Saturday, December 19, 2015

I'd Like to Buy the World a (Diet) Coke.

Some would say I just want to give the world a Coke. I say what's wrong with that?

We see so much poverty around us. It's heartbreaking knowing how our elderly are living around us. Here's a little something I want to share…

We awaken to a warm house with coffee already in the pot.
He awakens to a cold hard floor with cracks so wide, he can see the critters beneath who wait for the fire to get going.  He has some instant coffee, occasionally, if he had the money  to buy it.  I'm not sure he has firewood or the wherewithal to get it.
If he did, how does he get it to the house?
If necessary, we would get into our warm truck in the garage and go out a cut some wood. But in reality, we flip a switch and immediately have a fire in the fireplace, to enjoy as we sip that coffee. He could use the truck, to go out and gather some wood for the old wood stove,  but the holes in the floor board are bigger than those in the house…and he has to park it so far from the house and walk quite a distance back to the house. In the rain, snow and mud.
Since his momma died, life has seemed so much harder. She received a little check every month that helped pay the few bills they had, and when that last check hadn't been cashed after her death, he called to ask if they could cash it. Our great government told him he must return it and find his own way to pay those bills and buy the few groceries he would need to survive, along with his mentally disabled sibling who was left behind for him to care for.
They would spend the next several years surviving from the small check the sibling received, all the time avoiding any more government assistance, because he was too proud, yet at the same time, too embarrassed by his slight lisp and stutter, and the fact that he never learned to read, to attempt applying for assistance of any type, including Medicare and SSI.
Our hearts break for this situation and many others that are hidden in the nicks and crannies of our little mountain, but we swell with pride that there are people in the world, however forgotten, who still want to do the right thing and pay their own way.
I don't know what we will do to help them in the future, but as they age, the need is going to be great. Mobility issues will likely leave them stranded, or in a nursing home….except they have no insurance coverage for that. I'm  afraid a Coke is not enough this time.

These are my people. 

Mountain Health Clinic

Del Rio is a small town in upper East Tennessee surrounded by the Cherokee National Forest and the French Broad River.

In The Beginning

The idea for a clinic started with my cousin, Tina, and I on a road trip to Lake Lure, NC. It had humble beginnings as a free clinic because we didn't know what else to do, so we just did it free. 

First, we needed a place to hold the free clinic. The community center came to mind. We spoke with Tammy, went to the meeting of the board, and were approved to have it rent-free anytime it wasn't already booked.

We held our first clinic in September and saw ten people.

Second clinic, about 7 people.

We then decided there wasn't a great interest in this free endeavor and people were asking us to open a "real clinic." There were many Medicare and Medicaid patients in the area.

I started by hiring my friend, Dawn, to help with the credentialing.
Things we learned:

First: come up with a clinic site. We were lucky with the Community Center, but it will be more expensive when we outgrow it. They even had a phone and free wi-fi.
I spent $800 on an attorney and probably didn't need to. He did the LLC paperwork and drew up the articles of Organization.
Get a clinic name (LLC). This was $300.00
Get a supervising physician if required. This will cost whatever you and he/she decide.
Get insurance. $1100 - $
Once you have the LLC, you will need to get a business license in the County where the clinic is located. You can have the billing/mailing address at your house even if it's in another county. This was $15.
While you are at the court house, you will need to go to the Register of Deeds office and file/register your Articles of Organization. This was $7.

You'll need someone to help you with the credentialing paperwork if you have a full time day job, because hours and hours are spent on the phone, on hold and getting nowhere fast. If it's an option, use email first - we got quicker answers that way. 

Go to the Medicare website cms/gov and update your profile. You can do this online. I found I was still credentialed with four previous employers and had to remove them. 

Go to the Medicaid site for your state and look for provider links and follow the instructions. This, again, gets very frustrating and cumbersome. If you have someone who's done this before, it will help tremendously.

Tuesday, December 13, 2011

How Long is too Long to Live?

We often say we don't want our loved ones to suffer at the end of their lives, that we hope they just die in their sleep one day rather than have a prolonged illness. Often, in my line of work, I'm faced with hard decisions to make on behalf of a patient who cannot speak for him/herself, but more often than that, I am relying on some family member who just can't let go to direct the care of the patient.

Recently, I went to see a patient in an in-patient rehab facility. If you don't know what that is, it's one step above nursing home rehab. It's the type of rehab facility that treats head injuries and strokes; multi-trauma victims often benefit from the care that's offered there. Unfortunately, some in the community have figured out that some people make it there instead of going to a nursing home after a hip surgery or total knee replacement. This is all fine and dandy until it becomes obvious that no amount of rehab is going to put a 95 year patient on her way to living independently again. 

Mrs. Longevity looked really BAD. Most of the patients that afternoon were up in their wheelchairs, or up in the room, fully dressed, visiting with family members. This one not so much. I had seen her a couple weeks before, and had admitted her to the unit. At that time, she looked OLD, but not BAD. Make sense? This day, she looked dusky and gray; her voice was weak, but she was answering my questions with one word answers appropirately. She admitted to feeling short of breath, and her daughter just happened to mention that she had vomited after lunch, but only after I asked. After doing a physical exam and finding some major issues, I began to address them with the daughter. She mentioned that the swelling was new, that no one was following the fluid restrictions that had been ordered, and that her mother seems to be getting worse instead of better. She had not mentioned any of these concerns to the three specialists who had already been by that day (physiatrist, nephrologist, and pulmonologist). They had all written orders for various treatments like diuretics, chest xrays, EKGs...but no one had addressed the real question - how aggressive are we going to be here  in this rehab unit where we don't have telemetry available, or any type of standard cardiac monitoring. 

You see this patient was a full code status, meaning if her heart stopped, she was to be resuscitated. Her daughter was expecting full treatment and recovery, but the staff appeared to just assume that she was going to die in the rehab unit if she didn't make it out to a nursing home soon. The nurses kept saying to me, "she has been like this since admission." Which I knew was not true, since I was the one who admitted her and did her exam on admission. They documented she could walk 50 feet with a walker (but that was with the assistance of THREE people).


So you see, in a patient who is critically ill, which she definitely was, just being a "DNR" does not mean "Do Not Treat." She was neither, and was not being and could not be appropriately monitored in a rehab facility. The best a rehab facility can do for a critically ill patient would be comfort care, and in those cases, she would never have met criteria for in-patient rehab.

So then the conversation took place with the daughter:
Me: do you think your mother is worse today?
Her: oh, yes, she's been getting worse the last few days.
Me: are you prepared for her to get worse, because from what I see, she is much worse already?
Her: yes, I know...but what do you mean, prepared?
Me: well, if her heart stops, do you want us to do everything we can to keep her alive?
Her: oh, I can't make that decision, you'll have to ask her because she has always said she wanted to be on machines if it came to that.
ME to the patient: Ma'am, you appear to be very tired and sick today...
Patient:( in a very weak voice): yes, I sure am
Me: well, I think we need to be prepared in case something really bad happens, although I don't think it's happening right now, no one has put your wishes on the chart. If your heart stops while you are in rehab, do you want us to do CPR and life support, or just keep you comfortable?
Patient: keep me comfortable.
Daughter starts crying, and says she agrees it's the best choice.
I go out and tell the nurse, who says she has to get a paper signed by the patient, and at that point, she goes back in with the paper to sign, and says "Do you want us to do CPR if your heart stops?"
Patient: YES...(sometimes it's the delivery of the question, sometimes the patient really had no clue what you were asking them).
So at this point, I spoke with the ICU physician who came and talked with the patient and daughter...the patient remained quiet, but the daughter, when presented with the options of comfort care vs full court press, wanted everything done "because I can't send momma to a nursing home, we have to get her better." She was not hearing a word we were saying. (Later, according to the staff, she told one of them "I can't send momma to the nursing home because I can't live without her check.")
So, the patient went to ICU, received a foley, IV, telemetry, xrays, EKGs, and continued her dialysis (yes, she was on dialysis already when she was accepted to this rehab facility).  She will likely end up on a ventilator and her loving daughter will get to decide when to turn it off. (Update, she did end up on dialysis three times a week, totally bedridden and dependent on others for meals, toileting, turning, etc; but thankfully they decided not to do CPR at the end, approximately 3 weeks later, still in the acute care hospital).


What a way to go...would love to hear your thoughts!

Wednesday, December 7, 2011

Ashamed and Frustrated Nurse

Today I went in to see a patient in the hospital, and while I was taking his history, the LPN came in to give him some medication through his IV line. Lung cancer had taken its toll on his little body, and even though he has finished treatment and was told he is in remission, he is still quite frail. As he lay there, telling me about how the last two days had been filled with nausea, vomiting blood, and diarrhea every time he drinks water, the smiling nurse went about her business. She seemed so competent from where he lay. No hesitation in her actions, as if she's done it a million times. Oh, the confidence he had in her. He had no idea that she (1) didn't wash her hands upon entering the room, (2) laid two syringes on the bed without capped ends (one with saline and I assume the other with medication for pain) and (3) that she didn't use alcohol to wipe the IV port where she attached the needleless syringes - the same ones that were lying open on the bed. She smiled as she left, he thanked her and called her "honey."

This is not the first time I have reported this nurse for incompetence. I really don't think she understands that those simple omissions could lead to bacteremia, and in a patient this weak, possibly death. Please remind your students and colleagues to treat every patient as they would want their own family member to be treated.

Thursday, November 17, 2011

The Day the Med Students Cried

That's right. They cried. Because they felt they were in the way.
They were in the way, but we shouldn't have made them feel in the way.

The really interesting part was that I went to another medical office in town and saw a med student in the hallway - and she was CRYING! What is this school putting in the water? Are they flu shots laced with hormones? Wow!

How do I feel about helping train the med students? I love teaching, and have a lot to offer; most of them come in with the idea that they won't learn much, but by the time they leave, I make sure they can tell me something valuable they have learned. Like where to listen for CAROTID bruits, and the difference in Tylenol and Aspirin. Yes, I thought they should know that by third year, but I was wrong. Lord help us. And I mean that sincerely.

Monday, November 14, 2011

Renewing and Re-naming this Blog

I had abandoned this blog for a while, but I really need an outlet to express my frustrations with the state of the nursing profession. I will not get into details of where I work, but let's just say it's a community hospital that is fairly small, but we have access to most specialties, and if not, a patient can be seen for almost any problem within an hour's drive.

I work as an NP doing hospital rounds, so am writing lots of orders, admitting and discharging patients, and everything in between. One day this week, I went into work to be faced with 4 complaining (rightly so) nurses, who started their shift on a busy med/surg floor with an assignment of ten patients each. This is a floor that has a lot of elderly patients who require total care, and these nurses have two CNAs to help answer call lights, feed patients, take them to the rest room, bathe them, etc...I wanted to scream for them. Patients were frustrated, nurses were frustrated, and CNAs were just in survival mode.

This is not a new problem for this facility; when I graduated from RN school, my first job was at this same facility (over 15 years ago). I must say nothing has changed. I am so disappointed in healthcare at this point in my career. I do not work for the facility, but my company is contracted to work there as hospitalists, and our patients are at risk. Medication errors are found on every single chart I pull. I report to the supervisor, she tells them "don't do that," and it's the last that's ever heard about it.

Here are some specific examples:  I call the pharmacy to see why steroids were not given to an asthma patient the day before (they were not on the medication administration record even though they were for two days before that). The pharmacy reported they never received the original MAR, until 3 days later, which was the day I called about it. This went through 3 nights of "chart checks." Of course the nurses are blaming the person who was supposed to be doing the chart checks, but my response to that was, "if it was done correctly the first time, we wouldn't have to blame anyone for not doing chart checks."

Routinely, if home meds are restarted by the provider in the afternoon, I look at the MAR and 10 pm meds are marked "N/A" meaning "not available." I have asked pharmacy why these meds would not be available and all they can tell me is "the Pyxis is stocked." This is a problem. In my frustration, I told the supervisor about it, and she said she would take care of it. Her way of "taking care of it" was to go to the day shift nurse and tell her to pass it on to night shift that they have to give the meds that are ordered. DUH!

I had a renal failure patient with GFR of 15, on the verge of dialysis, and no labs were drawn (that had been ordered by both me and the nephrologist). The nephrologist came there to see her on a Sunday and no labs on the chart. How embarassing and frustrating that is, and it's happening way too often. The lab could not tell us why they were not drawn.

Sadly, many physicians never know there are medication errors or omissions, because they do not look at the MAR and pay attention (they think they can trust nurses, and they should be able to, but really...no).

Saturday, March 26, 2011

How I Met Burger King

This may or may not have really happened. All names have been changed to protect the guilty.

Picture THIS:

Med student comes out to give me report on a new patient he just saw and the report I got went something like this:

Student: Well, first of all he says his name is Burger King.

Me: Burger King?

Student: yes, apparently we are supposed to know this already.

Me: let's go meet this guy

Me to patient: Hi, I'm Jane, the nurse practitioner with the hospitalist service, I will be seeing you today; the med student gave me a report that you were having some chest pain.

Patient:  Yes, I was, but that ativan is all I need, I been telling the ER and now him and now you, that's all I need. And you know I'm Burger King, right?

Me: (further into the history) - do you do any street drugs?

Patient: Me? Hell, I've done them all in the past, not anymore though, not since 2011. No, really, it's been a long time, not since I became Burger King. I used to do it all, pot, special K; HORSE TRANQUILIZERS - but I don't drive when I do them.

This was the point where I burst into laughter and said THANK GOD FOR THAT!