Friday, July 31, 2009

Thoughts on things...

Something shocking happened to me this week. Well, not TO me, but sort of. Someone I love very dearly told me a terrible secret. Here's what happened.

Background. Leslie and I used to work together in the same hospital a couple of years ago. She's a surgery resident. The two of us became sort of inseparable. She is a great resident, a mom, a wife, and all around a pretty cool chick. We've been close friends for a few years now, inside and outside of work.

I haven't heard from her much in a couple of months though, save for a few text messages. I knew she was having a rough time with her sister, troubles at home... and some struggles at work so I kind of blew it off. Finally last week after a million attempts we made it out to dinner. She said she had a lot of stuff to tell me.

When we sat down, she said that she was off work for two weeks and didn't know if she was going back. I figured she had maybe decided to quit via using her vacation time or something like that... but then I saw something was wrong. Really wrong.

"I got caught", she said. She looked at me like I should know what she was talking about. I had no idea WHAT she was talking about. Did she have an affair, I wondered? How could you get put on leave from work for that?? When I finally was able to drag it out of her, she admitted that she had been using for three months.

Folks, I couldn't have been more shocked than if she told me she was having alien children. This was Leslie, for god's sake. She was the most straight, together, awesome resident, and a totally devoted mom. She's uber-responsible, and doesn't really show that she's stressed. I never saw her drink more than a glass of wine, I'd usually have to drag her to go to the mall or to dinner, and and far as I knew she had no drug or alcohol history. I could not fathom how this happened. Of course I knew she had been having rough times over the past year or so... but I never imagined it was this bad.

Turns out she'd been taking un-used fentanyl and injecting it a couple times a day at work and at home before bed for a couple of months. Finally, one of her co-residents suspected her, and reported her.

So why am I telling you this? Because if it can happen to Leslie, the most normal, awesome chick in the world... it can happen to anyone. Quickly. Medical professionals have access to drugs that street junkies can only dream of... and stresses just as bad if not worse. She was dealing with so much pressure on every side of her life that something had to give. I think she created this situation by using drugs so that circumstances in her life would change... because she was stuck in something she couldn't get out of.

Thankfully, medical professionals are allowed chances for rehabilitation and depending on the circumstances of the drug use (if they don't harm a patient) can often petition to have their privileges re-instated. But it will be a long process for her.

The moral? Be in tune with your own emotions, and know when you need help. Don't wait until you crack to make a change. All of this isn't worth it. I'm just her friend and couldn't sleep for three days over this... can you imagine how she feels?

I'm not the oldest one!!!

Well, my fears have been put to rest, I'm not the oldest one in my med school class. Someone (I don't know who) is 33. What a fossil :-)

Anyway, today was the first day of orientation, and I swear I have never been so excited/nervous for anything in my life. It was basically just an introduction day... got a t-shirt, met the deans, met some 2nd years, got my clicker (I've never had one before.. they didn't have them when I was in college)... overall everything went well. Funny, I was eating breakfast and the girl sitting across from me was like "Oh my god, you were my TA!".... of my chemistry students had actually managed to graduate from college and get into med school in the time it took me to get accepted. Awesome. That made me feel like a dinosaur... but everything else was great!

Thursday, July 30, 2009

Wired like a Xmas present from the Unibomber

Can't sleep, can''t sleep. Tomorrow is my first day of orientation... going to meet all my future classmates, meet the instructors, see the school.... OH MY GOD!! The facebook page for my class is lit up with all the insomniacs with the same problem.

Some of my friends who've been accepted to med school were like "oh, my acceptance was so anticlimactic" or "the novelty wears off soon". BS ! Since I was accepted almost a year ago I have become increasingly more and more excited. Tonight I am so excited I made chocolate chip cookies to celebrate and was so excited I forgot them in the oven. Ha! My boyfriend just shook his head and suggested that I get it together before I start medical school.

Neck Deep Already

Yesterday I met with my friend and mentor Dr. J, and a 4th year med student. We're starting a project looking at pancreatic tumor cells... which is pretty cool because of several reasons

1) I'm in at the planning phase which means I get my input on the project. I get a say in what type of time commitment this will be, and how much work is involved.

2) Bench research in GI is very hard to come by for a med student. Not that I want to do GI, but if I did.

3) Pancreatic cancer research. Need I say more? Awesome.

Anyway, I'm basically spending my last free day before med school starts writing a protocol. Sweet. Well, that and I got my hair done :)

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Wednesday, July 29, 2009

Nun's Quarters

This is getting so old. I've been making an honest effort not to crash into any furniture over the past two weeks in my band-aid sized apartment... mainly because I don't want to have bruised and battered legs when I have to walk across the stage for White Coat.

This week's score - apartment furniture 15, Ella 0

Tuesday, July 28, 2009

ACOG Revises Labor Induction Guidelines

Midwives are applauding the American College of Obstetricians and Gynecologists (ACOG) latest revision to their labor induction guidelines. The new ACOG practice bulletin recommends avoiding labor induction before week 39 of pregnancy—an improvement over the previous 37-week recommendation.This comes on the heels of more good news: a recent study at Brigham and Women’s Hospital in Boston found

To DO or not to DO

So here's the controversial subject of the hour. MD vs DO. Is one better than the other? The following are my opinion about DO school and the debate...

Here's a refresher: Osteopathic schools grant a D.O. which is a doctorate of osteopathy. Allopathic schools grant the traditional M.D. DO schools are a little newer, and a DO has all the same "doctor powers" as an MD. They can prescribe, treat, do surgery, etc. The cool thing about DO schools is that they teach physical manipulation techniques which are damn awesome. For example, they may learn to treat a condition with physical manipulation of lymph nodes to promote drainage before resorting to an antibiotic. It's like getting regular medical school plus something extra cool.

There are pros and cons to both schools I believe. The pros of DO school seem pretty obvious to me. You get to be part of a pretty progressive community and learn modern techniques in medicine. Unquestionably I think the education is equal if not better, and your skills will be just as strong as any MD program. DO schools are a little less competitive to get into (but probably not for long... they're catching on quickly!)... meaning that you still have to have all the pre-reqs completed and to take the MCAT, but you can get in with less competitive scores.

The cons of going to DO school are basically that you're going to have to work in a world full of dumb-ass MDs that think that you're inferior. And this can really limit you. First you have to consider the specialty that you want to enter. Most DOs train to do family medicine, pediatrics, internal medicine, etc. There are actually DO residency "slots" that you apply for as a DO based on the DO specific board exams. If you want to cross over an train in a traditionally allopathic residency, you'll ALSO have to take the USMLE boards which are for the MDs. This would grant you access to apply for some allopathic spots, which may include some more competitive specialties like anesthesiology, radiology and orthopedics.

All in all it sounds great, right? So you're probably wondering why I didn't just go to DO school instead of spending so many years waiting for an acceptance to an allopathic school. Well, looking back I probably should have just gone to DO school. But here's the reason I didn't. Basically, I didn't think that I had the strength (nor did I want to), spend the rest of my life defending my education and my credentials. Like it or not, there is a huge stigma from the majority (the MDs) towards the minority ( the DOs, the international graduates, the Caribbean grad, the foreign medical students). I figured I'd had a hard enough time getting here, and I didn't want to add to my problems.

Looking back, this was probably naive... but at the time that's what I felt. And since I'd been rejected by allopathic schools, I guess I felt that I had to prove something to myself by making it. Whatever. I definitely could have saved myself a lot of time and heartache if I'd been a little less proud. Because truthfully, I know a lot of MDs who wish they were DOs, but I don't know any DOs who wish they were MDs.

Sunday Night

My boyfriend and I went to have dinner with his co-worker Greg at a cute little quaint restaurant across the lake. Greg is also kind of his boss for the time being... and it was my first time meeting him. Greg turned out to be a pretty awesome guy. Full of med school advice and he even bought us dinner as a "celebration" since I'm starting medical school next week.

Best part of the night? He asked me when my white coat ceremony was, and then told my boyfriend he could have the whole day off!!! Yay! Now everything will be great!

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Sunday, July 26, 2009

White Coat Ceremony

I've waited for this for so long! Years ago, I lived across the street from the Boston University Medical School, and I could see their White Coat ceremony from my window. For those unfamiliar, the White Coat ceremony is a formal ceremony where each incoming medical student is presented with his or her first white physician's coat. It's the short waist-length coat to designate that the person is a student. You can wear the hip-length coat after you graduate from medical school. I have dreamed of my own ceremony for so long. And it's almost here!

Of course my parents are coming... but my boyfriend has to work. Damn residency. Hopefully he can talk his way into being able to come. And we're going out for lunch after the ceremony to the most fabulous restaurant in the city. You know how some high-profile restaurants are simply incredibly expensive but a big let-down once you get there? Well, this one is incredibly expensive, but totally worth it. The food is basically sex on a plate. I can't wait.

So my current dilemma (albeit so important) is finding something to wear to my White Coat ceremony. I swear it is apparently the style now to wear only miniskirts... as that is basically all there is in the stores. And since I'm really tall, I can't even "sorta" get away with it. I am on a mission to find a dress in five days.... and I've been to every store in the city. Might have to move on to another city. Crap.

A few stresses...

I guess I haven't mentioned too much about my personal life, but the situation is a little less than perfect.

My boyfriend is a psychiatry resident at the same school I am attending. We bought a house together about a year ago, and have been completely renovating it since then... hoping that we would be done by now. HA HA. Needless to say we are still living in one bedroom, with one bathroom. No kitchen. No space. Definitely no place to study. I do my dishes in the bathtub. It's less than ideal to say the least. And since we are now both officially in school or residency, the prospect of time and money is looking a little dim.

But I do have to say that I love the house. It is over 120 years old, and we are renovating from the ground up. I've designed the floorplan myself, and shopped endlessly for farmhouse sinks, vintage toilets, salvaged chandeliers, beadboard, etc. It's going to be fabulous. Someday.

Nursing Informatics - Innvations LISTEN

Here's a nursing lecture about the LISTEN (Learning Information Seeking and Technology for Evidence Based Nursing Practice. It covers and indepth analysis for the nursing informatics.

  1. LISTEN Learning Information Seeking and Technology for Evidence-based Nursing practice --a nursing education, research & retention grant founded by Health Resources and Services Administration (HRSA)
  2. Our Solution: Informatics for Healthcare
    • Increase information technology (IT)
    • and information literacy (IL) attitudes,
    • knowledge, and skills of nursing students
    Objective Learning Information Seeking and Technology for Evidence-based Nursing practice
  3. Course Description
    • Overview of healthcare information technology and computer science systems to prepare students to effectively and efficiently use technology for the identification, collection, processing, and management of data and information.
    • Exploration of legal, ethical, cultural, economic, and social factors that affect healthcare information technology.
    Learning Information Seeking and Technology for Evidence-based Nursing practice

Five Days Left of Freedom

Today is Sunday and orientation starts on Friday. Looking at the first year schedule, a little nervousness is replacing my excitement. Or maybe it's just nervous excitement.

Anyway, I consider myself incredibly lucky to be at the school I'm at. Somehow, they've received the "progressive" memo and have made conditions highly bearable for medical students. For example, they have restricted the number of hours per day that students spend in lecture... this based on recent studies that students don't absorb and retain material after a certain number of hours in class. How novel. I mean, did it really take a scientific study to prove that students become zombies after 27 hours of lecture? Anyway, I'm happy... because while all my friends are in class from 8:00 am to 5:00 pm every day, I really only have to be there 9:00 am to noon, then 1:00 to 3:00. Some days less, some days more. My school has also implemented a pass/fail system so there is less pressure to compete for grades. Sweet. Not to mention... here's the best part... they stream all the lectures so you can watch them later at your convenience..which makes all classes O-P-T-I-O-N-A-L!!!! Who ever heard of med school where attendance isn't mandatory??? Yay!!!

Saturday, July 25, 2009

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Friday, July 24, 2009

compilation of 90+ videos on technology and media literacy

I have just come across a very cool podcast site which has made an excellent compilation of videos ( mostly youtube) available to anyone as education tools on the topics of technology and media literacy. More than 90 links to videos are freely available and would be excellent additions to education presentations. Kudos to Dr. Alec Couros, a professor of educational technology and media at the Faculty of Education, University of Regina who created EdTech Posse .

Some really GOOD MCAT advice

I suppose that since I took the MCAT 4 times that makes me either the biggest idiot in the world, or an MCAT expert. For the sake of this post, lets go with the latter :) In retrospect, I know that if I'd done the right things I would have done well the first time. But I didn't. So here's what went wrong.

I have always been a student who was a good reader. You can put a huge amount of material in front of me, I could read and know it all quickly. I have also, however, been a poor test-taker. Well, not exactly a poor test-taker... but a poor standardized test-taker. Timed exams give me extreme anxiety. And to avoid the anxiety, I avoided timed tests like the plague while I was studying. I just read read read everything I could. Kaplan, Princton review, ExamKrackers, EVERYTHING. I knew every scrap of material. And after every failed attempt, I went back to the books and read more. I would do lots of questions, but not under timed stress. Of course, I would get most of them correct during practice.

Finally, I wised up and realized that I wasn't lacking in knowledge... but rather I wasn't skilled at the test and my anxiety about it was preventing me from even using my knowledge to answer questions correctly and to finish the test.

I've seen a lot of other students fall into the "but I really don't know this material" trap. IT DOESN"T MATTER. I swear. No matter how much you don't believe it, the answers are almost always in the passage, and what you are required to know yourself is very minimal information.

The best advice I can give you is the following:

1) If you have tons of time (several months), then go ahead and read all the material.

2) If you are down to several weeks, FORGET reading the material. You need to practice full length, timed tests. Buy as many as you can, get them off the internet, synthesize them from practice questions. Time yourself, use real conditions, do as many as possible.

3) This is important. Always go over every answer. Right or wrong. You need to know why you got every single question correct or incorrect. You are actually "studying" during this process. Believe it or not, there is, I SWEAR, a finite amount of material that can be on the MCAT. Scenarios may be different, but there are the same concepts over and over. Correcting your exams thoroughly will make you very familiar with them.

4) You're practice score is very close to what you will get on the real thing. Don't waste your time and money if your practice exams are not close to the score you want.

5) Study courses. Wow. What to say. Here's my thoughts. Overall, I think these courses are gimmicky and not worth the exorbitant price-tag they carry. In fact, I straight out disagree with many strategies they advocate. I think many of them are time-wasters. For example, Kaplan will tell you to first off scan over all your passages and then pick which ones you want to do first. In my opinion that is a huge waste of time. In order to score well you'll have to complete all the passages anyway, may as well tackle them systematically and in order and save yourself a few valuable minutes. But hey, they have to come up with something to sell. I guess these classes are good for people who can't motivate themselves to study, but if you're in that boat you probably won't make it to med school anyway.

I do like their materials however. If you can pay for their online package just for the materials I think it is worth it... but otherwise I really feel it is a waste.

6) If you have severe anxiety, start addressing it. If the problem is that you haven't practiced enough, then practice. If the problem is deeper, then I really suggest being open to the possibility of working with a psychiatrist to see if you have a learning disability or other simple anxiety issues that can be treated with behavior therapy or possibly medicine. Don't dismiss this idea. You might be surprised at what a difference small adjustments (not necessarily with meds) can make in your ability to retain information and to remain calm during an exam.

Ok, that's it for now.

Thursday, July 23, 2009

Denis Walsh, mommy wars, and coming together On Common Ground

Originally published on Science and Sensibility by Amy Romano, CNM, for Lamaze InternationalLast week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate. I was asked to help readers who

Introducing Science and Sensibility

Blogger Amy Romano, CNM, and Lamaze International have graciously agreed to share their posts from Science and Sensibility with Midwife Connection readers. Check back for periodic Science and Sensibility posts that are of interest to midwives and midwifery fans.

Non-traditional Snapshot

I just wanted to say how great it is to have a group of non-traditional pre-med friends who've been with me this whole time. And I can safely say, we have ALL made it to med school. Here's a semi-anon list of the best support group ever! Thanks, you know who you are!

"E" - age 29, female, we got our masters degrees together, and she's one year ahead of me at the same school, stats unknown but she's damn smart

"T" - age 34, male, previous career in the military for years, a lot less than stellar undergrad gpa but made a comeback as a post-bac, got his masters with me, rocked the MCAT with a 36, had to apply twice, is now kicking ass as a 2nd year in Texas.

"J" - age 35, male, married with 1 kiddo, took the scenic route to college graduation, got to experience a few pre-med requirement several times, said he did horrible on the MCAT, but is now in his first year in the Caribbean and loving life and med school. He'll be a great doc one day!

"G" - age 30-ish, applied at least twice, just graduated from dental school in California. Yay!

"K" - 31 year old female, old friend who was a very smart girl but was a marginal undergrad student, got her Masters degree, got published, got a 24 MCAT without studying, and is a second year DO student.

"P" - basically all around a smarty, 32 year old male, previously at Annapolis, a couple Master's degrees, rocked the MCAT and got into a Colorado school.

"S" - we did post-bacc pre-med together at Harvard. I'm not sure how old he is but I'm guessing late 40's maybe older. He had a previous career as an engineer, decided to switch careers after his kids were grown. Got accepted at YALE, but he chose a cheaper school.

Ok, I love you all and none of you can be angry that I put your stats up. I'm HELPING other pre-meds. XO

Moral of the story? You can do it!

A few good things...

Last night I had dinner with one of my girlfriends who is a year ahead of me in the same medical school. She's my inside connection for all things in medical school. In fact, after dinner she presented me with a huge stack of first year books, ALL FOR ME! I was so excited! Those things are damn expensive... all you pre-meds might want to start a piggy bank or something. So big thanks to her, my book bill should be significantly lighter. For those of you who don't know, med school books run upwards of $1000 per semester. Yikes!

Ok, so the point is that she is one of our school's delegates to AMSA (American Medical Student Association). She just got back from a conference where they were of course discussing the nuances of Obama's health plan, as well as the new implementation of the Bush admin's loan repayment system for residents.

A couple of new things:

1. She said residents do in fact have to pay back loans during residency, but the payments are income sensitive... and you won't have to pay above a certain portion of your income regardless of how much you owe. Ok, fair enough.

2. After 10 years in public service, or 20 years working anywhere, along with continuous payments, the balance of your debt is forgiven. The years paid during your residency count towards this. Sweet!

On the Obama Plan:

1. A big part of the Obama plan is about "standardization of care". Meaning that condition X is successfully treated with treatment plan A which works 95% of the time. As a physician, if you choose to do anything other than treatment plan A for condition X, the services will not be paid for.

Ok, this sounds like bunk to me. In this case why do we even need physicians? If we can just standardize patients into little checkboxes, we can just get high school grads as technicians to follow the set protocol. Ridiculous. What about the percentage of people that treatment plan A won't work for? The role of a physician isn't just to treat a patient according to a checklist, but to assess other mitigating circumstances in the patients life... to ensure the treatment will match his condition, his capability, his lifestyle. Oh, boy... don't get me started on this.

2. The Obama plan doesn't allow for pre-existing conditions to exclude patients from coverage. Yay! About time!

But overall, I think many things in the Obama plan have the potential to be good... but physicians really need representation on the things that will negatively impact our decision making.

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Wednesday, July 22, 2009

Clinical Narratives

Clinical Narratives are nurse stories of caring. At St. Joseph Hospital, clinical narratives are submitted to the Clinical Development Council as part of the Clinical Advancement process to move up the ladder from Clinical Nurse II to Clinical Nurse III (CN III) or Clinical Nurse IV (CN IV). As each proficient (CN III) and expert (CN IV) comes before the Clinical Development Council for advancement, they read their narrative aloud and have an opportunity to answer questions. The richness of their stories are shared.
The clinical narratives are also written by New Grads during the New Grad program. These narratives are submitted to the Clinical Development Council anonymously, and as we read them, we identify themes. The themes help to define nursing practice at St. Joseph Hospital. Over the years, the themes identified have opened up dialog and changes in our practice.
The Clinical Nurse IIs (CN II) are asked to write narratives during the months of July and August. The majority of RN’s at St. Joseph Hospital are CN IIs, but we tend to get fewer narratives from the CN IIs. In an attempt to encourage the CN IIs to write their stories, we are trying something new: Clinical Narrative Mentoring sessions. We are hoping that offering encouragement and 1:1 writing assistance will help to bring forth more nurse stories to share. I suppose the motivation to write a narrative is less for the CN IIs than the rest of the nurses, and as a consequence, we are missing hearing the voice of the majority of our wonderful nurses.

AHRQ Evidence-Based Practice Update

The U.S. Preventive Services Task Force, which is part of the Agency for Healthcare Research and Quality, recently posted a report entitled : The U.S. Preventive Services Task Force : An Evidence-Based Prevention Resource for Nurse Practitioners.
According to the abstract "Purpose: To describe the work of the U.S. Preventive Services Task Force and to encourage nurse practitioners (NPs) to use its evidence-based recommendations for clinical preventive services.
Sources: Evidence reports, recommendation statements, and journal articles published under the auspices of the U.S. Preventive Services Task Force since its establishment in 1984.
Conclusions: A core competency for NPs working in primary care is knowledge about and provision of appropriate preventive services for their patients. The U.S. Preventive Services Task Force, an independent panel of experts in prevention and primary care, is an important resource for NPs.
Implications for Practice: NPs can use Task Force recommendations to guide their screening, counseling, and preventive medication decisions. They can also educate patients about the missed prevention opportunities related to underuse of effective services and the potential harms of overuse of inappropriate preventive services.
Keywords: Advanced practice nurse (APN); primary care; prevention, clinical practice guidelines; evidence-based practice.Purpose: To describe the work of the U.S. Preventive Services Task Force and to encourage nurse practitioners (NPs) to use its evidence-based recommendations for clinical preventive services.
Sources: Evidence reports, recommendation statements, and journal articles published under the auspices of the U.S. Preventive Services Task Force since its establishment in 1984.
Conclusions: A core competency for NPs working in primary care is knowledge about and provision of appropriate preventive services for their patients. The U.S. Preventive Services Task Force, an independent panel of experts in prevention and primary care, is an important resource for NPs.
Implications for Practice: NPs can use Task Force recommendations to guide their screening, counseling, and preventive medication decisions. They can also educate patients about the missed prevention opportunities related to underuse of effective services and the potential harms of overuse of inappropriate preventive services."
Trinite T, Loveland-Cherry C, Marion L. U.S. Preventive Services Task Force: An Evidence-based Prevention Resource for Nurse Practitioners. Originally published in Journal of the American Academy of Nurse Practitioners 21(2009):301-306. Agency for Healthcare Research and Quality, Rockville, MD.

Good thing I'm not doing this for the money..

After watching the news in recent weeks, I'm wondering if in ten years I'll look back and say "Well, the week that I started medical school was the week the healthcare system turned to shit". Ok, no really... is anyone else concerned about what is happening with healthcare reform? Yikes.

Now please don't misread what I'm saying. I voted for Obama, and consider myself to be a middle-of-the-roader. I generally identify as a social liberal, fiscal conservative, and part of the democratic party... but if I really loved a Republican candidate I'd vote for him or her.

So as a catch-up to those of who who aren't in touch with the news, President Obama's healthcare plan is on the table, and he's pushing to get it through legislation by the beginning of August. He wants it approved before the congressional annual holiday in August.... essentially so the plan doesn't get stale and forgotten. The three parts of his plan are:

1. Quality, Affordable & Portable Health Coverage For All
2. Modernizing The U.S. Health Care System To Lower Costs & Improve Quality
3. Promoting Prevention & Strengthening Public Health

Now, I'm not a political analyst... so these are just my thoughts. #1 sounds good. Basically Americans who have a plan that works for them get to keep their current plan (generally paid for by their employers). Americans who don't have a plan would be able to receive government healthcare benefits in the form of a plan similar to Medicaid or Medicare. Ok, sounds ok.

Skipping to #3 Promoting prevention and strengthening public health. Seems a little lofty, but overall a nice notion. However, what does this mean in terms of the government? Funding for what? Wellness and public health programs? Now, as someone who has a degree in public health, I am a huge proponent of the ideas that propel public health. But after being part of many large scale public health programs, I have seen such disgustingly huge wastes of resources that I nearly felt ashamed to be part of the program. And yes, folks, they were government sponsored programs. Oddly, I have often found that privately financed programs often fare better and accomplish more. Maybe because there isn't a never-ending governmental scholarship that will fund the program regardless of results. In my opinion, many programs have merit, but many many more are a huge waste. Ultimately prevention is something that must be initiated and maintained on an individual level. But for the sake of this discussion lets just go with it and say that wellness programs are a plus.

Ok, now #2 really makes me nervous. The text sounds like something I would completely agree with. Healthcare needs an over-hall... and by modernizing healthcare so many things could be incredibly efficient. For example, Obama has mentioned electronic medical records. Duh. Should have been implemented years ago. For any of you that have worked at a private hospital with primitive (or none at all) electronic medical records, you'd be shocked to see whats going on over at the VA. Completely electronic medical records, user friendly, readable, you can access the patients entire medical chart. Pure bliss. Now tell me that doesn't save money when you are ordering yet another MRI because the system doesn't show that the patient had one yesterday. $2700 down the drain.

So the part that makes me nervous? What does this mean for physicians. With all the talk out there these days, who knows? The big topic is getting rid of the fee-for-service system. Meaning that a doctor gets paid for what he does. If he orders additional tests, he gets paid more. Which has a bit of circular reasoning to it. You could easily point out that this policy just provides physicians with incentive to order unnecessary tests. Maybe. But the fact is that physicians have a huge burden to shoulder, and that is the threat of litigation. Being sued. For every little thing. It's pretty rare these days to find a physician who hasn't been sued for something. Because American culture is sue-happy, physicians spend more time covering their ass than actually addressing the issues. So maybe the answer is dealing with the threat of litigation. Mayo clinic pays their physicians a flat salary, so that tests are ordered on behalf of the patient, not the doctor's wallet. Some systems have a cap on liability for physicians. This might work.

Maybe getting rid of fee-for-service would be a plus... but what about other aspects? There is some talk of basing physician salaries on patient feedback and health improvement. WHAT??? Now that might sound perfectly reasonable to middle-classers who go to private hospitals and like filling out suggestion cards. But as someone who has worked in community hospitals, inner-city teaching hospitals, and other non-sensical places... this would be the kiss of death. First of all, no one is EVER satisfied in these places. These type of facilities are generally overbooked and understaffed.... and the physicians are always blamed. Not to mention, depending on your specialty, you may have a patient population who in general never gets better. Working in GI, very few of my patients actually "got better". Much of medicine isn't about healing or curing, it's about managing a condition to the best of our capability. Managing hepatic carcinoma, pancreatitis, and Crohns is MUCH different that curing syphilis or pneumonia. And who's responsible for the treatment outcomes of patients who have detrimental lifestyle behaviors? I don't want to be held responsible for the outcome of a patient who is a chronic smoker or who is morbidly obese.

As for my own financial concerns, I really don't care if my future salary is less than what doctors make now. Fee for service, salary, whatever. As long as I can live reasonably. I am concerned, however, about how to pay off my crap-load of educational debt if we are going to start paying physicians significantly less. And what's up with that paying for loans during residency stuff? Can we do away with that please?

Anyway, the point of this post was simply to point out that with all due respect, President Obama, I think your timeline is a little premature.

Tuesday, July 21, 2009

Time for reflecting...

So now that I have a little time off between work and starting medical school, I have been thinking a lot about my situation. I know I've touched on this before, but I have been thinking how HAPPY I am that I did things in this order. Sure there is part of me that hopes I'm not the oldest one in the class (I did see one person who is 29, close but I'm still older)... but really I am overall ok with it. I was daydreaming and wondering if someone gave me a real choice... to give up my house, my travels, my Master's degree, my previous careers, my epidemiology experience, teaching at an inner city school, my dog, my debt, living in Boston, Phoenix, San Diego, Miami, Washington DC, Italy, learning languages, my friends I've met all over the world... Just to be graduated from med school and done with residency by age 30, I can safely say "Hell no!"

I must admit, when I look at my college friends facebook pages and they are already practically done with residency I certainly feel envious. I have friends in ID, medicine, OB, ER, etc. But then I remember that they didn't do all the things I've done... and frankly I'm looking forward to medical school and residency. All of that is over for them.

I'm not going to say that they did it wrong or right... I'm just saying that this way is right for me. I don't think I realized it until I was accepted into med school. Before then, I was so worried about what the hell I would do if I didn't get in that I couldn't even see the benefits of starting medical school "late" in life. I felt so behind. I guess I've always been behind up until this point. I didn't do the right classes in high school so I had to catch up in college. Since I was catching up in college I wasn't prepared for my pre-med classes... it was a big cycle. For the first time I am suddenly "in" the game.... and assuming I do well in medical school I'll be ahead of the game for residency. I'll have my Masters degree, epi experience, research, papers, etc.

In my opinion one of the greatest gifts you have as an older student is perspective. I think by my age you learn not to be bound by what everyone else thinks, and you actually enjoy being the out of the box thinker. I am able to sort through advice and not take anyone's word as gospel, which I don't think I did when I was younger.

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Monday, July 20, 2009

Survivorship Education for Quality Cancer Care

Survivorship Education for Quality Cancer Care
News Release for Participants of SEQCC
Disseminating Survivorship Education to Cancer Settings

Interdisciplinary teams of physicians, nurses, social workers, and other health professionals such as psychologists, radiation technologists, chaplains, and administrators are involved in the multitude of treatment options for cancer patients during the course of their illness. These professionals however are inadequately prepared to meet the follow up needs of cancer survivors.

I recently attended a comprehensive three-day course for interdisciplinary teams from cancer settings on survivorship care. The City of Hope (COH) Comprehensive Cancer Ceneter received a 5-year grant from the National Cancer Institute to conduct this course. The project is led by Marcia Grant, RN, DNSc, FAAN, principal investigator, Betty Ferrell, RN, PhD, FAAN, and Smita Bhatia, MD co-investigators, and Denise Economu, RN, MN, CNS, project director.

I was one of over 2-person teams from 53 institutions competitively selected from cancer settings across the United States to attend this course. The prinicipal goal of the course is to provide interdisciplinary teams with information on survivorship care issues and resources to implement goals aimed at improving survivorship care in their cancer institutions.

The course was conducted by a distinguised faculty of researchers, educators, authors, and leaders in the field of survivorship care. Topic areas targeted the recommendations from the 2006 Institute of Medicine report, "From Cancer Patient to Cancer Survivor-Lost in Transition." State of the Science lectures addressed quality of life decisions and identified areas of need for survivorship care as well as issues related to insurance coverage, developing survivorhsip clinics and quality care issues. Additional questions or information about future courses can be directed to

Thoughts on specialties...

Although I am trying to keep an open mind through out medical school as to which specialty I would like to pursue, I do have a few preferences... which I would like to document on my blog so I can see how I've changed over time.

I must admit, I really want to be an ER physician. Ever since I've had the doctor bug, I've wanted to work in the ED. From watching 1000's of hours of ER and Trauma, Life in the ER, to working in the Beth Israel Deaconess Hospital ER in Boston, and working as a firefighter....I've always seen myself best suited there. My reasons are as follows:

1. Exposure to every kind of pathology, and you aren't just limited to one part of the body. I'm not going to be staring exclusively at eyeballs or vaginas all day long. And you never know what you're going to see. And for those of you thinking "but you'll really just consult everything out", I KNOW... but I still like it.

2. Awesome schedule. Shift work = no call. Plus you can schedule shifts tight together for a few weeks and then have time off for travel or whatever.

3. No patient follow-up. I don't have to continuously tell the same guy to stop smoking, or to lose 20 lbs, or to PLEASE take his damn metformin.

4. Since EM is a relatively "new" residency training program (just for the past 20 or so years), there are fewer 500 year old doctors who stand there and say "we do it this way because that is how its always been done"

5. I don't have to wear dress up clothes. Just throw my scrubs on and save my money for clothes I actually want to buy.

6. I really like the personality of most ED staff I've met. A little more quirky, a little less stoic.

7. I feel that emergency medicine gives me a strong skill set that I can use if I want to work rurally or internationally in under developed countries.

8. I can work abroad for part of the year and moonlight (picking up shifts on the side) at most any ED I want in order to finance my work abroad.

9. You get a lot of procedure-based medicine.... deliveries, extractions, suturing, intubations, etc. Cool.

10. You can consult out anytime there is an "eye" thing. I don't do eyes. Yuck!

I also really like family medicine for some of the same reasons as above. Lots of exposure to medicine, depending on what type of residency program you are in. You don't want to get bumped by the medicine docs all the time.

My mom and my boyfriend want me to be a dermatologist... but I can tell you I didn't come all this way to be a damn dermatologist. I mean, the lifestyle seems ok, but it just seems so damn boring. Hmm. You have a rash. Well THIS looks like a rash. That would be an um... lets see... my best guess would be a rash. Maybe you'd get lucky occasionally and get to excise a mole?

My friend and mentor wants me to do GI, but I really don't think that suits my personality. I thought about ID, since I have a degree in tropical medicine and I do think its incredibly interesting and relevant to working internationally... but ID has essentially no procedure-based component. You basically treat everything with meds.

OB could be cool... but the schedule sucks... and no varied anatomy and pathology... but you get to do surgery... which could be fun.

I really have no opinion on surgery, anesthesiology, radiology, ortho, peds, IM, cardiology, PMNR, urology, etc... so I guess we'll see.

Sunday, July 19, 2009

Shutting down for awhile


I'm going to have to shut this down for awhile. Things are deteriorating very quickly at work and I need to continue to pursue other methods of dealing with it.

I'll hide the blog for awhile until things chill out.


Friday, July 17, 2009

Getting Close...

I'm so excited today... This week my mom was in town and she bought me my first scrubs. Thanks Mom and Dad. So awesome!

Nurses Stand with Obama; Are Midwives Next?

by Dawn Durain, CNM, ACNM Vice PresidentI was trying to find some news coverage on the Sonia Sotomayor hearings on Wednesday afternoon, when suddenly there was President Obama on the White House steps surrounded by women! This being an atypical sight, I quickly unmuted. As it turned out, the people accompanying the president were mostly nurses and members of the Congressional Nursing

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Thursday, July 16, 2009

Maternal Nursing Lecture Presentation

A new updated Maternal Nursing Lecture Presented by an RN, RN, MAN

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Tuesday, July 14, 2009

Robert Wood Johnson Foundation, Institute of Medicine Launch Unprecedented Initiative on the Future of Nursing in America

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Monday, July 13, 2009

Admissions and Transfers: NIGHTMARE

I wrote some bits and pieces about what happens when we get an admission and transfer in and old post.

Let me expand on that even more.

We are taking admissions and transfers when we already have way more patients than we can possibly get around too.

They are arriving on my ward when it is convenient for the sending ward to send them. I get a "ball park figure" for when my new patient(s) may arrive. He may come in 5 minutes or 5 hours. That is all I know. I don't know when they are coming. Therefore I cannot organise my time around my other patients to accommodate the new ones.

But that is a mute point. I cannot organise anything. I am trying to accomplish anything I can in the 30-90 second periods of time I have between interruptions. The entire shift is like this. We may be working our assess off, but we are only ever ever hitting on the very top priority things. We are getting the tip of the iceberg chipped away but nothing else.

The patients have this idea that if the nurse is not at their bedside as and when they want her, that she is not caring for them. They have no idea how much goes on behind the scenes, or behind the nurses station really, to keep their ass safe and alive throughout the duration of my shift.

Admissions are sent unexpectedly at mealtimes, during handover, change of shift, when my MI patient has another heart attack stopping me from getting to the cancer patient with the pain medication she has been crying for during the last hour. Unless you are retarded you will understand that the heart attack patient is first priority in this scenario with 02, ecg's, stat orders and organisation for possible transfer to the coronary care unit etc.

If I skim the surface with heart attack man and do the bare minimum to keep him (and my nursing registration) safe from harm then I can get to the cancer patient needing pain killers in 45 minutes. That is 45 minutes if I ignore the other patients crying out for me. IF I don't ignore them, it will be hours before I get to the cancer patient with her pain killers. Setting up her narcotics, checking them for safety and administering them between all the other interruptions takes another 15 minutes.

Where am I now? Oh yes, the admission. And the other patients crying for help and everything else. I go to the admission, walking past multiple voices begging me for help with everything from getting a drink to getting a commode . My new admission and his daughter look at me sharply. "We have been on this ward for nearly an hour and YOU have not bothered to come and check on my father". The other patients are still crying and I really need to check back on my cancer patient to make sure that she is tolerating the narcotics okay and still breathing. They may not be infusing properly because of a kink in the line and she may weep in agony until I get back to her. They might infuse to fast or be too much and she might die. And I will be blamed. Your grandma and ten other people's lovely grandma's are sat weeping in their own urine right now. Right. Back to my admission and his pissed off daughter.

The admission itself is a lot of work and that right there is the crux of this blog post. When these patients come to us they are a fucking mess secondary to a lovely stay on what I term "the sending ward". These wards are called acute medical admission units, short stay medical units, medical admission units, medical assessment units. It is all the same thing really. From here on in I will refer to these places as sending unit hell, or SUH.

They come to us filthy. They come to us in pain with no prescribed pain medication. They send them up with insulin infusing IV. It was ordered to stop 10 hours ago, 10 hours before they were sent to the ward. But it is still infusing without any dextrose etc. The patient has a BM of 1.5. They come up dehydrated with orders for IV fluids prescribed hours ago, yet not started. No venflon is in place. Half the paper work is missing. Trying to figure out what is going on with these people is a mission in itself which can take a lot of time. When these people come, and they come with no warning, I need to leave my other patients and do a bit of assessing and research. Otherwise all hell breaks loose. Most of them are elderly people, who need someone there at all times to ensure that they are clean, hydrated and that their dignity is maintained. If I spend any more than 30 seconds at a time with any one person then all hell will really break loose and I just won't get to see some people.

Sometimes SUH will handover that the patient had bloods done. They were not done. Or that sando k was started yesterday for a low potassium. It was never ordered or given. Last bloods were 36 hours ago and the potassium was 2.1. If I don't contact the medics and let them know that this stuff is going on then they cannot sort it out and treat the patient. It is the nurses legal responsibility to field this crap. SUH tell us that the patient is for an urgent OGD, and that the test was ordered. It was never ordered. Now I have to chase up a doctor to order this test. The patient has been sitting and waiting for this test, and has been starved. The test department doesn't even know he exists. The medic is overwhelmed and cannot get to the ward to order this test for awhile. But the patient again has a dropping HB. Not good. Lots of phone calls and paperwork to sort this nightmare out. And you can bet your ass that it is indeed my problem, with my ass on the line.

They send patients up with the wrong notes, without wristbands, and dump them in the middle of the ward. They send them up as they are taking their last breaths. They have sent septic patients with a low white cell count secondary to chemo without warning, and the porters have dumped him in a dirty bed that has only recently been vacated and not yet cleaned. They did this while I was down the hall in another patients room hanging blood. It was 10 minutes before I saw. I just had to hang that overdue blood then the hca was going to finish ups and our first mission after that was to clean that room. But they couldn't hold off for 10 minutes. They dumped him. Its not like we have any kind of domestic support.

They send them up with dressings and ulcers but no documentation as to how long they have been present and when the dressings were last changed. It is very doubtful that I will have the dressings I need in stock and pharmacy is closed. If this is a Friday it will be Monday before I get those dressings. They send them up without telling us that they are diabetic, or that they are allergic to wheat.

Why does this happen? The nurses in SUH don't have an easy time of it, by any means.. First of all, they have A&E on the phone every 5 seconds demanding that they move people out NOW. Secondly, there are twits with clipboards and magnets constantly up there ass screaming about targets and getting patients moved NOW. With all that going on, it is very doubtful that they ever see their patients for very long and get to sort things out before transfer to the wards. Targets Targets Targets.

They send up confused and wandering fall risk patients without warning, when I and the other staff are already outnumbered by confused, wandering fall risk patients who need one to one supervision. This is often happening while I am trying to help your gran with her tablets, which will then end up on the floor as I go running to hear what that "thump" was. It is the sound of a body hitting the floor. Third time this shift, same person, and a big fat piece of paperwork for me. Those have to be filled in whenever someone falls. No, I do not leave them unsupervised because I want them to fall. You are crazy for even suggesting that.

Then send up violent alcohol detox patients, before I even get the the falling and sick ones. The families come onto the wards with the new admissions and demand to speak to the receiving nurse the second the patient arrives onto the ward. But I am in the middle of a 100 things and people are dying and they are falling and they are shouting out. The family member makes a snotty comment about how "that nurse cannot be bothered speaking to us because gran is old, and they don't care about old people".

The powers that be tell the ward nurses to stop complaining about the screwed up transfers that we are getting. "They have done all the admissions work in SUH, you only need to settle the patients onto the ward".

Um Right.

The Retired Nurse

I love this one.

Once upon a time I got an admission. This lady was technically elderly but was very youthful in looks and manner and as sharp as a knife. She is a nurse and worked on my ward about twenty something years ago as a staff nurse. I think she retired in the 80's. I think she was pretty old then.

"Over there in that side ward we had the cardiac arrest from Hades" "You see that closet over there, they used to have 2 patients in there and once we got stuck behind equipment".

This woman was great. We didn't want her to leave the place. She kept us laughing with her stories about things that happened years ago.

She seemed very concerned about Nurse Anne and her colleagues...

"Why are you not taking meal breaks, they used to prepare meals for the staff"

"Why do they not launder your uniforms or provide changing areas?"

"Where's the staff?"

"Why do they let the visitors interrupt and harass you so? Matron would have dragged them out of here by their shirt collars"

"Who is in charge? You cannot be the only nurse for that many patients and be 'in charge'!"

I couldn't answer her questions. Did they really provide all those things for nurses years ago?

One day she leaned in close to me. "There are 5 of you on duty right now. How many of you are nurses"

Hmm. I decided right then and there to be brutally honest with her. She isn't stupid. I wasn't in the mood to hold back. She was on her way home that afternoon anyway. And I trusted her.

"Two of us are actually nurses. I have been qualified for over a decade but am still technically a junior staff nurse because they won't promote and because of agenda for change re banded me downwards despite a pristine nursing record. I am the most senior nurse on duty so that makes me charge nurse as well as primary nurse for 12+ patients without the pay and official title. Susan is the only other nurse. She has been qualified for 6 months. She is the primary nurse for the other 12 patients. The other two members of staff are health care assistants. The third member of staff is a "kid" with even less training than the care assistants receive." That is all of us, for the whole ward, for 12 hours+.

My Nurse-patient took off her glasses and looked at the ground, rubbing her eyes. "They really are bastards you know. In the mid eighties, they started with this 'health care assistant idea'. We were very against it you know. Patients need trained, qualified staff. We were against all this, but they reassured us that the health care assistants would be used in addition to qualified nurses not instead of qualified nurses."

I would have liked to tell her that we are lucky if we get an experienced health care assistant these days. We are down 5 members of staff in total and if we are LUCKY we get 2 junior staff registered nurses and 2 or 3 untrained 16 year old "kids" for an entire shift. That is if we are lucky. These kids don't seem to hear call bells, nor can they feed patients without the patient aspirating, they don't seem to notice nil by mouth signs, nor do they understand about not sharing commodes between the MRSA patient and the surgical patient. They cannot seem to understand about intake and output charts. They leave side rails down. The next day they are sent to work on a different ward. And I will get a couple more who don't know their way around mine. The medics want the staff nurses to also function as a charge nurse/sister and have us at their beck and call following them on ward rounds for hours. This basically leaves the patients with nothing, NOTHING as far as nursing input.

We cannot watch these kids. They need babysitting and we can barely get the drugs out let alone watch Brittany and Brandon and stop them from fucking up. Tell them off and get stern and they call mummy and cry. It is dangerous. We need direct RN to patient ratios in line with the RCN recommendations that are dependent on adjusted for patient acuity. We need this right now.

The retired Nurse assure me that we were doing well considering what we were up against and said "God bless. I don't know how you do it. Thank you so much".

I hope she continues to recover and would like to see her kick Claire " I haven't nursed since Nixon went to China but I am convinced I have a clue" Raynor's behind. Ms. Raynor doesn't really understand what is happening on these wards. She thinks that an RN can go to work and spend all shift focused on basic care without killing someone and getting hung drawn and quartered. It ain't the nurses who made things this way darling. It's not the nurses who wanted this. They have this level of responsibility without being pretend doctors. It's not the nurses who decided that nursing needs to be a well educated profession. So who/what is the culprit? He goes by a few names: progress in medical care, increased knowledge, changes in health care delivery and economics.

Saturday, July 11, 2009

More fun during "protected mealtimes"

By 2PM I had discharged 3 of my patients and transferred two others to rehab and long term care facilities.

I had 5 empty beds! I made sure that the bed manager knew this. Our patients are always breaching the targets in a&e due to lack of beds. If she knows I have beds then she can get patients out of express admissions unit/medical holding and send them to me. Then she can get patients out of a&e and into medical holding.

I was left with a mere 10 patients (25 beds on ward total, and one other nurse). The healthcare assistant and I ran around making sure the beds were cleaned. I had to walk away from some important time sensitive things to help her do the beds quickly. Usually the discharged patients are not even out the door before the transporters are dumping another into that bed. What if the staff hasn't had time to clean the bed because the new patient is coming before the old one is out the door? Well then the porter will just dump the new patient into a dirty bed and go off on his merry way. He has other places he needs to be and it isn't his problem if the nurse gets an admission with no notice. It isn't his problem if she cannot sort the discharged patient's bed out right away because Gladys in the next bay collapsed onto the floor with a massive GI bleed. The buck always stops at the nurse and the numerous support staff goes on their merry fucking way and do as they please.

If the new patient complains about getting dumped into a dirty bed or gets ill as a result the ward nurses have to take all the blame. The porter can do as he pleases. Even if the patient has been on the ward less than 10 seconds anything that happens to that patient during that 10 second period is the responsibility of the RN. And they often send up admissions that I am not expecting and dump them and walk off while I am in another patient's room and don't see.

Sometime after I declare our number of planned discharges/empty beds to the bed manager the nurse from the "sending ward" calls me on the phone and tells me about the patient they are sending to me. This is called handover. After that happens the patient may arrive on the ward 3 minutes or 5 hours later or anywhere in between. They get sent to me at the convienance of the sending nurse's unit. I have no idea when they will show up on the ward. What I do know is that they like to send them all at once either at change of shift or mealtime. I don't know why it is that way. Either they are being twats or the situation on their unit is such that they have no choice.

Sometimes there is so much going on with the patients I already have that there is no fucking way I can nip down to see the new admission as soon as I want to and need to. I do not get given an exact time as to when they are coming so I cannot plan for it really.

I want to and very much need to go and see my new admission and give him a once over and a kind word of welcome as soon as he comes onto the ward. As a matter of fact I really fucking NEED to see him. But it isn't always going to happen right away. The ward receives admissions when it is convenient for those who are sending the admissions. That means admissions are arriving when I am up to my eyeballs in other things.

No thought whatsoever is given to what is happening on the receiving ward. That means that I am often getting new patients when it is unsafe. It means that I cannot always get to them straight away. Wanting to get to them straightaway and understanding that it is crucial for me to get them straight away is not enough to make it happen. This is the case even though I am an extremely hard worker and easily able to multitask.

If I had 5p for everytime a walking wounded transfer said "well I have been here 20 minutes and not one of the staff has seen to me yet" I would be rich. How I would love to say "well they sent your ass up here when I was smack in the middle of inserting an NG tube into someone with an obstruction.

As a matter of fact it is a crime for me to leave that very unwell patient at anytime for any reason EVER especially to be down here apologising and kissing your medically stable ass. But I took a risk to come down here because I care about your welfare too. Believe me, I took a massive risk when I left him and came to you. It's because I don't trust the ward who sent you or the transporters who dumped you here not to leave you in a bad way. Once upon a time the ward who sent you handed over that they were sending me a stable patient and when the man got here he was dying. It may have taken me 20 minutes to get here. But I got here as soon as I could. I did it in the only 30 second period I had to check on you and make sure that you are actually stable as they said you were. Your welfare is important to me, even if you are a complete twat. A word of thanks rather than a stupid smart ass comment about how long you had to wait would be more appreciated. Not one thing about this situation is created by the nurses. Nor can they control one bit of it.

Back to the point of this post. I had 5 empty beds at 2 PM and the bed manager knew this at 2:05 PM. She knew that those beds were coming up and already had transfers slated to come to us.

We got the beds ready right away because we know what happens. 3PM rolled around and I had not received a phonecall from a medical holding unit nurse to give me handover on a patient that she would be sending. By 4 PM I had received a call from the holding unit nurse. She handed over two patients. I told her to send them now, before mealtime.

By 5Pm nothing. At 5:50 they called and handedover 3 more patients. At 5:55 they sent all 5 of them up together. The porter left them in the middle of the ward and walked away. I found them all when I came out from a bay where I was pulling a central line.

3 of them were confused. None had wrist bands on to ID them. The one who was supposed to be treated for dehydration with an IVI and a had low potassium according to today's blood report had NO IV. No venflon. Nothing. Nothing prescribed for his K+ of 2.2. First priority above all else right there. Had to get a venflon and get something prescribed. He wasn't taking oral anything. The last note from a doc who saw him prior to his arrival on my ward said to hang IV N. Saline with 40 mmols of K+ and monitor fluid balance closely. Well duh. But he never prescribed it onto the medication chart. In the UK nurses are not allowed to transcribe orders from the doc's notes to the drug chart. The doc has to write it on the drug chart. Yeah. And for those of you who don't know, if your potassium is that low your heart will stop.

The one that had urinary retention (according to handover) and had not passed urine in 11 hours (bladder scan that was done in medical holding showed 800mls in bladder). The sending nurse handover to me that she was going to cath the patient. This was a few hours ago. He was supposed to have a catheter inserted. There wasn't one.

So all this was happening at the same time and there were 2 nurses and 2 HCA's. It was 5:55 PM. The supper trolley comes now, and we have 20 minutes to get all the food out and served and fed to all 25 patients (and 10 feeds). I also have an hours worth of a drug round due now and people need their pain killers. I can't even get to the new patients new and read up on them to see if there have been any changes since they were handed over. This is because the notes are on the desk and that is where the visitors are queing.

I go for the notes to read up on my patients and make sure there aren't any other life threatening "surprises" left over from the sending unit and the visitors of the other patients go for my jugular." Patients are crying for nurse and suffering and there is that nurse with her face in the notes" "Don't you know that grandma cannot feed herself cannot reach her drink? Don't you horrible people care?" It's not like I can through all the notes in a few seconds. Getting all the information that I need to takes time and concentration. But the families go nuts when they see me open a chart....then mistakes happen because the nurse does not have all the info she needs to be able to function.

The domestic was stood with the supper trolley hands folded staring at me menacingly while I was getting the venflon into the low K+ guy. The other nurse did the catheter. One HCA sorted the ID and wristband situation and tried to get the new people settled into their beds. They new admits got really pissy when she moved at the speed of light and wouldn't stay or organise their belongings in the cupboard. The reason she was moving so fast is because one HCA was now trying to serve and feed all the patients on the ward by herself. Impossible for speedy gonzalez let alone 50 year old Linda. We all needed to pitch in and help. Even with all 4 of us on deck it was never going to happen, let's be honest. It was 20 past 6 before I sorted out the man with the low potassium and by that point the fucking domestic was trying to collect all the dishes in so that she could get home on time.

Now it is 20 past 6. I was trying to keep an eye on my unstable patients, figure out who actually ate and who didn't...everyone was simultaneously shouting "nurse nurse nuuuuuursssse" as I walked by and the visitors who just arrived were queing up at the nurses station to bitch at me and tell me things I already know. My drug round still wasn't started. At this point I would be lucky if I finished it by 7:30 PM. That means it is going to be another hour before I get around to everyone in pain with their medicine. IF I stop at any point to talk to visitors or answer the cries of "nurse nurse nuuursssssse" it's going to take a lot longer.


Later on we again had two empty beds by 7PM. I told them so no later than 7:05PM. They handed over patients at half past 7 and then sent them both up together at 9PM. I am off duty at 9PM but the night nurse was going to struggle handling two new admits, her initial drug round, and all the problems that were happening. Really no choice but to stay late and unpaid and sort the new admissions. You would think that transfers from medical holding would be easy to deal with because the staff in medical holding due the initial admission and paperwork and "supposedly" get treatment started. When they are coming to us, they are merely transfers not proper admissions. Therefore it should be easy and straightforward. But it is not straightforward as that and I'll explain why later.

In the meantime if there are any medical express/holding/admissions nurses and bed managers around can fucking you tell me why the hell you send them up in clumps at mealtime and change of shift?

To be continued.

7/10 Nurse Practitioner Jobs ARNP Jobs

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Friday, July 10, 2009

A good thought

So today was my last official day as an epidemiologist. Truthfully, yesterday was my last day since today I decided to use my sick time ;) But that's not the reason I'm posting today. I'm posting because the most amazing thing occurred to me today. That is that there is a very good chance that I will never have to have a bullshit job ever again! In fact, my next job very well might be as a physician. As I look back at the crappy jobs I've had over the years... I seriously cannot believe it! Oh, god... so many of these were awful and oh-so-boring!!! Here's a quick list.

1. Counter/server @ a pizza place (age 14)
2. French Bakery (age 15)
3. Women's consignment shop (age 16)
4. Life guard (age 15-17)
5. Coffee shop inside a Lowes -type building supply (age 17)
6. Secretary at lumber supply (age 18)
7. Mervyns (age 18)
8. Orthopedic medical records (age 18)
9 Railroad secretary (age 19)
10. Lifeguard manager and swim teacher (age 19)
11. Camping store sales (age 20)
12. Personal assistant (age 20)
13. Resident assistant (age 21-23)
14. Abercrombie and Fitch (age 22)
15. Vice president of associated students (age 23)
16. Server (age 23)
17. Adult/child swim teacher (age 24)
18. Ecology research assistant (age 24)
19. HIV/Std educator
20. High School Chemistry teacher (age 25-26)
21. University Chemistry Teaching Asst. (age 27)
22. Fine dining hostess (age 27)
23. Clinical Research Coordinator (age 28-29)
24. Public Health Epidemiologist (age 30)

And even though I've jumped from job to job... I've never been fired or disciplined. And I've quit nearly every job out of sheer boredom! And possibly, just maybe... I'll never have to feel that way about a job ever again. Lets hope that's the case, and not that I'll be laughing my ass off in five years thinking how naive I was for writing this.

Thursday, July 9, 2009

Nurse Practitioner Jobs ARNP Jobs 7/9

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Let's get something straight: The Chicken or the Egg.

All over the Internet I see posts that try and blame nurse education and nurse "snobbery" for the state of things on the wards. It's true that the wards are violently short staffed. It's true that many registered nurses are no longer ward based. The fact that many nurses are no longer ward based has nothing to do with the situation on the actual wards. Short staffed wards are that way as a result of business managers.

Let me tell you what I know after over 13 years of nursing in multiple countries and an obsession with issues surrounding nursing care.

We'll be real simplistic in case any daily mail readers are looking at this blog (doubt it but I'll endeavour to keep things on a year two reading level anyway, just in case).

The wards did not suddenly become short staffed overnight when health care delivery became more complex and the role of a ward nurse changed. Having a caring heart and a strong stomach are not enough to make a good staff nurse anymore. I often hear comments from people on seem to think that degree educated nurses do not want to be at the bedside. Complete rubbish.

They are educated to work at the bedside, they need years of bedside experience before they can change jobs into specialist roles. The abusive conditions at the bedside drive them away time and time again. These working conditions drove the 1972 grads with certificates away and it is driving degree/diploma grads from the class of 2009 away too. People who like to look down on nurses just cannot STAND the fact that nurses of the class of 2009 have more escape routes from this hell than the class of 1972 ever did. They want to keep it hellish for nurses and ensure that nurses have no escape routes. It allows them to put money towards things that give the illusion of decent patient care without ever really providing it.

The wards have always been pitifully staffed by greedy managers. This has always resulted in an abusive work environment for nurses. Their experiences were so harsh that they will never return. For these people, working a 40 hour work week with lunch breaks minus life and death responsibility is like a permanent vacation with a paycheck. Most escaping nurses do not go into practitioner jobs within health care. They go into everything from teaching to theology to working at GAP. And you wouldn't get them back into health care as a nurse if you offered them double the pay, so atrocious were their experiences.

Many people seem to think that if specialist and managerial nurses were forced back to the wards then we would magically have enough nurses to do the job. This is bullshit. Ward staffing by registered nurses does not follow the rules of normal supply and demand. "Supply and demand" of RN's is very tightly controlled by twats with a financial agenda which does not benefit nurses or patients. Do you know how many new grads are still looking for jobs, and feel that they have very little in the way of options?

Most of the time we only ever have 2 RN's per shift. This number seems to remain constant no matter how many new staff we hire, no matter how many leave, no matter how many are off sick, no matter how many want to work over time. If we have 3 + nurses for the shift, one gets sent away for the shift to staff another unit. If we only have 1 for a shift either she attempts to cope alone or they take from another unit to ensure that we have 2 RN's. 2 RN's for the whole ward seems to be the minimum number that management can get away with, without they themselves looking like the bad guys. The number 2 is the magic number and usually constant no matter what. We have 20 something beds. The medical ward downstairs has over 35. Neither ward ever really seems to have more than 2 RN's per shift even when they hire new people and have staff begging for overtime.

The ward budgets as designed by business managers do not allow for the wards to be staffed well with much needed RN's. They just don't allow for it. The specialist nurses and the managerial nurses will never be brought back to the ward for this reason. Ask any one of them, they would come back if they knew for certain that they would not get shafted i.e. have a manageable number of patients rather than ratios from hell. But even if they all came back, we would still be heaving with only 2 RN's per shift.

If we ever, god forbid, get 4 RN's for a shift, one gets sent to staff another ward and the other gets sent on a study day that she should have gone on two years ago (legal requirement) but could never go because the ward would be left too short. No matter what happens we always end up with 2 RN's per shift.

If all the nurse practitioners, nurse specialists, and practitioners came back and begged to be ward based we would still only have 2 RN's per shift.

IF every nurse who left health care came back, re-qualified, and begged for a job as a staff nurse on the wards as well...we would still only have 2 nurses per shift.

If every British nurse who left the UK for pastures anew came back to Blighty and begged and begged to be put to work in an NHS hospital as a staff nurse....we still would only have 2 RN's per shift.

And, if in addition to all that, every single dead nurse arose from their graves like something out of Thriller, and came along dancing with Michael Jackson towards the wards looking for jobs....we still would only have 2 RN's per shift most days.

Being only one of 2 RN's for a whole ward is hell on earth. This blog does not even begin to touch on how much a nurse in the position is crucified and made to suffer. When I was a kid I shoveled horse shit and worked as a sales assistant. When I was at Uni I worked in a bank and a museum. I know I take on more work and abuse in 5 minutes as a staff than I ever did in all of those jobs combined.

If you think that the normal rules of supply and demand apply to nursing then you are batshit fucking crazy.

The nurses who have long ago left the bedside know this. See, they know a lot more about the situation than the likes of NHS blog doctor. Doctors may be highly intelligent and brilliant at diagnosing an illness and prescribing a course of treatment. But they don't know shit about nursing. My 5 year old understands nursing and nursing issues better than any doctor ever could.

The AWOL nurses who left the bedside know that even if they come back, and all their friends who left came back and they all got jobs on the ward......the business managers would find ways of shedding other RN's through what they call "natural wastage".

All nurse managers and nurse practitioners know that if they come back, and everyone else comes back to the ward, that they will end up getting overloaded with too many patients. They know that they will be in the exact same position that Nurse Anne is in right now. They see us working 12 hour shifts without being able to eat drink and pee, getting crucified and screamed over things out of our control, slamming our heads into the wall with stress etc etc. If they all come back, the staffing numbers STILL would not change one fucking iota...and these returning nurses will be straight into our shoes.

It's a classic chicken and egg scenario with a bit of catch 22 thrown in for good measure to deflect blame from the real culprits who are responsible for shit nursing care. Did the wards become horrific and short staffed because of nurses being too snotty to work at the bedside, or did the nurses leave because the wards were horrific and short staffed? Make no mistake about the fact that the latter statement is correct while the former is complete and utter bullshit.

Never forget the golden rule of nursing. There is no shortage of RN's. There is merely a shortage of RN's willing to put up with appalling conditions. Appalling working conditions for nurses saves money....well that's how the business managers see it anyway. The reason that people cannot stand a well educated nurse is the fact that she has more options to escape than older nurses ever did. People resent that.