Saturday, February 28, 2009

A Swing and a Miss

This XRay demonstrates a dislocation of a prosthetic hip. This is bad news for the patient as once you dislocate a prosthetic hip you are more likely to do it a second time, and a third, and may eventually need a 'redo' which often fails.

These things are a bear to get back in, but we have propofol and I can pull hard. I thought I had reduced this dislocation twice... felt a nice 'clunk' both times, but I missed. It was a hard thing to do to call in Orthopedics but I got over it.

The Ortho guy was ready to put the hip back in and wanted the propofol. Unfortunately he got the wrong answer from the wrong nurse, "The paperwork isn't done." I said, "Just give it to me and let's do the paperwork later", but it was to no avail. Ortho-guy, with the patient's permission, torqued on that poor man and got the thing back in right as the nurse was walking through the door with the propofol and five sheets of conscious sedation paperwork.

"Oh? It's done?"

Yes dear, it's done. The patient was very appreciative in spite of the lack of sedation with the last yank, bless him. Never underestimate the power of people with protocols, it allows one to turn of the common sense part of the brain and do things that are annoying if not dangerous. Oh, and there's lots more of it coming.


  1. Dude....I love love you...a doctor after my own heart. That is one good thing about working in inner city war zones......people don't get obsessed about the paperwork. patients tried to kill me....but believe it or not...paperwork is more stressful than that!

    Now I am working in quieter more sedate place, where I just had my 90 day evaluation. Oh...they love think I'm player blah blah blah....but management is "disappointed" in my charting. It seems I forget to screen my MIs and acute strokes, and sick traumas for domestic violence and their immunization status.......made me livid.

    I have always contended that the best nurse on paper for management is usually the worst nurse clinically.....because she (and yes...they are usually female) are NEVER at the's usually me in her room....ignoring MY patients and falling hours behind because she is too busy filling out her skin assessment form while the doc has pulled me into the room for the BP of 60/40! But when MY patients full out their Press-Gainy stating "that I took too long to discharge them".....guess who gets called in the office! there no end to this madness?!?

    Sorry made me go on a bit of rant there:-P

  2. After I became an NP I had planned on continuing to work occasionally as an ICU RN - in part to satisfy my adrenalin junky needs and in part to keep my skills up. But then they implemented computerized flow charting, all meds in the Pyxis and bar coded wrist bracelets that needed to be scanned before meds could be given. Decided the aggravation was not worth it. As an NP managing a sub-acute ward I had a DNR pt dying from lung CA with tumor wrapped around his great vessels and bronchi. Near the end he had severe air hunger. I asked for a syringe of MS to push to alleviate his sx while we waited for the MS drip to arrive. Nope, sorry, we can't get into the Pyxis until the order is confirmed by pharmacy. Argh! Left the hospital for the clinic to avoid crap like this. Still have hoops, but generally they aren't acutely threatening to the welfare of the pt.

    PS - verify word was tetherds!

  3. This has to be so frustrating. I'm a tech in the ER and work with Great RNs and Docs. I don't think the nurses really CARE more about the paperwork, at least most of them don't. But at every staff meeting I sit thru they are constantly reminded by thier administrators that if they miss any checkboxes, it's thier ass on the line, not the doc. I've been given way more responsibility by the docs during codes, sedations, etc. because the nurse is busy finding forms, getting meds from the pyxis and having someone "double check" everything, since we can't have a near miss. And yes,if the case of "chest wall pain" 3 curtains down is waiting too long for her discharge papers, well, that nurse be hearing about that later. So, I sure get some great experience in while I'm in nursing school, but I'm not as skilled as the nurse and I know it. Who suffers if I make a mistake: the Patient. Not to mention the nurse who will get in trouble because they let me do something outside of my scope, even though they probably didn't know I was starting that line, or putting that NG down for the doc who's telling me to just do it it's what's best for the patient. It's heartbreaking every shift because as a team, we are set up to fail. And most of us want to do what's best for the patient whether they are acting like a bastard or not. We show up and we still care even if we act like we don't in front of each other. You get that bad MI or krumping 2 year old on your cart and you get it together real quick. We've been there.

    It's the most frustrating place I have ever worked.

    Yet I can't wait to be an ER nurse. I'm addicted. Even with all the bullshit beaurocracy and press gainey crap I gotta pretend to care about. I must be a masochist.

    Ps. Sorry about the bad punctuation and spelling.

  4. 911! I'm shocked. Shocked! What's the matter with you for thinking of the patient first? Don't you realize if it weren't for those damned patients, the hospital weenies's jobs would be so much easier? Come on, man, buck up and play by the government rules!

  5. I don't think docs realize how much shit nurses have to do with paperwork. Stuff like sedation charting is gone over with a fine tooth comb and if you missed checking a square you are called on the carpet. Its about JCAHO doctor.

  6. It's about the patient, nurse. If, for you, it's about JCHAO, then go work for them.

  7. 911 thing that really really matters (at least at me) is this "will my ER doc have my back" .....if I get called before the management due to shoddy paperwork...while I was kicking ass at the bedside.....will my doc back me up. I have worked with mostly amazing docs...and I have worked with some who will deny giving a verbal order and watch a nurse crash and burn (mostly residents do this)

    TBH...I have never ever understood this barrier between MD and nursing personal....what my docs think of me means a hell of a lot more than what management (who NEVER actually work with me) think of me. I would welcome with open arms MD input on nursing evaluations....yet dare to bring that up....and you are nursing enemy number one. On the other hand....I think nurses should be asked their input on working with various docs also.

    But that would make too much sense wouldn't it....and leave many in "nursing leadership" obsolete....can't have that now can we?!?

  8. jennifer,

    the not dirty little not so secret is that doctor's do not have much pull anymore with administration. in fact, i have been welcomed to resign from three facilities based on my predeliction for calling a turd a turd and for standing up for skilled nurses (who save my ass regularly). it continues, at my current facility my best nurse is in hot water for not checking all the boxes and other nurses talk him down for it. he is the VERY FIRST person i want to see at the bedside of a dying patient however. got your back sister.

    i keep thinking the pendulum will swing back to clinical competence but if it is swinging back i'm not seeing it.

  9. All this sounds so familiar, like when I was a kid in the 1970's, when doctors who accepted Medicaid were still rare, and I sat in waiting rooms for 3 hours to get a checkup for my asthma or get an allergy shot. Even in a big city like Detroit, MI.

    It was just more paperwork, and less service. I mean the nurses were nice when they got to you, but they were overworked, and the good ones quit soon enough.