Vacation Ramblings

Or How I Went Nowhere On My Summer Vacation

(Disclaimer: the following has nothing to do with donation, you've been warned)

I can't think of anything that excites a greater sense of childlike wonder than to be in a country where you are ignorant of almost everything. Suddenly you are five years old again. You can't read anything, you have only the most rudimentary sense of how things work, you can't even reliably cross a street without endangering your life. Your whole existence becomes a series of interesting guesses.
Bill Bryson
Neither Here Nor There

This is the first year in a long time that we haven't gone anywhere. I mean, I go a lot of places. It's just that there all intensive care units. The locals don't have much to say, being mostly intubated and all. I felt a real longing yesterday while watching Rudy Maxa in Australia. I'm not a big fan of Rudy, who's sort of a Rick Steves for staid, conservative types. For instance, Rudy went to the Gold Coast and watched people surfing. But did he surf? No, Rudy laughed at the very idea. But Steve, he totally would have surfed, even if he looked like a total dork. I'm a big Rick Steves fan.

A big G'Day to all you Down Undah

So it made me long for Australis. I went to Oz several years ago and it made a big impression on me. I stayed a week in North Sydney and woke up every morning to a gorgeous view of the opera house, the harbour bridge and Luna Park's smiling, lunatic face. If you've never been, Sydney is like San Fransicso meets the Bahamas. The people are friendly, like Americans, but nicer, tanner and better looking, with cute accents. I can't really say enough about it. Except it's hard to find decent coffee. We did all the touristy things:the Opera House, Syndey Zoo. We took a tour of the Blue Mountains and saw kangaroos hopping around like deer in our parks. We had billy tea and wellingtons. I ate crocodile, which really does taste like chicken. Oh, how I want to go back. Except that I could put a down payment on a house for what it would cost 4 people to fly there. It's really far. So far, that when it's today in Australia, it's still yesterday back home.

If I went back, I'd want to go all over too and make a big trip of it. I've always wanted to go to Perth, which, as Dame Edna says, is the nicest city 30 hours from everywhere. I go to Adelaide and Uluru and pretty much anywhere, but I'd really like to go to that place where the people live in caves dug in the ground.

And of course I'd want to visit New Zealand, cause, duh, there right next to each other. I mean, look at a map of the Pacific, right there in the lower left. See, they're right next to each other. My ER preceptor was from New Zealand, a snotty girl who all the guys were in love with because she was cute, perky and had the cute accent. Once we had to explain what a back-ho was to her. It was an interesting conversation. Really, all I know about the place is from an old boss of mine at a tool and dye shop I worked at during high school. The job was dead boring, but he used to tell me all about how New Zealand had the best trout fishing in the world and that the weather was in the 80's all year round. He was going to go there when he retired, I hope he made it. And, of course, the whole place is populated by hobbits. But you already knew that.

Tomorrow, if I'm done with cleaning out the basement, I intend to go to the beach. The shore, if you will. Whooopeee! It won't be the Gold Coast. But then, my chances of being eaten or stung by something deadly poisonous is much slimmer.

File under "WTF"

Medscape has an article that debunks an article from last year that says nurses shouldn't be paid well. The economist who did the study reasons, poorly, that if nurses receive low pay they'll do the job out of love and vocation and consequently the quality of nursing will stay high.

Medscape does a good job of showing why this is complete bunk. The first good point they make is that nursing is not just about caring for people, but is also a skilled profession. Think about this:could you imagine asking a doctor to take less pay to keep his motives for becoming a doctor pure? Why stop with healthcare? Can't this economist think of any other professions that shouldn't be motivated by (gasp) a paycheck? How about clergy? Not your average clergy, like my best friend's dad. I know he's not doing it for the money. I'm talking about those Tammy Faye/Jim Bakker types. Or how about keeping the pay down for lawyers? Surely they're not in it for the money? Or teachers? Or police?

One group of professionals that definetly needs a paycut are politicians. You want to be president? Fine, but you're going to make minimum wage. And only work 35 hours a week, so my tax dollars don't have to pay for your healthcare.

For me, what this study is really about is how nursing still labors under a stereotype. (Medscape also makes this point). Because the field is still dominated by women, people don't take it seriously. I remember working at a hospital where they wanted to cut back on our health benefits. A lot of the married women were like, "why should I care? I have my husbands policy to fall back on. " Forget all of us who weren't married and depended on our benefits. The point is that we deserve to get paid what we're worth(and that includes good benefits-how can a hospital rationalize bad health benefits?) We're not caretakers, we're health care professionals.

Also check out Medscapes article about nursing salaries around the country. I know it talks about the cost of living and how it varies to justify why nurses get paid so little in some parts of the country. I realize that a $400,000 house in my neck of the woods might be half that somewhere else. And car insurance is high here, too. But the price of a car is the same no matter where you go. Groceries aren't any cheaper in the South, neither are clothes. So why are some nurses still making $16 dollars an hour? It boggles my mind.

I'm all for the office of the national nurse, but I also think it's time for a national nurse's union.

Here's a thought

I got a lot of comments recently about the lack of support at a small, community hospital. And an offer for an 8 year old to come speak to them(thanks, Katie's Aunt), which would probably help more than anyone. It got me thinking. If this hospital had ONE organ donor a year, they could save up to 7 lives with that donor. Over a decade, that would be 70 people receiving organs and off the waiting list from just one hospital.

Catching Up

Because Sunday is the new Thursday. No, actually because I finally have 5 minutes to sit and surf....check out Change of Shift, this week at Intelinurse2b. Some really good posts, I must read them all some day.....

Auntie, as in, What's wrong with Auntie? was in the hospital last week with a nasty pneumonia. I went to visit her to make sure she wasn't scared and make sure the staff knew that she was delayed and also couldn't read, so she'd need help with instructions and menus, etc. I brought her a magazine to look at and hard candy and Love Monkey talked me into buying her a BIG box of chocolates-which she loves. Then the next day Mom tells me she diagnosed with diabetes. Great. The guilt, the guilt.

Action after review happened Friday. For this case. In case your keeping score at home. The manager of the unit allowed that the referral was late and that next time they'll call us sooner. And they're going to look at their policies and update them as needed. Hospital services told her that they really need a donor counsel at the hospital, because more than 2 people are needed to make significant changes at the hospital. She suggested the director of nursing and the VP of patient services. Her reply? They're too busy and aren't interested in donation. Which I find hard to believe. Because, bottom line, hospitals now need to show their conversion rate(possible donors/consented donors) in order to get accredited by JCAHO. So I think they'd be interested.

And I'm on VACATION!!!! Two weeks off work. Not going anywhere and I'll be cleaning out the basement, but I couldn't care less. Time for surfing the net, playing with the baby, maybe even going on a date with LM. Oh, glorious!

Grand Rounds

Grand Rounds is from South of the Border this week at Mexico Medical Student. Now excuse me while I pluck the baby out of the dog's dish.

All riled up

I don't even know if I spelled "riled" correctly and now I'm under pressure to be grammatically correct, after the last post. I was really mad last week. I'm better now, but still feel the need to SHARE MY WRATH with the blogging world. And I'd better type fast, cause the Little Einstein videos only last 30 minutes, and I've already spent 10 minutes yapping on the phone. BTW, I think biscotti from the local coffee joint are totally acceptable teething biscuits, albeit expensive ones.

Anyhoo. Last week I got called out for an organ donor referral to a teeny tiny little community hospital with a not-so-great reputation. Although, in all fairness, once when I was younger I smashed my finger at work and they did a top notch job of taking my finger nail off and stitching a little laceration I had. The finger nail never grew back in the right way, but I guess that's not their fault. Anything larger than fingers, though, I'd be afraid. That's all I'm saying.

The patient was a middle aged man who had minor surgery the day previous, went home with a headache and had an enormous bleed. He came in after midnight. It's now the following afternoon. His blood pressure has been 60/30 for 10 hours. He's not on any meds to keep his pressure up, just IV fluids. He also has a lot of medical problems, but his liver numbers are good, so we proceed. The hospital called 45 minutes the first clinical was done. He's not going to make it long with his blood pressure in the toilet, so I will have to ask the family pretty quick.

I get there and the patient is in nuclear, getting a cerebral blood flow (with a pressure of 60, you're taking him off the floor? Nothing like a code in radiology, I always say). I have already introduced myself to the family practice resident who's handling the ICU. There are no intensivists, no hospitalists. Any orders needed, the attending(s) have to be called. Another WTF, as Kim would say, but whatever. When the patient returns, she says she's going to speak with the radiologist and talk with the family. I ask her if I can be present. She says no, it's a conflict of interest. I ask her if, after she's done talking with the family, could she introduce me. No, that's also a conflict of interest. Really, cause at the other hospitals I go to it's called a "collaborative approach". Apparently she can't even be SEEN in the same room with me or it may imply that "I only want his organs" to the family.

All right, let's review:

1. They do nothing for the patient for 10 hours except scan his brain and give him IVF's.
2. They call us late. We should get the referral when the patient has a Glasgow Coma Scale score of 5 or less, not 45 minutes after the first doc says he brain dead.
3. Working together to ask a family to consent for donation is not unethical. Being pro-donation is not unethical. Possibly being a medical person and hindering the donation process may be unethical, but more on that later.

Finally, I ask the nurse to introduce us and to come in with me when I speak with the family, since she's been working with this patient all day and knows the family as well as anyone. I bring them into a conference room. There's the wife and two daughters. First, I assess their understanding of brain death and they get it. They know he's gone, they just don't want him to suffer. Understandable. Then I say to them, "Because of the way he died, (the patient) has an opportunity to save someone else's life through organ donation." The first daughter immediately says yes. Mom is unsure, but she defers to the daughter. The first daughter and the nurse both say how it would be a great thing for him to save another life and then the daughter says that he won't need his organs in heaven. The second daughter is distraught. We comfort her as best we can and she says it's okay with her. They all want to go back to the bedside and I tell them that in a little bit I'll have paperwork to go over with them, when they're ready. I give them an idea of the timeline and assure them that he will be able to have an open casket.

I go back to the nurse's station and start making phone calls. By now, a colleague of mine has arrived to help me out. We both note that the first clinical is not completed correctly. It has no time on it and it doesn't note if the patient is spontaneously breathing or not. She calls the neurologist back to see if he'll come and correct it or if we can fax it to him. I should note that the hospital system that this hospital belongs to uses a check list for brain death, for comformity and clarity, since many docs don't do this often and aren't familiar with the process. This one hospital doesn't use it, they have kept their own brain death policy. So it's just written in the progress notes. She gets a hold of him and he refuses to come back or have it faxed to him. He'll be in the next day, he says. She tells him the organs won' t be viable by then. He says that's not his problem.

The next thing I know, Dr. It's-not-ethical comes out of the patient's room and says, "They changed their mind." I'm suspicious. I go over to the daughter. She says that she wants to, but the rest of the family, the extended family who are now filling the room, don't want to. "And I can't go against the whole family." I talk to her for a bit, without being obnoxious about it, to see if there's anything I can do to change her mind. She's says she'll call if anything changes, but with a systolic blood pressure of 50 he won't last much longer. My colleague and I start packing up. I hear the resident and her attending going over the brain death policy. I offer to clear up anything for them. They just look at me. Then I mention that if this had stayed a consented case, we really would have needed a time on that first clinical for it to be accepted by the transplant surgeons. For it to be LEGAL. They go back to talking and ignore me. We leave.

Several days later my colleague gets an email from the nurse manager of the unit. I'm too flabbergasted to editorialize, so I'll just post it in full.

I also need to let you know that there were multiple complaints about the last referral in ICU by both the resident and the primary nurse with regards to the person who approached the family. They felt that she was placing the burden of approaching the family on them because she was not comfortable doing so. The resident tells me that she was placed in an uncomfortable position by your rep. In addition, when she finally did approach the family - the both stated that she was not assertive and they were not at alll surprised that the family refused. This is feedback that I am getting from my staff and physicians that I thought you should know (signed, the nurse manager)

Do I even need to say that this is complete bullshit? And hello-I did get consent. And then got it rescinded due to extended family pressure. Listen, it's hard enough to get a transplant. Why make it harder? And for the resident who's so concerned about ethics, think about this: you took an oath to preserve life. When your patient has an unsurvivable injury and you have stopped treating them in any meaningful way, the onus is now to preserve the lives of the prospective recipients. You are no longer saving one life, you're saving up to 8 lives and if you fuck it up you're potentially harming 8 lives. So put that in your Hippocratic Oath and smoke it.

Pet peeves, et al

There is a word that has made its way into the nursing vernacular. I refer, of course, to dilitate. Please, believe me, nothing dilitates. Your pupils, your cervix, your pores all DILATE. Look it up yourself. Go to dictionary.com and look up dilitate, and you will find this. See, I told you.

This naturally begets the second peeve: orientate. As in, I orientated her to the unit. Listen, I am not Protector of the English Language. I've even been known to use "good" when I should say "well". But I beg you, please stop, you're making making my ears bleed.

So, anyway, I'm orienting someone. And she's quitting, quitting for God's sake. I've taught her everything I know, some things I'm sketchy on and few things, quite frankly, I've just made up. No, seriously, she even knows to bring her preceptor a Gatorade. Brilliant is she. A natural. Oh and she's really good at the job, too. But her heart is in the ER and brother, I've been there, so what can I say?

I even told her about the blog. It's like she's seen under the Lone Ranger's mask(no Tonto/Kemosabe jokes, please). She wanted to know why I haven't written about any of our coworkers. Good question, 'cause that would be some entertaining shit. I guess I'm afraid that the transplant community is too small, that people would recognize who I was talking about. Or that when "Donorcycle:The Movie" comes out, everyone will be mad at the unflattering portrayals. So you won't be hearing about my boss, Mr. Keaton. Or Sister James Margeret. Or Stiffy and Scratch. Sorry, I just won't do it. And now, Tonto, you know too much. I must kill you. Death by dilitation.