Not when I'm swimming...jeez

Pulling out my Dr.A stories today....

Another elderly pt of his was failing. I consulted with my coworkers, and called the pts Dr. He didn't care..."there's not much we can do, it's what we expected."

Okay fine, fair enough, we knew one day this would happen.

Again, consult with my coworkers, decide to call back to get orders for pain relief and to make breathing easier.

Dr.A: "How did you get this number?" (It's on the list at the nursing station)
"Well I'm still swimming" (in my head: dont answer if you dont want to talk on the phone)
(Ask for orders) "No, I don't think so"
"I'll be there in an hour or two. Don't call me again."

So, this was quite upsetting, the most I had ever been at work. Told Dr. on call as I thought we would have a code on our hands as of course the level of care was not signed by Dr.A. (even though we knew the pt would die soon??)

Dr. on call said I could file a complaint, and I fully planned too. Unfortunately the day totally got away on me and now I am sure it's too late.

"I

Dr. vs. Dr.

Good thing there are some Dr's willing to change the plan of care on others Dr's pts.

Back to Dr.A and his elderly pt with the harsh cough and a set of lungs filled with gurgles and crackles and wetness. (Not normal)

Dr.A 'assesses' pt, writes "chest clear" (? Dr.A actually listening to chest)

Later Dr on call orders xray, which shows plueral effusion, and thankfully starts antibiotics. Pts chest remains full of adventitia.

This lasts a week or so and it becomes obvious pt is not going to be with us much longer. Dr.A, paged twiced, does not answer. Dr on call again to the rescue to order pain medication and talk with next of kin about Level of Care. Thankfully Dr on call did this so we would not have to perform CPR on this frail and elderly lady when she passed about 12 hours later.

Try some water

When it comes to palliative care, there is generally a standard of care, a path that each patient follows. The patient shows X sign, we do X intervention...so on and so forth, it is pretty basic.

Or it is unless you are a patient of Dr.A. Then it all changes. In Dr.A's opinion you likely aren't even dying. In your chart under Dr's Progress Notes will likely be written "Pt improving. More responsive today." The day Dr.A writes this the nurses will have noticed and reported to Dr.A that you are no longer opening your eyes and still do not have a gag reflex.

To this Dr.A will say "Try giving pt more water." When nursing staff object as the pt is not swallowing, Dr.A will reply "It will take a lot of water to kill the pt."

And the nursing staff all gasps and is horrified...news of the new order spreads.

The consensus is "it's not going to be me who tries giving him water...I'm not going to kill him."

Thank goodness nurses have minds of their own and do not follow Dr's orders to a T.

Protect and Serve?

Whenever we get informed that the police are bringing a patient in to Emergency I get scared. Scared for the patient, and scared for what I might see. Sounds strange. However, I wonder how bad this patient will get beat up while in the hospital, beat up by the police. You must be thinking, what do you mean? and don't they get sued? No, I don't think they get sued, and yes I have seen patients beat upon by cops (and by doctors, but more on this later). I have seen it often enough that I thought it was a normal occurance all the nurses knew about. None of them have ever said anything to stop it, or that it wasn't right, and as a new nurse I just thought that's the way it went.

The first time, a skinny little guy, smaller than me, comes in escorted by two cops. He is kind of loud, but drunk, and using the 'f' word, just in general, not directed at anyone. Well, after warning him to stop swearing the cops literally slam this skinny little guy to the ground. The sound was heard across the atrium of the hospital. Being a year ago the details are a bit fuzzy, but he continues swearing, they continue twisiting his arms behind his back, pushing his head to the side against the ground and other such things.

There was one other similar incident.

But the icing on the cake is when one of the Dr.'s got involved, Dr.P. Another patient gets brought in after falling down some stairs. Drunk and maybe on drugs. Really loud, rude and threatening, but still he is handcuffed. He is also basically taking his turn beating himself up - throwing himself off the bed onto the floor, throwing his head against the floor and walls, once so hard he knocked himself out - the worst sound in the world. This night there was a good cop/bad cop situation happening. Good cop and I almost at one point settled him, well, until he knocked himself out. However, bad cop would come along and antagonize the patient, talking loudly in his face, getting him riled up, and once the patient got louder, twisting his head to the side, pushing him into the bed, doing his cuffs up tighter. Horrible how they always make the situation worse. And the Dr.P sure lost his cool that night. At one point threw a cup of water in the patients face (like that ever works to calm someone), and after getting spit on (haha jerk) grabbing the patient by the face, the cheeks, and pushing him around that way.

Honestly, I think if these patients weren't usually drunk and high they could likely remember more about the night, and have a good case to take against the cops. And sometimes doctors.

in addition

Also stemming from my conversation with DrP about the pt with the infected ovaries....I asked if she should be started on antibiotics, as it made sense to me and some of my coworkers had also been wondering the same thing all day. So I ask, and he orders two antibiotics. The next day I hear DrP talking to the patient and say well the nurse asked me about antibiotics so I ordered them to make her happy. Jeez, really. That sure made my day! Not! As a doctor you take the information the nurses give you about the patient as we are there 8-12 hours/day, you listen to our concerns and questions, and then you make a Medical decision. I should hope you are not so unthinking, and put off by nurses that you just agree with whatever we say or ask. It is okay with me if you disagree, tell me your plan for treatment, and maybe if you want to be nice tell me your rationale so I can learn too. You won't help me by just doing anything I suggest, its okay to have different opinions, and I am still trying to learn all the course of treatment for all the different ailments out there. And don't blame the nurse in front of the patients for what is ultimately your decision. We are supposed to be a team, be partners. We are each supposed to use our brains and our educations to make the best decisions we know how to provide our patients with the best care.

shh....dont say anything

The other day I had a few conversations. The first was with a coworker, who agreed with myself and others that a pt with infected ovaries and uterine cysts, as seen by ultrasound & CT should be seen by a surgeon in the city. The second was with that pts doctor who when I asked if we were going to send the pt to a gynecologist, or for surgery in the city by a gyne surgeon briskly and close to rudely told me 'No,' finalizing that our older, rural surgeon was good enough for someone who might have real gyne problems. The third conversation was again with a coworker, who although agreed that our sugron might kill the pt, and that he might in fact be a sociopath, as floor nurses we basically cannot say anything to our patients that might hint at or encourage them to seek a second opinion. For if we did, it would likely come around to us, and our jobs would then become 'hell', as made by the surgeon. Even as a group it would be hard to speak up against this failing surgeon, we are not the OR nurses, and only hear second hand what happens in the OR, and see some patients come back from surgery sicker than when they left. I had looked into how to report a Dr for the wet floor sign incident but the patients family has to be made aware, as does the patient (if they are still alive) and you have to witness the incident first hand. Which is hard to do as floor nurses. My coworker also said that as floor nurses we arent the best ones who know the most about surgeries. Basically, for this older surgeons practices to be brought to the authorities it would have to be his peers doing it - the other doctors that go in the OR and even the OR nurses. And although I have heard other Drs complain about the surgeon, it doesnt seem as anything is happening. Patients with cancer have been opened up, and then closed, left to die without intervention. Tumors have been 'completely removed' and problems denied by the surgeon, only for the patient a year later to get to another Dr, and find it wasnt all removed, and a year of treatment had been denied for what, pride, ego? Surgeries that take an hour in the city have taken four or even eight. An artery cut accidentally. But, as these are only a combination of stories and second hand experiences, I cant say too much, it is just some of what I have seen and heard in my three years here. And to be honest I wouldnt be suprised if when and if I ever get enough information to speak up my job is negatively effected. Likely from my peers and doctors belonging to this old boys club not saying anything against the surgeon, and from the surgeon himself - he can be difficult to work with as is if he doesn't like you.

things that make me mad and stressed at work

The list:

going to work to find I have 10 pts, 2 of them in ICU. and then finding the other nurse only has 7, but thats okay cause 'she will help me' yeah right, if I ever see her. way to stick the most critical patients with the nurse with the least experience. thanks.

going to work to find I have 6 pts, but two are coming back from calgary my shift, post MI. and still no one cares that I feel overwhelmed.

dealing with DR.T. the quickest disappearing, hardest to find, poorest penmanship dr. esp. when he is on call.

newborn babies that dont eat for 16+ hours. please maintain your bloodsugar little baby.

coworkers who are 'helpful' by checking on my patients, finding out they need something, then passing it on to me instead of doing something about it. if you have enough time to 'peek in' on my patients, you have enough time to give them their prn med. otherwise let me see them when I have time.

coworkers who get all worked up when pts orders are changed to their dissatisfaction - if its not your patient today, and you havent been here, give it a rest.

having to go through and delete 20+ 'notice of downtime' emails in a week. if the internet is down, I'll figure it out when I go to use it. and then the equal amount of 'internet is working' emails. Duh.

policies and procedures from 1990. how is this uptodate and best practice?