Yeah? You and What School of Thought?!

I was assigned a patient because she was considered relatively easy, but by noon she became confused and hostile. At one point she told me her son was a cop and she was "gonna get him and his philosopher buddies, I mean police officer buddies after you!"

I wish I had a tough gang of philosopher buddies. I bet the alchemists were pretty tough.

Ethical Dilemmas in Nursing School

The Peaceful Parenting blog featured my post on circumcision as Circumcision: A Male RN's Perspective. With a comic I should've used here.

She has another guest post related to nursing and circumcision, The Day I Withdrew From Nursing School. I was never put in a bind like that in school (and a circumcision is pretty bad to watch), but there were a few things about the mother/baby rotation in school that didn't sit well with me, and one was definitely the way moms handled the circumcision decision (since you have to sign consent), and they all just shrugged and said yes or sometimes, if they were African-American, no. If they asked the MD or RN for their professional opinion, the answer was usually "Well...it's not really necessary, but you can do whatever you feel is best." (Funny, this is sorta like the half-hearted position on circumcision which the American Academy of Pediatrics takes.) And the parent would say whatever they felt like saying. I felt like I couldn't say much of anything, as a student who was being constantly watched. The only good thing about such lackluster half-hearted decisions is that it would hopefully be that much easier to get society to abandon the practice if nobody really cares one way or the other.

I did, however, almost pass out and feel like giving up when they gave a woman an epidural without what any prudent practitioner would call informed consent. But I generally chose to put the blinders on when it came to things I didn't agree with or feel comfortable with—especially in ob/gyn and peds because those are chiefly observational rotations. I wanted my professional license and I knew how I would practice.


Some of these dilemmas may even occur for those studying for a medical coding certification.

And By The Way It's HIPAA Not HIPPA

I'm finally finished drafting a privacy statement regarding my blog. I've been researching and writing it on and off for a few weeks now. I'm curious what you think.

Believe it or not, the law does not have a lot to say about blogging and patient privacy. Because HIPAA is about privacy from a business point of view, it deals more with clinical record-keeping, insurance payments, and whether you, as a working medical professional, are accessing the correct records at work. It has little to say about what you, as a professional, write about on your days off.

But I ran across this interesting quote (which I put in my statement):

There are no restrictions on the use or disclosure of de-identified health information. De-identified health information neither identifies nor provides a reasonable basis to identify an individual. ...the removal of specified identifiers of the individual and of the individual’s relatives, household members, and employers is required, and is adequate only if the covered entity has no actual knowledge that the remaining information could be used to identify the individual.

I like to think that my blog goes above and beyond this. I think that, even without identifiers, I wouldn't want to see my entire health story displayed for the world to see by some blogging nurse or physician who, say, thought I was annoying or bizarre.

I don't want to get all preachy and moralistic, but I think that in anything you you write about a particular patient, you should ask yourself, is this edifying? Does it help anybody? Is it interesting, or is it just gossip or voyeurism? If my coworkers or the patient saw this, even if they were assured of their privacy, would they be happy in how I depicted them? Etc.

Any thoughts? Or criticism of what I say on my privacy page?

Read the Privacy Statement and Disclaimer here.

Wearing RN Pants. Fer Real.

I forgot to mention my other I'm-a-big-boy-now story. I accompanied one of my patients down to have a central line inserted and it ended up taking FOREVER. I was sitting at the desk in the observation room since they were shooting live x-rays. At one point the interventional radiologist, exasperated, pokes his head out the door into where I'm sitting and says "Hey! Can I shoot some contrast dye in this guy or does he have an allergy?" And before my eyes I saw the whole process: anaphylactic shock, doctor gets sued, I lose my weeks-old license, doctor sues me because he lost his practice, etc. But somehow I said "No, just to Vicodin" and without a word, he went back in and the insertion proceeded—successfully. And nobody died!

On the Job

I've had two days on the job as a real RN. I got the job in the surgical ICU. We do mostly trauma, but we're also a big neurosurgery center.

I'm operating on my own license—under a preceptor, of course, but after two years of shadowing nurses and learning on the job I'm finally able to do everything legally on my own. My preceptor is extremely proactive. She momentarily asked if I wanted to observe or to do things, and before I could say anything (though I was thinking, I've seriously observed enough nurses in my day), she changed her mind and said I would take a patient.

So far I've spoken as a nurse in person and on the phone with family members, other nurses, doctors, anesthesiologists who have important questions before surgery, etc. Nobody has told me I sound like a moron!

Today I admitted a patient from another hospital's ER. It's interesting being a referral center. And as I was walking home (since I love close enough to do that) there was an ambulance blazing into the ER. The place never sleeps.

Circumcision: A Male's Perspective

Update: This post has been featured as a guest article on the Peaceful Parenting blog...and features a comic. So you almost might as well go there!

Before having my first son, we were presented with the routine decision (at least in the United States) of whether to circumcise him. While we were initially assuming we would, we did some research. We began finding that not only is male infant circumcision almost never medically necessary, but it's not even performed by most of the developed world. Most European countries never began circumcising in the first place. The United Kingdom doesn't pay for it; it's an out-of-pocket expense. The United States is the only secular country which routinely circumcises males.

I can attest to this now, because I worked for six years as a certified nurse aide prior to becoming an RN. I worked with countless uncircumcised men, mostly European immigrants in Chicago: Poles, Serbs, Lithuanians, etc. Younger men and older men. Men who could walk to the bathroom and men who constantly soiled themselves. Men who had indwelling Foley catheters and men who didn't. Men who were impeccably clean and men who were homeless. Men who were healthy and men who were critically ill and severely immunocompromised.

Never once did I encounter an adult male patient who had ever had a medical problem due to being uncircumcised.

Not only that, but during the cleaning of patients, I only ever worked with two nurses (that I remember) who would actually go through the rigamarole of retracting the foreskin, cleaning the glans, and replacing the foreskin. That's what we were taught in CNA and nursing school, but almost everyone would leave it alone. I suspect most people who work with a high uncircumcised population do the same. If it never presents a problem, it's always clean, and you're just causing discomfort, why do it?

In fact, female patients are far more prone to fungal and bacterial genitourinary infections than male patients are—yeast infections, urinary tract infections, abscesses, etc. And we know that this is largely due not only to their shorter urethras, but also to their labial folds—their "excess" skin. Why don't we cut that off? Why isn't female circumcision considered for infection prophylaxis? That's how we think of male circumcision. Except the reality is that, as with male patients, the benefit of circumcision would be minimal, because the number of serious complications of letting women stay "uncircumcised" is extremely minor.

So as it stands, we have two boys who are uncircumcised. One's almost five years old and the other's nearly three. They've never had a problem. During diapering they required less care and bother than our girls did. And now, during bathing, we don't retract or mess with it.

They're clean. They're fine. I suspect that someday they'll be like my patients were: ninety years old and uncircumcised—with no regrets.

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An Ideal Business Model for Hospitals

I think I'm working at the perfect hospital. Okay, so it's not perfect, but there's two things that make it stand out from anywhere else I've worked or had clinical experience.

One: a few years ago, under a former administration, its satisfaction scores were apparently in the toilet. Patients hated it, physicians loathed sending their patients there, and employees were all unhappy. Some of their scores were apparently below the 10th percentiles. Under the new administration, over the course of a couple years, all those percentiles went up to the 90's. The new CEO thinks that you can't do business in a hospital without associate satisfaction, patient satisfaction, and physician satisfaction. Okay, sure, anyone can say that, but it seems like their money is where their mouth is. They reinforce and reeducate constantly on how happier patients means an easier job for the nurse, who can then take care of real issues; how happier nurses means better care for your patients if you're a physician; and how happier nurses and physicians means you're probably receiving very good care if you're a patient.

There's a real contrast between this hospital and other places where physician and patient satisfaction are the only valued indicators...or even just physician satisfaction, at the cost of patients.

Two: it's a Magnet hospital. Magnet status is the highest award a general nursing staff can achieve. I don't understand the whole process, but for me it essentially boils down to: they believe that RN certification and education, and RN autonomy, benefit patients and improve outcomes. They will help you get your bachelor's in nursing, your master's, your advanced practice license, and all sorts of subspecialty certifications like critical care (CCRN), trauma nurse specialist, certified emergency nurse, etc. They have nurse-led committees to improve patient care. They have a shared governance group that works with administration, since administration admits (how often does this happen?) that nurses know how nursing units need to be run. Each unit has a traditional manager, who does payroll and scheduling and maintains discipline, and a clinical manager, who educates staff and monitors outcomes and maintains the clinical operations of the unit. And they develop nurse-led protocols which the physicians then all consent to—so there are tons of protocols—for heart attacks, stroke, lytes, diabetes, whatever. If your patient's potassium is low, and you're in a protocoled unit, you just hang a potassium rider. The protocol guides you. You don't have to bother the physician and wait for orders. It exercises your critical thinking skills more, which is probably a good thing, but it's also more timely and efficient for patients.

And the collaboration between physicians and nurses is incredible, especially on specialized units like mine where the same intensivists and residents are there all the time. They know how to communicate and trust each other. The physicians have a high expectation that the nurses to know what they're doing, more than I've seen at other hospitals; but for the same reason they trust the nurses to know what they're doing.

It's too bad not every hospital is like this.
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My New Robotic "Coworker"

The pharmacy at my new hospital has a PHARMACY ROBOT (not pictured below). His name is TUG (actually, it is a TUG), and it looks like a mini-fridge on wheels. It delivers medications to the floors. It is "mapped" to the entire hospital, so it navigates itself, even using the service elevators. It also speaks.



It's been in the hospital for a long time, longer than the pharmacy manager (who was doing our orientation) can remember, but they don't use it very often anymore. The reason is that, while it has sensors and has never hit anyone or anything, it gets very close to things—within inches. It makes close shaves by people and carts, or it will stop right up next to someone, which is apparently somewhat alarming, especially to visitors. It also sometimes blocks people in, following them into bends or corners in the hall and then stopping right up next them. It's trying to not to hit them, but they just feel like they're being held hostage in the corner.

Like I said, it speaks to people. If someone touches it, it says "Don't touch me!" If it's getting on the elevator and someone enters along with it, it says "I prefer to ride alone. Please let me ride up by myself." If you insist on staying, it tries to get back off the elevator, which leads to some awkward situations where people and the robot are both trying to get on and off the elevator at once. And if you push it, say if it's got you cornered and you're trying to escape, it tells you not to push it.

It also has a large button that people can use to send it back to the pharmacy if they think it's doing something in error (like cornering Grandma in the hallway), so nurses are always hitting the button and sending it back, while meanwhile some poor pharmacist is roaming the floors looking for it.

They say it's still useful, they say, for delivering heavy things, like fifty bags of IV saline. That's awesome, because hopefully I'll run into it (him?) someday.

Incidentally, the hospital where my final school clinicals took place had mopping machine robots, like little zambonis. Maybe the next sexy hospital drama soap opera TV show should be about hospital robots instead of residents.

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I'm Being Orientated. Oriented. Orientationed?

I'm finally beginning the orientation process for new RNs. After being informally offered the job by the manager of the unit, I then found I had to go through three formal interviews: one with the nurse recruiter (in human resources), one with the manager, and a "peer interview" by three nurses who will be your coworkers. The peer interview is, somewhat surprisingly, the most important one, because they have the final say on whether you're hired. Apparently nurses have been hired by HR and management and denied by the peer team. I kinda like this idea, because I know I've worked for some good, insightful managers in the past, who sometimes still managed to hire people who made you question what they were thinking.

Anyway, this process took approximately a month after the initial job offer. In the meantime I had given my old job notice (assuming I had a new one!), so found myself unemployed for about a week.

RN orientation consists of several days of classes. Let me tell you, coming off of two years of nursing lectures, there's nothing a new ex-student enjoys more than EIGHT HOURS A DAY of more lectures! But some are pretty interesting, actually. A nurse from the Risk Management team came and told us all about what happens when you're sued as an RN, alone or as part of a suit against the hospital; how to not look like an idiot in court, and what lawyers have to do with your (hopefully complete!) documentation. But other things have been less appealing—covering some old ground on common disease conditions, etc.

The people I really feel bad for are the nurse practitioners and advanced OR nurses who have to endure this. Most of our class consists of new graduates, but these people must be bored stiff.

Thankfully most of our lecturers have not depended on Powerpoint. After college, I loathe sitting there watching people read Microsoft Powerpoint slides (in place of lecturing) more than anything else in the world.