nursing


Many moons ago, I worked on a cancer ward.  I was a new nurse at the time and discovered that one learns phenomenally more on the floor, than the classroom ever provides.  That’s another topic.  Anyways, I was on third shift meaning we started at midnight and finished when everyone else was eating breakfast.  That made rush hour traffic nice, though.  The normal routine was to receive report, then travel around the ward obtaining vitals and checking on anything remaining from the previous shift.  This one particular night, we had a fellow who was DNR and near the end.  My partner and I moved this patient up in the bed and once vitals were finished, I had this impression that I was to go back to be there.  I held his hand and told him it was all right, I was there.  Movement became less and less and I noted a carotid pulse on the right side of the neck.  This slowed, and eventually stopped.  It is a moment I will never forget.  I’m glad I was there to be company at that time.  Well, being a nurse, I started my nursing duties and called for pronouncement and began the cleanup.  The doctor came, instructed me on the particulars of pronouncing someone, finished his duties, and left the body for me to complete care.  Calling hours aren’t the same for me now.  I see a body in a casket, and immediately think “3 rolls Kerlix”.  (Kerlix is a roll of 4″ loosely woven gauze)  Well, I was trying to be nice to the funeral director and used one of those Kerlix rolls to try and tie up the jaw and close the mouth.  After several wraps around the head, I was somewhat, but not completely successful.  At least the mouth was a bit more closed than previously.  I finished cleaning up the rest of the items in the room and told the charge nurse it was ready for family notification and morgue notification.  The nurse came back to me and said, “no.”  I gave a quizzical look.  After all, this wasn’t my first rodeo.  I knew the procedure.  The nurse continued, “You don’t want that to be the last picture the family sees.”  I walked back into the room, this time with aesthetics in mind.  Yes, there was Jacob Marley in the bed, only lacking the chains.  I removed the Kerlix until after the family left.

1.) frequent flyers, or those who utilize services many, many, many times tend to adopt nicknames.  There is a general one I use in my present office – “the gift that keeps giving.”

2.) you know you have a frequent flyer when the name stimulates the medical record number without a search.

3.) I had to call a PCP in a town 90 miles away and the moment the nurse there heard my name and office, replied, “Oh, this is about A or B.”  It was about A.

I work in a neurologist office.  Dr. Grumpy stories are so normal.  Part of me wishes it weren’t true, but as I have talked with people in other professions, it has occurred to me that the stories presented are simply a reflection of people of the culture.  The actions show in whatever profession is out there because the people are the same.  Every once in a while, though, we have one that leaves a warm spot in the back of the dendrites.  Every once in a while, there is a patient who you just want to hug.  I sit in on the end of visits and create the visit summary and receive orders.  As such, I hear the discussion of symptoms and plans for treatment.  We had a patient with a tumor.  The description was: take a bowl of jello and right before it sets throw a handful of sand into it.  After it sets, cut out the sand.  That was the description of the issues related to this tumor.  There were a couple of possibilities, but nothing really good.  I typed all I was  supposed to and wished the patient and family a good rest of the day and advised them of the direction out of the clinic.  As the patient started down the hall, I noted the back of the tee shirt – “Never Give Up” in six inch tall letters.  When I was in chemotherapy, all things being equal, the attitude of the person was the saving or destroying factor related to their prognosis.  This tee shirt showed me an attitude on the plus side of the equation.

Our insurance plan in their infinite wisdom has everyone in the facility measure height, weight, and draw blood for basic testing every year.  They advertise an incentive of $25 per paycheck x 2 parameters for those who participate and fit within the number guidelines presented.  Stated differently, if you don’t want to play it will cost $1300 per year in added insurance cost.  If you do play, and don’t fit their guidelines, you still get to pay that $1300.  Doesn’t that just give you the warm fuzzies about our coverage?  Anyways, I took my turn at the assessments and was to the final stage where someone sticks a needle into a vein for the blood sample to decide whether the blood sugar is within parameters.  The Phlebotomist is a lady of my acquaintance for a couple years and was looking at my anticubitals for a good site.  Actually, that’s quite the normal procedure among nurses.  There is even a picture out there somewhere labeled “nurse porn” and consists of an arm with dramatic veins showing the entire length.  “I could hit that blindfolded,” being the common phrase.  The other sentiment is the “you know you’re a nurse when:” and in this  case the rejoinder is “you notice veins on perfect strangers.”  I knew the look and mentioned that the vein on the right was the one normally appreciated.  The lady of my acquaintance started talking along the line of agreement as this was her first stick.  I agreed to the plan and at that moment heard a rebuke over my shoulder.  “Girls, you never tell a patient that.  They know each other.”  I looked to see the local nursing school had students with their instructor standing there.  The two of us kept it going along the lines of never having seen each other or maybe passed in the BigBox store…  It’s definitely more fun on this side of a joke.

you have had this experience.

I had a patient once expressing nervousness about needles and was sporting a scarred cross on the arm.  Yes, scar.  Not even tattoo in this case.

In statistics there is a bell shaped curve.  Split the bell vertically and one has the high point considered 100.  From that point, going either direction, the levels reduce in equal proportion to the distance from the center.  Here is a graphic representation of the concept.  The greatest proportion of the population exists in the center of the graph with the outliers, the exceptions, being at the ends.  Consider this and apply bacteria to the picture.  The weakest bacteria occupy the lowest portion of the bell curve, most of the bacteria occupy the center and the most hardy, resistance bacteria occupy the top end of the curve.  Let’s say someone comes in with a urinary infection.  The doctor can approach this in a few manners.  One could be to provide a general coverage antibiotic and hope that the bacteria present would be susceptible, another would be to provide a general cover antibiotic and at the same time do a urine culture, then change the antibiotic later according to the culture’s results.  The last method would be to do the culture and only provide antibiotic upon the results.  I could describe the means the culture provides the information, but will save that for some post in the future.  At 48 hours past incubating the bacteria, the lab checks the results and sends the doctor a report listing the antibiotics for which the bacteria is susceptible as well as the bacteria which are thumbing their nose at the treatment.  The doctor then looks at the allergy and other clinical information of the patient and prescribes the antibiotic.  Know that this is the reason there is not an instant answer to what bug is there when the lab is done.

Back to the bell curve for a moment.  When the antibiotic is taken, the bacteria in the lower portion of the bell curve are quickly removed as they are the weak ones.  It takes a little time to move up the bell curve and kill the bacteria occupying most of the bell curve’s area.  At this point, the patient is feeling much better and may start to behave like my grandmother.  There was an upper cupboard which was covered on the bottom shelf with partial bottles of various antibiotics under the idea that “if I feel that coming on again, I can take it.”  Sound familiar?  Remember that the upper portion of the bell curve is still there.  This is the section representing the most antibiotic, hardiest bacteria.  If these are not removed, guess the characteristic of the subsequent bacterial infection.  Yes, the bulk of the bacteria now are of the hardier variety.  The bell curve still applies meaning of the hardier variety, there are still some more resistant and strong than their parents.  Keep cycling this concept and you come up with antibiotic resistant bacteria.  It’s no more complicated than that.  (Now I’m wearing my nurse hat)  When instructed to take all of the antibiotic regardless of feeling better, this is the reason.  We, in the medical community, want to ensure the most resistant bacteria of any given infection are killed so they may not have stronger babies – because any remaining bacteria will be of the stronger variety.  That will also save us nurses from having phone calls like:

Mrs UTI: I have an infection and was wondering if it would be all right to take the Cipro I have left here.  It’s still in date.

Me: How do you know there’s an infection?

Mrs. UTI: my urine is cloudy.

Me: Well, you need to have that tested so that the antibiotic given may match the bug there so the infection is actually treated.  Remember that if the bug is not susceptible to the antibiotic, it can stick out its tongue at the treatment and keep on going.

Mrs. UTI:  OK.  I will go in.

It’s for your health as well as the population’s general health that we say to take all of the treatment.  Thank you.  Class dismissed.

I have had the occasional patient wonder why they had not been called back in “x” amount of time.  The end of day Friday seemed to offer a good illustration.  We have a patient in a facility receiving extra treatment who is on No More Spots for a condition.  The NMS is extremely expensive and as such has to go through prior approvals and a third party research before the patient is allowed to receive it.  Understand that these are like bank loan applications.  We have the “fun” of filling them out and getting them to the appropriate location.  Back to the subject at hand.  The medication was prescribed to be given at home, and as the patient was receiving facility care at time of refill, the pharmacy didn’t want to send NMS.  I was told the patient called and was informed that the facility was going to have to provide the medicine.  That would never happen.  NMS is not available from your regular pharmacy.  I decided to tackle this Friday afternoon.  Per the information given, I called the insurance company and after 20 minutes two different times and being transferred to at least 4 different departments and then back to the first one that wasn’t able to help, I finally threw in the  towel and decided to try the pharmacy.  I was transferred between another 3 departments and the pharmacist before receiving the word that they needed approval from insurance to send the prescription.  Sigh.  This time, I looked on the account and called the number on the scanned insurance card.  I finally received an agent who would not say if there was coverage of NMS while the patient was in facility, but did provide the number for the pharmacy insurance coverage office.

I called that number next and verified that the patient did indeed have a prior authorization which covered NMS through the next couple of years.  They gave me a number for the pharmacy help desk in case the pharmacy needed assistance in filing the claim.  With this new knowledge I called back the pharmacy and was given to another office that instructed that they needed to know what insurance the patient had, or if they were paying for the facility stay by cash.  I stated that the patient had insurance and they said that it was an issue of double billing the medication.  Bink. Blink.  It’s a specialty medication that isn’t available anywhere else.  How could that be double billed?  I was passed to another agent.  This one stated they needed to have the facility director sign off on a particular form and once that was processed, they would send the prescription.  I said that was fine, let’s get this form over here.  Some information was presented, and then I was informed that their department dealing with this form had gone home  for the weekend and we would hear from them on Monday.  It was now a good bit after 5 on a Friday.

I told the doctor what had transpired, and that I was just pushing the ball up the hill.  The doctor noted the reference to Sisyphus and stated so. I later was thinking on the subject and decided the Sisyphus was cursed to push the ball, we could just call it job security.

As for the work list, this effort to obtain one form to get medication for one patient took me well over an hour and a quarter.  So when you are wondering why the nurse hasn’t answered yet, and notes they’re busy, understand we aren’t playing Solitaire.  We are playing “Press Number 3” with a computer at the insurance company.

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