Thursday, January 29, 2009

health disparites enrage me

Here is a copy of the email I wrote to the nurse educators on our floor about the patient I took care of yesterday:

Hi [nurse educators],
I would like to pass along the plight of a patient who was recently discharged from our floor. Because you are a nurse I very much respect, I thought I would share his story. This gentleman is 66 years old, a military official from Guinea, Africa, recently arrived in the US to visit his daughter and grandchildren. He collapsed in their home and was brought [here] by EMS. Unable to afford missing work, and caring for four young children, his family did not accompany him to the ER and did not arrive until the next day. He speaks no English, and required a French translator for all communication.

The patient was found to have a blood sugar greater than 500. He was re-hydrated and put on a sliding scale and intermediate acting insulin for meal coverage. Even this did not control his blood sugar, he still had chemsticks consistently in the 200-300s. He told us via interpreter that he took insulin in his home country of Guinea, but did not know what kind, and had not brought it with him to the US because he "felt fine".

His service was Medicine Newburgh, and they decided to discharge him the same day, but had to wait for family members to arrive before he could go. I took care of him both days. When his granddaughter arrived to take him home, she also spoke so little English that she required an interpreter as well. I paged social services and the MN service to come in and talk with her and the patient. The resident came in and told the patient that he could go home now. He did not mention to the patient that he would require insulin injections and frequent blood glucose monitoring. He did not explain to the patient what diabetes was or its consequences. After the physician left the room, I asked him about patient teaching. I was told that it "didn't matter", he was going to "end up in the ER again anyway". His discharge paperwork included prescriptions for a glucometer, insulin syringes, and novolin insulin to be taken 10 units BID.

I brought our glucometer, and insulin to the patient's room and with the interpreter present, I spent more than an hour and a half discussing and demonstrating how to check the blood sugar, what is normal and what is not, what to do if sugar is very low, or very high, what symptoms he might expect, to test and write down his glucose levels four times a day, how to draw up insulin, where to inject it, what to do if he misses a meal, the importance of eating consistently and a healthy diet... etc. I taught everything I'd ever learned and remembered about diabetic care. The patient and his granddaughter are very intelligent, he demonstrated back to me how to check his sugar and inject insulin correctly on his first try, and they both asked intelligent questions. I gave them written materials in French. I could tell that they were very concerned about money, and social work was working with them on temporary insurance. I sent them down to our pharmacy with the interpreter.

The patient is supposed to have a follow-up in the clinic within one week. I asked the physician for the name of his clinic nurse, so I could let her know ahead of time to speak slowly and clearly when scheduling an appointment with the family. I was told that he has "no clinic nurse". I worry that the patient will not receive an appointment time, or that he will not understand instructions on the phone. I also know that the insulin coverage he will administer to himself will not adequately control his blood sugar, and the long-term consequences will be devastating. I am disgusted with the care he received from the MN service, and wonder how it might have been different if he had had insurance, or had a been a white English speaker. The way I see it, those patients who face the great challenge of communicating across a language barrier, or who are unfortunate enough not to have insurance, ought to be given extra attention the best care that we are able to give, not simply sent home as though we do not care what happens to them just because they have no money, or don't speak English.

I have discussed this case with [our nurse manager]. I know that disparities in healthcare for minorities exist, but was shocked to see it playing out right under our noses on [our unit].

Thanks for reading.

Tuesday, January 27, 2009

language lessons

I had a patient today who spoke no English, only French. His family was not around, so I spent the better part of my day trying to remember high school French. I did ok... I guess. The interpreter came for the important stuff. My friend had a guy down the hall who only speaks Hindi... I did much better interpreting for him. I just love the fact that we are a hospital in such a diverse area, with so many beautiful cultures and languages flowing around us. It's refreshing.

So my Pod, or the section of our unit that I'm assigned to, has been nicknamed 'The Pod of Death'. Our acuity level is sky-high, with a ton of off-service total care patients. All these broken bones, and ostomies, and seizures... they need to go! We want CABGs, esophagectomies, and lung biopsies! This is other stuff is just... crap. And we're working like slaves.

Saturday, January 24, 2009

what a day, what a day

I never knew it was possible to do a 12 hour shift like I just did. Two discharges before 11, two admits before one. My first experience with a foley irrigation system, and a fresh esophagectomy who yanked his NG tube out 10 minutes before I was supposed to go home. Coffee, coffee, more coffee, and not enough time to pee.

My feet flew all over those halls, the hour hand on the clock was spinning out of control, but in the end I had a couple of satisfied patients, I think. At least, I'd like to think it made some difference.

Thursday, January 22, 2009

knock me down a few pegs

My manager was extremely impressed with my email from the previously mentioned world-famous surgeon who paged me with a kudos. She even showed it to my supervisor. After my stellar weekend, though, I took a patient with a fistula-turned-ostomy that kept leaking. The resident came and did the dressing change when it leaked, much to my relief. But an hour later, it leaked again. I've never changed an ostomy bag, especially one this complicated, and had to scramble to find someone to help me. I found someone and we got it done... in about 45 minutes, dressed in extremely stifling plastic gowns because the patient was VRE precautions.

Still, the patient was very grateful and wanted to fill out a 'You're super' for me (patients can fill these out and we get a certificate and a pin each quarter if we receive one).

I think I have my team for the Nepal trek. I'm hoping for permission to take a total of four nurses, including myself, from day shift, and at least one from night shift. I also have three nurses from other units.

The inauguration of our new president brought hospital staff together... I bonded with the transporter over our mutual excitement. Usually, they don't even talk with us nurses. I think it's been an amazing experience, and so many african americans have been talking with everyone now, instead of just with each other. It's made me happy that we are uniting like this, and crossing racial lines.

Tuesday, January 20, 2009

getting things done

I worked three days in a row, without switching patients. I find this the be the best way to move a patient's progress forward, consistency in nursing that leads to follow-through. I think it gets a nurse fired up to see improvement the day after she put in a lot of hard work. At least, it does me. I had some arguments with interns and residents, and really stood on my own two feet as a patient advocate and equal member of the health care team. I was proud of myself, proud of the flower that my patient gave me, proud of the message from our best surgeon that said 'Good Job!' on my pager, and proud of way I handled a particularly difficult patient, one that no other nurse could stand.

I am thinking about doing a self-defense program for the nurses on my unit. Not now, but later.

Thursday, January 15, 2009

my unit, my ball and chain

I'm frustrated. As interested as regular nurses seem to be in doing a service trek, management (especially senior management) is not that excited. Well, we've never done it before so I guess it's to be expected. We will just have to will it into being, without any extra support. Maybe when we do it again, it'll be different.

I feel very tied down in this job, the schedule is so rigid and I know that it has to be, to maintain order with such a large collection of employees. Still, it's stifling.

It's still amazing to sign my name with RN, BSN after it.

Tuesday, January 6, 2009

ambitious projects afoot

Yesterday was a long, tiring, yet worthwhile day at work. Near the end of my 12 hour shift, I had a patient wheezing loudly and desatting rapidly. Respiratory was paged, without response. The supervisor was paged. No response. 20 minutes later they showed up to give this guy his albuterol treatment. I was fuming mad. Only a few minutes later, I gave a scheduled dose of IV metoprolol to 73-year-old patient with a HR of 77. Less than a minute later, she was bradying down to 42. I stat paged our assistant charge, and then paged her service. She was asymptomatic so I wasn't panicking, just concerned. Everything worked out fine with both patients.

I spent much of the day working out the details of our unit trek to Nepal this coming fall. Springing the idea on my supervisor was nerve-wracking. She seemed cautious and I hope the idea will grow on her. We will be able to put a lot more in stone when the holiday schedule and vacation schedule comes out.

Today I met with the program coordinator for the Alzheimer's and Dementia certificate program at my alma mater. She was ready to sign me up for classes right then and there! Unfortunately, financial and time arrangements prevented that. I am hoping to get started right away and can't help but feel SO excited about it. Just working towards another academic goal thrills me to death.

Thursday, January 1, 2009

mandated, schmandated

It's not cool that they mandated me off on my ONLY holiday. I'm pretty sure it's an issue because I was already mandated in September. Totally didn't follow the rules on that one. I wanted the money, dammit!