Wednesday, August 31, 2016

Worst day, or worst day ever?

So we have this new thing at Sunnydale: the nurses from the neurocritical care unit charge for both the NCCU and an overflow surgical/med-surg/ortho unit on a different floor.

Right now we have our usual nine beds in NCCU and eleven beds on the other floor. (I'll call it "ortho," because it's mostly post-op and pre-op orthopedic cases, but there are important exceptions, one detailed below.) Once the NCCU expands to include epilepsy patients and an epilepsy monitoring unit, we'll have a total of twenty-six rooms to charge: thirteen on each floor, with the possibility of two of those rooms on each floor being double-occupancy. That's thirty patients, give or take.

On two different floors.

Yesterday I got saddled with charging both units. Tiny Dancer and Diamond Bright were on the CCU side, and Bender and Kali were on the ortho side. Thank God for good assignments: ortho was staffed with two experienced nurses, and Tiny Dancer, though she's new, is totally unflappable. She moves through life with her head held high, her posture perfect, and her hands and feet moving at a million miles an hour, if need be.

Halfway through the day I had two critically ill patients on the ortho unit, three different patients who needed blood (no overlap there), a very sick person on the neuro floor, two interns, no nurse aides, and no prospect of lunch. Did I mention that these two units are on different floors? As in, I have to ride the damn elevator to get from one to another?

I did? Okay. Just wanted to make that clear.

At about two o'clock, just as my blood sugar was tanking, I made a major mistake.

We were about to get a patient who was in the middle of a no-kidding psychotic break. His family had found him, two nights ago, wandering naked around the neighborhood, talking about death and God and angels, and had brought him to the ED--from where he'd been discharged and sent home with instructions to present to the psych clinic the next day. The next day he was no better, and was possibly worse, talking about going home to God and taking his kids with him. He still hadn't been able to keep his pants on. This guy was badly off and getting worse.

Obviously, he hadn't taken his meds in about ten days. Part of the problem was that he had had his thyroid and parathyroids removed about a decade ago, and had been well-maintained on replacement therapy until ten days ago, when he stopped taking everything in pill form. His TSH was 15. Because he had no thyroid. And no meds.

So psychiatry, rather than admitting him to one of the medical beds in the psych unit, decided he needed a bed on a med/surg floor. . . and sent him to us.

Suicidal, on an OPC, unwilling to let anyone touch him, combative, hallucinating, unable to settle to reality, on a med/surg floor. With only two nurses, no aide, and eleven patients (I took the eleventh patient, an unstable post-op, because nobody else could).

So, anyway: the mistake. I called the psych doc on call rather than the hospitalist on call, because we didn't have an accepting hospitalist yet. I wanted to ask a couple of questions, like "Is this patient appropriate for a general med/surg floor?" and "Are you sure you don't want to admit him to the psych unit?"

I called the wrong person. I should've called the hospitalist, even though one wasn't yet assigned. This was explained to me at length and in the most insulting, condescending way I have ever encountered, by the psych doc.

Here's how you respond if somebody fucks up: "That patient is going to be admitted under Dr. X's service, so you'd best call Dr. X's on-call for that question." In that situation, I would apologize and get off the horn asap, then call Dr. X's resident.

Here's how the psych doc responded: "I don't think it's appropriate or professional for you to blah blah blah blah wasting my time blah blah blah well you know thyroid storm can cause blah blah blah blah blah blah ad infinitum ad nauseum so very unprofessional of you blah blah blah if you really knew how to care for these patients you would realize blah blah blah. . ."

I finally broke in and said, "You know what? You're right. I was totally unprofessional and inappropriate, and I am so very, very sorry for wasting your time." I then hung up the phone, gently, and will probably get written up anyhow.

All I can go by is what the admissions folks and the computer tell me. You're listed as the admitting doc; nobody's bothered to let anybody else know that you've handed off your patient to a different service. What could've been a thirty-second conversation turned into a five-minute harangue.

Maybe she was having a bad day. I know I was by that point.

My boss walked in to the break room and found me crying tears of rage. She was completely un-fazed and asked me why I was upset. I told her I missed my teenaged flattop and bicycle chain and Doc Martens; that, if I'd had them, I would've gone and curb-stomped that cunt. She didn't even blink.

I love my boss. At that point I flat-out worshipped her.

So, yeah. That was my day. My legs are screaming from running up and down stairs (elevators are slow in our building), I'm incredibly proud of Tiny Dancer and Diamond Bright for handling tricky, delicate people without incident, and I wish I'd had a quart of ice cream last night.

Monday, August 01, 2016

Minor corrections.

It is "welt," not "whelp." A welt is something you get on your skin. A whelp is a newborn puppy. If you tell me your patient gets covered with whelps when they take penicillin, I will be momentarily charmed by that mental image. I might miss what you say next.

It's "stent," not "stint." I don't want you to stint somebody's heart, as that means that you've given that organ less than it deserves. You can stent it, however, in order to improve blood flow and muscular function.

It is pronounced "lairINKS," not "lairNICKS." Likewise, it's NUClear medicine, not NUCUlar medicine. I can forgive G.W. Bush everything except this perversion of pronunciation.

I know that "menstrual" is a difficult word. Men-stroo-al. It requires that you do the difficult "str" move with your mouth. It's not "mensurral" or "mensril" or "mensrahl," however. Men. Strew. Uhl.

(Also, while we're on the subject of things that sound like other things, I am Ms. Miz. Rhymes with "his." That should make it easier.) (If you really have a hard time with "Ms.," might I suggest "The Great And Terrible Jo, Ruler of the Five Kingdoms, Holder of the Shadow Proclamation, Destroyer of Worlds, Boss of All of You" as an alternative?)(You'd have to prostrate--not prostate--yourself.)

(Do I really need to mention that it's not a prostrate gland? I don't know of a single gland that lies down on its face.)

It's really, really important to know the difference between micrograms and milligrams. If you tell me you gave somebody twenty-five milligrams of a drug that's normally dosed in micrograms, I will assume one of two things: either that you're a large animal veterinarian or that you're a dope.

Likewise, the difference between liters and milliliters is kind of important. Please don't chart that you gave five hundred liters of normal saline to a patient intraoperatively, unless you really, truly did have them floating in a small swimming pool.

If I'm giving you report and I tell you that the patient's t-max is thirty-seven-point-two, don't ask me to convert that to Fahrenheit. You have a converter in your charting program, or on your phone, or via Google. (It's 99F.) You're an ICU nurse. Use your converters.

I should probably make it clear here that I don't mean to rag on civilians. If you're not a medical person, I don't expect you how to pronounce words, or spell them, or even use the correct term. Remember that patient I had who reported a fibroid tuna in her uterus?

I will not laugh, smile, or even rub my upper lip if you're a patient or other civilian and you use the wrong word or say it wrong or don't even know what that widget at the bottom of your whatever is called. You're not supposed to. This is specialized terminology, used by people in a specialized field. It saves time and increases accuracy for us, but it's confusing and discouraging for you.

However, if you're a nurse giving me report, or calling me report, or a doctor, or somebody who's paid to know how to express themselves clearly about a given situation in nursing or medicine, I will quirk one eyebrow up slowly if you use the term "whelp" or "stint." And I'll stare at you.

While I imagine your patient covered with puppies.