life missing something? Do you feel empty inside? Try some CHICKEN! Fried or baked, it can bring new meaning to your existence!"

The Boyfiend's lawnmower was stolen last week and returned within three hours, thanks to the efforts of the local PD. Though they have pursuit cars and a bomb squad and a mobile emergency management truck, the officer still responded with "That sounds like Steve. Dammit. Steve needs to stop stealing lawnmowers" when he took the report. Despite technology, our PD is still small-town enough to be exasperated with the one crazy guy who makes a habit of liberating lawn equipment.

The city fathers decided to lock up the free public electrical outlets around the courthouse, but only after people started pitching tents there and setting up full-sized refrigerators that ran off the city's electricity.

We get the traffic from South By Southwest, but none of the other headaches. Bars that have live bands put up signs that say "OH MY GOD BECKY LOOK AT HER BOOKING" for that week. Gas is cheaper here, and the gas station is likely to have Mexican, Indian, or Korean home-cooked food for sale. The place I buy my beer smells of incense and kimchee.

There are four terrifying barbecue places where the meat melts off the bone and you're not advised to ask about preparation, and three terrifying Mexican places that have excellent strange salsas you've never tried before. Oh, and that little Japanese restaurant that will serve you amazing sushi if you shrug and say, "Whatever the chef wants; I'm not particular."

Soul food is cheap here. Grits are an option with everything. You can be literally thrown out of a bar, onto the street, on your ass, if you misbehave. Yet the patrons of the local gay bar will leave you alone if all you want is a beer and a book. There's a running club that meets at a local bar, three bike clubs (road, mountain, and casual), and a bird-watching group. There are two breweries and a dude who bottles home-made ginger ale and flavored seltzers. There's a soap company, two of those places that will sell you boxes of vegetables every month, and some guy who runs a barber shop out of his pickup truck and specializes in beards. Drag queens are an everyday sight. Nobody turns a hair at people of different/the same ethnicities/sexes holding hands in public. The library is one of the finest I have ever seen, and is enthusiastically supported by the locals. The city council is made up of a lawyer, a stay-at-home mom, a guy who runs the vegan restaurant, a history professor from one of Bigton's universities, some woman with oil and gas ties who is retiring this year thank God, and a couple of random business owners who want to legalize pot and skateboarding.

I was shopping today and had to do the excuse-me-I'm-in-your-way dance with a seventy-ish man in the soup aisle. It turned into a full-on dance-off and ended in a tango.

I love my town.

Wednesday, September 09, 2015

Happy Lumpiversary and 'Bye, Felicia.

Five years ago I was sitting in my dentist's chair when his hygienist found a lump on my hard palate. The lump, known as Cap'n Lumpy after that, turned out to be a rare-ish form of minor salivary gland cancer called polymorphous low-grade adenocarcinoma.

It started a year-long freakout on my part, most of which is documented on this here blog, that culminated in my wearing a cool plastic-and-metal prosthetic to replace the chunk of my mouth that a surgeon removed.

I'm not sure how I feel about this, so I'm gonna just mark this lumpiversary and leave it be. I have the latest set of scans (CT and MRI) coming up week after next. I'm not sure how I feel about that, either. Maybe it'll be easier once I transition to once-a-year rather than once-every-six-months scanning; maybe it'll be a whole new kind of hell. We'll see.

In other news, Keith is gone. I don't know the details, having been on vacation this last two weeks, but he's been relieved of his duties at Sunnydale and has gone back to the pit that spawned him. It probably had something to do with a patient decompensating to the point that she had to be intubated on his watch, with nobody but him being aware of it. I don't know. All I know for sure is that I can work now without having to worry about somebody else's patients as well as my own.

So. One okay thing, one good thing. Not a bad way to start off the new year.

Sunday, September 06, 2015

The best new nursing blog out there is "Florence Is Dead."

If you want smart, funny, badass commentary on the nature of nursing today, go read Florence Is Dead. It's a brand-new blog, but already it's creating waves. The Diet Coke Incident has some of the most bloviating ridiculousness in the comments section that I've ever seen.

In case you couldn't guess, I agree with pretty much everything Dead Florence writes. The one place we differ is on the scrubs issue: she'd like to see professional dress for nurses, while I stand firmly on the side of scrubs. The primary reason for that, you understand, is that I cannot dress myself. Other than that one disagreement, though, I'm firmly in DF's camp.

Go check it out. I got very excited when I stumbled across it (can't remember for the life of me how that was, sadly). Give her some love in the comments section.

Friday, September 04, 2015

Let's talk a little about patient satisfaction, shall we?

About a year ago, after Eric Duncan died at Texas Health Presbyterian Hospital in Dallas and two nurses who cared for him were hospitalized with the same disease that killed him (Ebola), Texas Health Resources got an independent committee to review what went wrong. It was like a root cause analysis, but more so: these were outside doctors and one nurse, they weren't paid, and they were given access to everything that was charted and all the folks involved in the Presby debacle.

They came to a number of conclusions: first, that education was lacking--the staff wasn't aware of what exactly to do in case of a person with Ebola coming in; second, that communication was poor--the nurse who took Mr. Duncan's health history didn't communicate verbally to the doc that he'd come from an Ebola-affected area; and third, that the fear of poor patient satisfaction scores led the doctors and nurses to rush Mr. Duncan through the ED that first time, in order to keep other patients from waiting and getting mad.

The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

Read that again. The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

I don't know what it's like in Dallas, but here in Bigton, every medium-sized hospital and most of the smaller ones have billboards touting how fast a person can be seen in their various EDs. Some of them even have big neon numbers that show the current wait times outside the hospital itself. A few even have those big neon numbers on billboards on the highways.

The entire focus of emergency-room care has become, at least in this area, about how fast you can be seen for belly pain. Or a broken arm. Or allergies. Yes, they advertise ED services for seasonal allergies. And it's all about the time it'll take for you to be seen. Come in with a head injury following a fall or a sore back that's been going on for a month? Doesn't matter--our goal is to have you back in a room in ten minutes or less and have you out the door in half an hour.

At the beginning of flu season here in Texas, that emphasis on speed, which is translated to patient satisfaction by administrators, contributed to already-stressed doctors and nurses missing a diagnosis that turned out to be fatal.

(There's a lot to be said on the communication front as well--why was the flag in the chart that the nurse filled out not enough to alert the doc? Was he, perhaps, rushed? Why the emphasis on verbally informing him of something, when the nurse might not actually see the doc face-to-face all shift because they're both busy? That'll have to wait, though.)

Let's take this down a notch. At Sunnydale General and Holy Kamole, there's a big push on to satisfy patients in every way possible. Press-Ganey cards are sent to each and every in- or out-patient within a week of their leaving the hospital or clinic, and the results are taken very seriously.

I work in a critical care unit. It's likely that the patients that I see will go on to spend a few weeks either on a floor or in rehab or both, and may or may not remember their time with me. Brain injuries tend to wipe out short-term memory. Even if they do remember the NCCU, they probably won't remember me by name. All this leads to a very minor chance that they'll be able to fill out a card that mentions me specifically.

Yet if I'm not mentioned by name by at least one patient in a year, preferably by two or three, I won't get a point on my employee review. It doesn't matter how many students or new nurses I precept, how many errors I catch, or how often my patients have good outcomes. What matters is that somebody who's stressed or ill, possibly without family support, remembers my name (perhaps weeks or months after seeing me for a day or two) and takes the time to mail back a postcard with my name on it. Missing that point can make the difference between a raise and no raise, or between a satisfactory or unsatisfactory review. It's weighted that heavily.

We no longer track how often certain nurses' patients get bedsores or UTIs or end up going back to the CCU. What we track now is how often they're praised by patients or family members.

As a result, I find myself doing all kinds of crazy shit to get people to remember me. We're not allowed to hand out the Press-Ganey cards or special-mention cards ourselves, so it's up to us to do everything possible to make ourselves stand out. Most of the time, for me, it's staying at the bedside a little longer to explain what's going on with the care plan, or the physiology of the disease we're dealing with, or why the patient is on a ventilator or has this or that tube.

Sometimes I have to sweeten family members or patients who are determined to be upset. I act as counsellor, waitress, and gofer. A lot of times, those patients or families take me away from jobs I ought to be doing just so I don't end up with a complaint--I didn't get them a cup of coffee, or something. If I have a patient I'm worried about because her neuro status is changing, I have to weigh the consequences of letting her go for another ten minutes versus the consequences of being seen as not "patient satisfaction oriented" enough.

The worst example of this happened after a patient, who was fully in command of all his faculties, took a swing at me. Only a complicated move reminiscent of the "Matrix" movies kept me from a broken skull. Afterwards, the assistant manager told me I had to go back and make nice with the guy. I told him no, that I would not, and further, that if he or any other patient ever tried to hit me again, I would be calling the cops and pressing assault charges, and maybe suing the hospital for making my work environment unsafe. I refused to reenter the room.

I got a note on my review that year that said "Jo is an excellent clinician but needs more work on her relationships with patients."

For all you folks who want to point out that service is part of nursing, and that serving is a holy and higher cause, you go right ahead. I serve every day that I work, from before the time that I punch in to whenever the job is done (whenever that is). Service to my fellow humans, though, does not mean martyrdom or risking personal injury. It certainly doesn't mean putting a patient's satisfaction scores ahead of their health or safety.

If you, Administration, want me to be a good nurse, then let me be a good nurse. Let me educate and comfort and calm. Let me commiserate and be compassionate and do all the things that I was trained to do, including catching med errors and fixing problems. Don't push the patient satisfaction side of the equation so hard that you forget what you hired me to be: the first, last, and best guardian of my patient's health and safety. Don't confuse happy people with good outcomes.

And for God's sake, and the sake of your patients, don't push my profession into waitress/hostess mode so hard that we all forget what nurses are here for.