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.


Pollyanna said...

How is it safe for a doc to ream you just for calling the wrong service? You should be writing him up for talking to you like that. It's completely inappropriate in a professional setting to not use common courtesy to talk to your colleagues. Instead, he treated you like a wayward inferior. This may make nurses slower to call him in the future -- maybe it will only be a deep breath before you dial the phone, but it can make a difference. You made a mistake, but he truly fucked up.

jimbo26 said...

A thousand ( or so ) thumbs up to you Jo . ( Keep slurping the ice cream ) .

Anonymous said...

Jo, I'm an ED nurse, so I don't play nicely up on the floors or unit. But for the life of me, I cannot see how the scenario you described is in any way safe for anyone, especially with critical patients, blood hanging, and a 1:1 suicidal dude. Protect your license and have your nurses do the same.

clairesmum said...

Yikes! So much crap!
Covering 2 units on different levels of the building is not a safe plan, IMHO. Don't know what rationale manglement is using to justify this idea, but I bet their malpractice carrier and JCAHO won't buy it!
At the very least you need more nurses on each unit to cover them..
Stay safe out there, Jo.

Oldfoolrn said...

We used to call non sense like this "vertical coverage." There were no happy endings here. After several disasters risk management put a halt to it. There actually was a hospital nearby in State College, PA that had anesthetists running up and down stairs covering ORs on 2 floors. It did not last long. Plaintiff's attorney's just loved vertical coverage. It was tough to defend.

Unknown said...

Buck up!

cowango said...

Yeah, well I see so many things wrong with your scenario that it makes me see double. WTF. Why do they have 2 separate units in a vertical configuration under one charge? This is insane. But you already know that. I would have been screaming bloody murder to clinical house and registration about them assigning an actively psychotic pt to your unit. I don't care about a thyroid storm, a med/surg unit is no place for him. Poor baby psychiatrist had to field a call from you, the over-stressed charge nurse. Poor, poor pitiful her! What a day she must have been having, pushing pts away from her as fast as she could.

Hope your week improves.

Dr. Alice said...

What the what. I see patients (outpatients) with TSH of 15 or more fairly often, as it is not unusual for patients to stop their thyroid medication. They can be treated as outpatients, it's not a big deal. Also, thyroid storm is due to OVERactive thyroid, not UNDERactive.

That psychiatrist should be spanked. And you should be given a raise. Best of luck.

woolywoman said...

You need to unionize. ICU patients are 2 to 1 in California. Vertical coverage is a disaster waiting to happen. Omg.

salsabike said...

Thinking about you and hoping you made your way past this okay.