Monday, September 24, 2012
The Teen’s sense of humor is literally in the toilet. I don’t really mind too much, because that’s what 14 year old boys are all about and what 49 year old men have never outgrown. Perhaps with age we have learned to hide our amusement until we are secreted by ourselves or amongst like-minded persons of similar age and gender, at which point we giggle uncontrollably like schoolgirls looking at a Seventeen magazine spread of Justin Bieber’s hair clippings. But I thought my son, who is very creative and often makes up his own jokes and one-liners, had hit a new low when he started telling me about the Wonder Boner, the Wet Banana, and A Man, A Girl, and His Johnson.
I normally don’t put videos on the blog, mostly because before today I haven’t figured out how to do so. But I need to include these under the category of The Teen is Not Making This Up.
So please accept this entry as my official apology to The Teen. Son, I stand corrected. Or sit, depending on what it is I’m doing in there. And above all, I’ll turn on the fan and light a candle. Giggle.
Monday, September 17, 2012
Verbal orders in the ER are a source of never ending fun. Health care pundits and poobahs would vehemently disagree and say that there is nothing fun about them. They are easy to misinterpret, often inaccurate, not documented, an abusive manifestation of the physician-nurse relationship, and major sources of patient harm. All of which I suppose are true to some extent, but it is equally true that in the hectic pace of the ER you simply can’t survive without them.
I think I like verbal order because unlike written ones, which are very much cut-and-dry, copy-and-paste sorts of things, virtually every verbal order is an exercise in negotiation. There are many factors involved in the request, the issue, and the acceptance of verbal orders. These include primarily the patient’s clinical condition, but also the nurse’s drive to get exactly what they want (know full well they can’t) and the physician’s impulse to prove they’re really in charge (knowing full well they’re not). The wild card in the negotiation is something will call the General Annoyance Value of the patient. The GAV is calculated by multiplying the subject’s Chief Complaint (like “chest pain starting thirty minutes ago” or “painful rectal itch for three months”) by the Actual Clinical Severity of the patients. This total is divided by the number of times (factorial) the patient or an accompanying relative pushes the call button in a 20 minute period multiplied by the number of seconds it takes before the patient requests pain or anxiety medications upon arriving in the ER. (The latter number is squared if a specific narcotic is requested by name). The resulting equation looks something like this:
GAV = (CC)(ACS) / (BUTTON!)(Request)2
The reason patient volume (measured by volume in decibels times type and variety of profanity) is not included in this equation is that if you’re spending that much effort to yell out we know your airway is intact, you’re moving sufficient air past your vocal cords, and you’re getting enough blood flow to your brain to allow you to perform the higher functions of acting out. In a general sense people who are really sick, who have problems with breathing and blood pressure, don’t do that. So we can block you out and make the noise a non-factor, unlike the call button but which we are mandated, by administrative policy or State Law or religious duty or United Nations Mandate… keep getting those mixed up… obligated to respond.
Once the AVS has been calculated, then the negotiation begins. It’s kind of like “Name That Tune.” You want to have the best chance of success with the least amount of drug, the lowest risk of respiratory depression, and the minimal amount of effort. Here’s how it goes:
(For the uninitiated, Haldol is an antipsychotic drug and Ativan an anti-anxiety agent. Both are used as sedatives in the ER.)
RN: “The patient in Room 36 is acting up again.”
MD: “I can snow that patient with 10 of IM Haldol.”
RN: “I think we should use 5 mg of IV Haldol.”
MD: “He’s too wild. I don’t think you can get an IV.”
RN: “I can if we give 2 mg of IM Ativan.”
MD: “But if we give 2 mg of IM Ativan why not just give 10 mg of IM Haldol?
RN: How about we give 5 mg IM Haldol, then start an IV to repeat if needed?
MD: “Snow that patient.”
(Personally, I have come to the belief that once we get to this point, the health care system has failed the patient. The actual solution to the problem is the Ativan lick. Just like a salt lick, you put one of these in each patient room. When the patient feels anxious, they take a lick. If they don’t calm down, eventually they will take enough licks that they will fall peacefully to sleep, which stops them from taking any more meds into their system. An alternative would be Ativan lollipops, but unfortunately the dose cannot be as well controlled, especially they’re treated like Tootsie Pops and no one can take more than three licks before biting through to the oh-so-relaxing center.)
Unlike most arguments in life, this really is a friendly exchange that can be win-win for all. The patient feels better and becomes quiet, the call button does not get pushed, nobody stops breathing so there are no complications nor the accompanying paperwork, and we carry on in peace until the meds wear off or it’s time to play the Golden Medley.
Wednesday, September 12, 2012
Apparently the Customer Service Professionals have decided that nurses no longer know how to ask patients how they’re doing. You know these people. They’re the folks having lunch with the Vice President of Patient Care (who was, back in the day, the Head Nurse, and before that the Matron), the ones who do the mandatory Patient Satisfaction Inservice on your day off replete with squishy foam stars as party favors and day-old bagels in the back and a mandatory fifteen minute showing of the video of guys throwing fish in Seattle. They’re the ones who always start their talk by going around the room and having everyone introduce themselves, the ones who pint to you and ask you to give an example of great customer service (“Leaving me alone so I can sleep in the back row” may be the correct answer, but not the right one), and who always remind you that they know what’s it’s like because they’re a nurse, too.
(Incidentally, when I went to Seattle, there were forty people standing around the fish stand waiting to watch a fish being thrown but nobody actually buying fish. I did see one guy buy a live lobster, but that didn’t get thrown. Probably something about hearing the lobster shriek as it flies through the air, claws open, antenna waving frantically, all ten legs spread out in terror. The fish-tossing industry is nothing if not ethical.)
The origin for all these highly paid and mostly useless consultants is the advent of something called the Hospital Care Assurance Program (HCAP), where patient satisfaction scores become a factor in Medicare reimbursement. It is another element in the general trend to regard health care in terms of subjective patient opinions rather than outcomes, despite recent studies showing that the “most satisfied” patients have higher morbidities and incur extra costs on the health care system. The advent of these scores have given consultants yet another vehicle to sell their services to unsuspecting hospitals. (If any of you highly paid and mostly useless consultants are out there and want to have a serious discussion about how HCAP scores are essentially flawed measurements, and how efforts to improve HCAP scores are often directed at lower level employees rather than established administrative systems, I’d be delighted to have that conversation. For now, it’s my blog and I’ll say what I wanna.)
As I’ve said, these Men in Black and Women in Pastels have determined that one of the keys to customer service is that nurses need to see patients more often and ask them more focused questions about their needs. The fact that nurses are overworked, overstressed, dealing with sicker patients with greater demands in an increasingly more complex clinical and administrative environment is apparently not the problem. So the Customer Service Professionals have put together an “Hourly Rounding Log.” It’s kind of like the sheet you see posted on the door of the restroom at Target, where someone named Randy initials that he has meticulously inspected the facility each hour and it has met his standards for cleanliness, the fact that Randy also has dog barf on his pants from his last job at PetSmart notwithstanding.
The Hourly Rounding Log is headed by a script that features the sequence of questions one is supposed to ask of the patient during your assessment. It also implies that you should be asking these questions every sixty minutes, even in the wee hours of the morning, because there is nothing that gives patients the warm fuzzy feeling of care like being woken from a deep sleep every sixty minutes to ask if you’re okay.
The script is not a Tennessee Williams production. (If it was, you’d expect one of the lines to be “Bedpan! Bedpan! BEDPAN!”). Here are the five scripted sayings:
Is there anything you need?
I have time now to take you to the bathroom.
Is there anything else you need?
Let me be sure your call light is within reach.
Please call if you need anything, otherwise someone will be back in an hour to check on you.
Professionally, I was insulted by this on behalf of the many highly trained and experienced nurses I’ve worked with over the years. Caring cannot be taught or scripted any more than clinical instinct can be, time is not a function of clocks and charts but of acuity and need, and the “script” is yet another example of how health care systems try…and fail…to reduce healthcare to factory piecework. Personally, I was offended by the fact that apparently the Hourly Rounding Log does not apply to me. I am a doctor, after all…a nice Jewish Doctah, at that…and I passed Physician Egotistical Behavior 101 with honors.
So I went and asked one of my nursing colleagues why no one was rounding on me. I was told that since I’ve made it clear what I really need is a winning lottery ticket, a bathtub in my home big enough to drown a pig, and one-way bus fare to the Frustrated Writer’s School, there was no way I could be helped. I was told they could take me to the bathroom if I wished, but I would have to know they would gossip about what they saw. (One of every male ER doctor’s fear is that they will get in a horrible accident, need a urinary catheter, and expose their assets to those who really do understand that saying how long it is in centimeters rather than inches is just a dodge.) And I was told that while they would be back to check on me in an hour if I hadn’t moved any patients, and they would do so with the expectation of doing CPR. Because if I’m not moving the meat, the only excuse is to be dead. Preferably with a Do Not Resuscitate Order in my hand so I don’t take up a bed.
Saturday, September 1, 2012
Last Spring I wrote about taking The Teen to a Yu-Gi-Oh tournament back home in Daytona ("The Yu-Gi-OH Blues, 2/11/11). If you couldn’t guess by the tone of that piece, it was my fervent hope that his adoration of this collectible trading card game of infinite editions (translated as infinite new ways for parents to spend money) would fade, much like I’m sure the Osmonds wake up every day and say “Crazy Horses? What were we thinking?” I thought that maybe he would come to realize that there are more productive things to do with his time them play cards, things like standing outside the house to get some sunlight and breathe unfiltered oxygen and learning to use soap and shampoo on a regular basis. (I mean, he’s now called The Teen for a reason. Although even this facet of his development has been interesting because maybe it wasn’t just personality that kept the girls away until I hit college. Maybe it was just the smell.)
Well, he’s still playing Yu-Gi-Oh, and he’s really gotten very good at it. And because I have the car and hold the allowance, I’m still along for the ride. So here is the 2012 update of what I’ve learned about Yu-Gi-Oh:
No, really, here’s what I’ve learned.
The Teen still wants me to learn to play. He offers to construct beginner decks for me. I appreciate that he still wants to have playtime with Dad, but I still can’t get my head around the game. Plus this year I can’t see the writing on the cards even with my bifocals.
For the third year in a row The Teen and I attended GenCon, the largest gaming convention in the world. I have come to the conclusion that My Own Flesh and Blood is actually the Crown Prince of Nerds, the hottest thing under 21 in the collectible trading card world. Of course, as my father noted when he came to GenCon for a day, my mother would also be the hottest thing at the convention. Mom is celebrating the 45th anniversary of her 29th birthday.
In larger card stores and gaming conventions, there is always a place called the Abandoned Parent’s Corner. This is where parents, all fathers for some reason, sit pretending to do something…anything…for the interminable hours their kid is playing Yu-Gi-Oh. It’s a quiet place, as everyone is too busy looking at their watches to talk. The only motion is when someone gets up to go find a refreshing adult beverage and returns 20 minutes later belching is a most happy fashion, hoping their kid is still there so there will be no awkward explanations for later.
Total count of Yu-Gi-Oh players at Collector’s Cache in Lenexa, Kansas on September 1, 2012: 43. Total number of females: 0. Total amount of soap and soap products used that morning: ¼ bar, unscented. Bowls used for haircuts: 38.
The only way to get a family photos that includes The Teen is to get him to pose at the “Make Your Own Yu-Gi-Oh Card” booth at a gaming convention.
There are a lot of themed decks. Many sound very ominous, like Anti-Meta Chaos” and “Skull Servants” and “Bain Capital.” There is, however, a Rabbit Deck featuring cards such as “Resuce Rabbit” and “Mecha Bunny” and “Super-Nimble Mega Hamster.” Apparently those playing with this deck get manhandled on a regular basis. But it sounds so nice. It makes me feel like Allen Sherman, who wanted his kids to avoid Crazy Downtown and it’s vices like The Frug, but instead stay home and do a nice dance like the Bunny Hop. Allen lost that one, too.
I get to witness conversations of great import such as “You don’t know what Thunderking Rhino does? You mean you haven’t played for two weeks and you’ve forgotten what Thunderking Rhino does? That’s f…ing lame.” I have also learned that while my generation’s conversational faux pas was “You know,” this generation’s is “sucks.”
There is a guy named Billy Blades who invented an Insector Deck. The Teen defeated him in a demo at GenCon this year. He has not smiled that much since he watched a cat poop on my head. It is also the only time outside of school that I have heard The Teen refer to any one as “Mister.” Billy is a pretty nice guy. He looks about twenty. I’d probably have to buy his beer.
But in the end there is hope. About three months ago The Teen asked me if I thought he should stop playing Yu-Gi-Oh, if it was too much of a little kid’s game. My answer could have been that it’s not a little kids game because at least I can understand Candyland, and honestly I’d probably give it up for Princess Frostine. But instead I took the parenting route, saying that I thought it was fine for now, but that as he grew older and learned more I thought he would find more things in the real world to be of interest. Yu-Gi-Oh is fine for now, but if you’re still playing in Grad School we’ll need to talk.
What I didn’t say is that, having been a teen at one faraway time, Yu-Gi-Oh will end when girls truly begin. So can I be faulted for encouraging him to seek out reruns of Baywatch? Hmmmmm. I think not.