Hospitals need to start working smarter, not harder

One thing I have learned about healthcare in the U.S. is that in general, medical management of disease is fragmented, inconsistent, and frequently ineffective. Some of it is due to noncompliance, but I believe more of it is due to an incomplete picture of a patient's medical history- and with the technology we have available to us right now, that's a shame. 

For example, say a patient presents to the emergency department with severe abdominal pain, fever, vomiting, diarrhea, electrolytes off, etc. There could be dozens of explanations for these symptoms. Labs are done, vitals obtained, current meds reviewed, allergies verified/documented, scans performed, possibly a lumbar puncture done. The Dr. has a verbal medical history, likely from the patient (who isn't feeling well), or from a family member who may or may not have been very involved with the pt's care over the past 30 years. The length of stay and positive outcome for the patient hinges on an accurate diagnosis and, in many cases, that diagnosis comes from a lot of what boils down to detective work.

What if, instead a patient presents to emergency with the same set of symptoms, but an electronic health record is available on the patient. A list of specialists the patient has seen for various issues over the years is attached. Various labs drawn over the past 10-20 years are seen so not only a baseline can be seen but trends can also be seen, graphed and visualized. New data (vitals, labs, tests) obtained from this visit is added to the patient's health record as well as a current list of meds from the pt's last Dr. visit.  A computer program begins taking all this new data compares it with old data, and begins suggesting possible diagnoses based on an algorithm.  New tests are suggested by the program to narrow down the possible causes further. While at first glance, it seems like the computer is doing what the brain of a physician would be doing while trying to diagnose, it's really used more as a tool since the program is only as good as the information put into it, plus there's really no replacement for a good old fashioned  physical assessment in a lot of cases.

Right now, there is a HUGE disconnect when patients see more than one specialist and the family Dr./health care provider isn't kept up to date on that pts condition.  To further complicate matters, now imagine what it must be like for the internal medicine Dr. to try and pull all those disciplines together and come up with a plan of care for the patient whose drs probably are not communicating with one another.  Very VERY frequently "the left hand doesn't know what the right hand is doing"- and there is no excuse for that in today's world with the technology we currently have available. 

It's funny how before I worked in a hospital, I thought a lot of this stuff was already in place. It's logical, isn't it?  Come on, America, we can do better!

DON'T... TELL... *ANYONE*!!!

I curse more than I should.  I laugh at inappropriate things. I think Honey Boo Boo Child is frickin hilarious. I drink to unwind. I like to smoke an occasional cigar. I rock stiletto heels and a low cut dress. I have fabulous friends who are incredibly with it and cool. By all rights, I'm a god damn Paris Hilton with a syringe in my hand. (well, my boobs are better)

My secret?

I'm a nerd.  I read research articles for fun. I read about advances in nursing care, medicine, customer service, business, and the relatively new field of pharmacogenomics. And if there's one thing I love more than reading about all those things, it is talking about it. This isn't new.  In high school, everyone called me the female Cliff Claven.  That hasn't really changed about me.  Maybe that's why I like being a nurse so much.  I have my own captive audience (trapped in a room with me, no less!! :) ) who generally hangs on my every word --and takes it as gospel! haha!

I could stay cooped up all day for weeks and as long as I have a soft chair under my ass and a good book in my hands and/or an internet connection, I'm happy. I do like to hit the party scene once in a while and catch up with friends, but it's a very infrequent thing.  Primarily, I'm an unsocial little bookworm with a penchant for the written word.

Which is why tomorrow, I embark on a new adventure.. tomorrow, I begin the next step in my academic journey.  Tomorrow, I start classes for my RN to MSN bridge program for a Master's in Nurse Administration.

Don't tell ANYONE, but... I'm kinda excited. ;)

My new fave Doc and the "Curse of Dr. Smartass"

There was a standout resident when I was at my first hospital of employment.  Very personable, unpretentious, smart as a whip, and fabulous with the patients. He's now one of our internal medicine docs!! I can't tell you how much we all enjoyed working with him this weekend and how happy the patients were with him.  Oddly enough, he was in the same class as Dr. Super Shitty. LOL

I love listening to him talk to patients. He actually communicates with them more like a nurse than a doc. An example of Dr. Awesome's patient interactions goes like this: "Wow, that sounds really painful, I'm so sorry you are feeling like that. :( How about we try xyz to help with that and if that doesn't work, we have a few other tricks up our sleeves.  Don't you worry- we see this a lot, you will be feeling better very soon.  I promise."  What a joy having him with us and what a stark contrast to his former classmate.  lol!!

In other news, had one of the most difficult patients ever over the weekend. She's a frequent flyer, has been in and out of our hospital every few weeks for several weeks at a time since March.  She has a laundry list of issues, but her biggest issue is that she tortures the staff.  Even worse, she was an RN in a major city hospital in a trauma unit and she is extremely intelligent (has a PhD in nursing) and she's also incredibly demanding. Going into her room is a 45 minute minimum visit.  Plus, she's on contact precautions for VRE in urine, she uses the bed pan (frequently), and she gets 18 pills at 9 am (I'm not exaggerating), plus q8 hr IV antibiotics, q4 hour IV narcotics (supposed to be prn (as needed) but are basically atc (around the clock) ).  She's part Gargoyle (sits indian style perched in the center of her bed surrounded by pillows), part Drill Sargent part Drama Queen. 

Her story is she was exposed to an exotic bird about 10 years ago and contracted a severe illness from a virus that becomes airborne once excreted from the bird. (I am not putting the name of it on here in case someone who knows her googles the virus and sees my blog).  Anyway, she wasn't feeling well for a while.  Saw Dr. after Dr. finally after a few months a Dr. told her to tell him EVERYTHING she did for the past few months.. she mentioned the bird and he ran some tests and it turns out she had it- and several other people she knew were also exposed.  She is on long term steroid therapy due to adrenal insufficiency, asthma, insulin dependent diabetes, unbelievably high blood pressures- even with a slew of BP meds, non healing wounds, spontaneous hematomas, chronic constipation (oh how I love manually disempacting people just prior to a fleets enema- two days in a row) brittle bones that can break from just looking at them (side effect of long term steroid use),  a severely compromised immune system and she gets I   G   G therapy monthly which costs over ten thousand dollars per treatment (Medicare is kind enough to foot the bill for that), I'm sure I'm forgetting a lot, but you get the picture.She'd actually be a great person to give to a nursing student because she loves to talk and teach and because she's extremely complex and understands her specific disease processes very well and enjoys talking about them and answering questions about them.   Most of all she'd be a great nursing student case because it would weed out those students  who can't cut it in nursing pretty fucking quick. 

Here's what it's like taking care of her.

me:  *walk up to her door, begin donning gloves and putting on gown*

Gargoyle Lady: *in sarcastic tone* "Oh, it's time for the pharmacy, again."

me: "it sure is! how are-

GL: "pleasse get this wrinkle out from under my butt.. move this pillow from under my leg, no not like that.. PLEASE just move it UP"

me: "Oh you mean back-

GL: "Yes, UP just like that"

me: "ok, let's get these pills started" *scan wristband* "name and date of birth, please?"

GL: "Gargoyle Lady 666... these pillows aren't right.  I need you to stand them up straight-ohhh my back ohhh my God I can't stand it!!"

me: *move pillows from horizontal to vertical*

GL: *condescendingly* "Nooooooooooooo not like that" *motioning hands vertically* "like THIS" *motioning horizontally*

me: *turning pillows back how they were*

GL: "now stand them up"

me: "so you want me to fluff them a bit?" *fluffing pillows*

GL: "no, I want you to stand them up, yes, just like that."

me: *start scanning pills.  Get about 5 done*

GL: "When you get a minute, I need a box of tissues"

me: "ok" *scanning pills 6 through 8*

GL: 'While you are in here, can you tell me what my hemoglobin was and what my blood pressure as at 3 am when they rechecked it after the IV labetalol?" 

me: "sure, as soon as I'm done scanning these.." *scanning pills 8-10.. 'damn, the prednisone still isn't entered into the pharmacy system, have to manually admin this one in' phone rings.. aide calling to tell me she can't hear the BP in my dialysis patient, I need to recheck it manually.. tell her 'I will go in there next..' scan pill 11*

GL: "ooohhhh I think I need to have a BM .. GET THE BEDPAN.."

me: *put down pills go into bathroom, get bedpan*

GL: "ah that's it.. I sure have a headache I wonder what my blood pressure is right now.  You know you have to check it before you give me my labetalol.."

me: "the aide just checked it 30 minutes ago.."

GL: "It could have dropped too low for me to take it... oooooooooooohhh the pain ah ah!! The bm is RIGHT THERE  please help me get it out!!"

me: "I have to get some lubricant"

GL: "OH PLEASE PLEASE HURRY! AAAHHHHH"

me: *remove gown, remove gloves, wash hands go to supply closet down the hall, get lube, get her tissues she asked for. put items inside doorway of room -

G: "OOOOHHH AAAAHHH OOOOH IT HURTS HURRY HURRY"

me: *cheerily* "okay.. getting gowned up!" *use hand sanitizer, put on gown, put on gloves, put on another set of gloves (crucial step when shithole spelunking)  tie gown, take 2 steps toward bed-

GL: *flatly* "I think I got it" *pulls brown finger out of her own rectum

me: * 'well, that will go well with her breakfast seeing as how she can't walk to a sink to wash her hands'*

GL: "ohh OHHHH there's MORE!! Please help me!!"

me: *squirt lube on double gloved index finger, start coaxing out poo balls*

GL: "aaahhhh AAAAAAA ohhhh DIG DEEEPER! It's right there!"

I will spare you the rest of the story.  Now, imagine 24 hours of weekend spent just like that. 

Oh,  so the Curse of Dr. Smartass?  One day while 3 nurses were chit chatting with Dr. Smartass (actually he was the Dr. that came to talk to the guy with the trach who was driving me crazy two years ago.. I posted about it here: http://codebabe.blogspot.com/2010/07/best-of-best-and-worst-of-worst.html)  about Gargoyle Lady he said (jokingly):

"That's because she was a nurse.  All you nurses end up like that."   

To which my jaw dropped with a combination of disbelief and despise said in a low tone, but quite distinctly 'youuu fucker.."    The combination of his saying that and my F bomb in response pretty much had us all in utter hysterics for about 5 minutes.  Dr. Smartass can be assured, if I do turn into Gargoyle Lady.  I'M ASKING FOR HIM EVERY TIME I GO TO THE HOSPITAL!! lol

How Dr. Shitty always ruins the day: What not to do if you are a hospitalist

My patients are primarily  followed by the the Internal Medicine group with my hospital.  (at my other hospital we had a mix of internal medicine and residents). Sometimes we have a PCP doc with hospital privileges (they ROCK, by the way.  The patients love them and the nurses do too.)

Enter Dr. Super Shitty. King of All that is Wrong with Internal Medicine Doctorin' ™.  When I work with him, I basically hum "I'm an asshole" by Dennis Leary the entire day. (usually something reserved for my husband when he pisses me off, so you know this doc has some serious talent)

What could Dr. Super Shitty possibly do that is so annoying?  Let's see...

1. Rounding on all the patients (usually about 20) between 8-9:30 and telling at least half of them they are getting discharged. Except, he has no intention of even starting any of the med recs or paperwork until after he takes his lunch hour at 1 pm.  Then, while the RNs are doing their 9 am med passes, we are greeted with patients in the process of taking off their telemetry, asking to have their IV sites taken out and wearing their damn street clothes.  Then they get pissed off when you break it to them that nobody goes home until after lunch because that's when the paperwork should be done.

2.  Except, Dr. Super Shitty does NOT start the paper work as promised at 2 pm for those patients, oh no.  You see, he is busy ignoring requests for things like pain meds for people admitted with intractable pain and requests for an order for kayexalate for a patient with a K of 5.2.  Because we really LOVE giving that to people anyway.  Oh, and the order a few hours later to send c diff stool sample on the same patient?  Brilliant.  (and I understand everyone has bad days when things don't happen in a timely manner but this is ALL. THE. TIME.  every time he works. It's at the point now where as soon as I see he is assigned to our floor, I want to turn around and punch out as soon as I clock in) As a result, close to a dozen patients are furious at 5 pm when they finally are ready to go home.

3.  Super shitty also is terrible about communicating with family members- I spend my whole day talking to families about matters I know nothing about and playing case manager too (they are typically on call on weekends). He also refuses to obtain DNR orders from a patient who has a copy of a living will and verbally tells the nursing staff that you don't want to be resuscitated int he event of a code.  The form is flagged on the chart-- all Dr. super shitty needs to do is have the already willing to sign patient sign.. but there the form sits.  All day.
which leads to...
oh yes.
Doesn't the patient code.
And don't we have to initiate CPR.

Thank GOD her cardiologist showed up and said "She does NOT want that! We have spoken at length about this just today. She said she was going to ask the IM doc for the form since he had the chart.. *flipping papers* Why wasn't this signed?!" * flipping more* .. she has severe arthritis and was unable to sign her general consent..  Code babe, you were in the room with me for the conversation, will you witness this?  I'm signing this form as patient unable to sign."  I witnessed it, of course.  I also witnessed a woman's last few minutes of bone cracking chest compressions she didn't even WANT.

The only people I feel worse for than the RNs and the patients on our floor, it's the other internal medicine docs who have to listen to his signoff and then clean up all his messes and put out all the fires he causes. It's a similar thing with RNs.. there are some nurses that habitually don't check labs, always forget to tell you important things and leave you with IV sites that are blown.

So, in sum.  Please, if you work in a hospital, don't do shit like that.  kthxbye