Saturday, December 21, 2013

In all parts of life, practice makes perfect.

Video of 20 day old Husky puppy learning to howl.
Probably won't be as cute when it is a 110 lbs.

Saturday, December 14, 2013

What nursing shortage?

The hospital system where I pick up shifts as an RN recently went through a round of asking nurses and other staff to take ”voluntary severance packages”, or more accurately early retirement. They needed more than 200 people to accept this offer or they would need to start layoffs soon. This is not unusual as many hospitals including one of the largest systems in the country, Kaiser Permanente, has been recently been doing the same thing at their 37 hospitals and asking people to take severance packages and leave.

This is a good and a bad thing for nursing. Why is getting rid of RN’s a good thing? Because a lot of these retirement packages were aimed at nurses and staff who were hanging on, and needed encouragement to leave. I can’t blame them when in the bay area a nurse can easily make over six figures. But, healthcare is a business in this country and money will always be a factor in how decisions are made. It is hard to see some of them go because of the wealth of knowledge they had for newer nurses. However, maybe in a few years this will open up jobs again for new grads in this area.

The bad is if there was a nursing shortage do you think they would be getting rid of nurses, even expensive ones? You can Google nursing shortage myth or not, and get many reasons for the pros and cons of whether there is a nursing shortage now or in the future. All I know is around here new grads are not finding jobs. This may be different other parts of the country, but if you are going into nursing do some research. Because nursing schools will cry shortage, but they need students and their money. People need to make sure nursing is what you want to do and not because it is a job or you can’t think of anything else. 

Saturday, December 7, 2013

Nurses are sick people, it keeps us sane

Floated to a floor with a nurse who was taking early retirement. Her daughter and a friend made two cakes to say goodbye. I had to take a picture and add an appropriate caption.

Preface: Nurses work with body fluids on a daily basis, and most have a sick sense of humor to go along with this type of work. We do not laugh at patients, but we do laugh at some of the things we have to put up with (OK, we do laugh at some patients), it is a pressure valve for a job most could not do.

Anyway, this is one of the cakes. It is a carrot cake with blue fondant icing in the shape of a bedpan, mango syrup in a colostomy bag, and a Baby Ruth candy bar in mango syrup filling the bedpan. Although tasty many could not eat it after the realism.

Tuesday, December 3, 2013

What to do?

I have been MIA on this blog for a while getting through the paperwork of both the state and federal government of my NP license. Now that I am an NP and have furnishing privileges , I wonder. No longer about the journey to get here or that I can write scripts. But what should I do now?  I need a job and to get experience. A minimum of 2-years if I want to practice in one of the independent states.
I see many independent practice state are trying to lure NPs away from restricted states (as in the article below), but the pay rate is about the same. I would love to be independent but the comfort of a doctor's availability and knowledge is invaluable.
I need to stop thinking about what if's and just get a job.

"New Mexico governor wants to recruit Oklahoma's nurse practitioners by Jaclyn Cosgrove

Governor Martinez wants to market New Mexico beyond its ski vacations, hot air balloons, beautiful desert sunsets and art museums.
Simply put, Martinez wants Oklahoma's nurse practitioners. Unlike Oklahoma, New Mexico allows nurse practitioners to practice with “full authority,” not requiring them to have a physician sign off on care in order for them to have prescriptive authority. Martinez specifically mentioned Oklahoma in her recent announcement of the campaign, adding that she hopes to further reform her state's laws to remove any barriers that nurse practitioners moving to New Mexico might face when opening their practices. “The full implementation of (New Mexico's Medicaid program), coupled with Medicaid expansion, will further increase the demand for highly trained and qualified health care professionals in New Mexico,” Martinez said in a news release. “By streamlining the requirements for nurses seeking to bring their talents and skills to New Mexico, we can further ensure that more New Mexicans, especially in rural and underserved areas, will have access to the high quality of health care our families and communities deserve.”

Time to move?

Moving to a state like New Mexico was, at least for a moment, in the back of nurse practitioner Damarcus Nelson's mind. Nelson graduated about two years ago and was thinking about where he wanted to practice medicine. But he had family in Oklahoma and a wife, pregnant with twins. Moving wasn't an option at the time. “I feel like if we stay here, we can push the envelope better to get independent practice here, as opposed to trying to run to another state,” Nelson said.
Nelson, who has a doctor of nursing practice degree, works near Yukon with Toni Pratt-Reid, the first nurse practitioner in Oklahoma to open a private practice more than 10 years ago.
Under Oklahoma law, a nurse practitioner cannot practice medicine unless he or she has a physician willing to supervise him or her for that prescriptive authority. However, the law doesn't require physician supervisors to review patient charts or even practice in the same building.
At Pratt-Reid's office, there is not a medical doctor or doctor of osteopathic medicine who works in the office with them. “We wouldn't practice any differently if we had full autonomy,” Pratt-Reid said. “Nothing that we did here would be different, other than we wouldn't have to jump through extra hoops to get the same amount of care ... . The sooner we get to where New Mexico is, the better.”

Many states open to practice

Oklahoma is one of about 12 states that requires a nurse practitioner to have a team leader or management from an outside health discipline — such as supervision from a medical doctor — in order for that nurse practitioner to provide care, according to the American Association of Nurse Practitioners. About 15 states — some that require stringent restrictions and some that simply curtail one element — have bills in 2014 that would reduce restrictions, according to the group.
No bill has been discussed or announced in Oklahoma. New Mexico and Oklahoma face similar problems, with large shortages of medical professionals across both states. Thirty-two of New Mexico's 33 counties are designated by the federal government as Health Profession Shortage Areas, according to the governor's office. Only four of 77 counties in Oklahoma are not designated as Health Profession Shortage Areas, according to the state Health Department.
Rep. Doug Cox, R-Grove, has focused many of his efforts at the Capitol on Oklahoma's doctor shortage. Cox, a medical doctor for more than 30 years, said medical “extenders” — nurse practitioners or physician assistants who extend the care medical doctors provide — are a necessary part of the health care system. Cox is the physician supervisor for a nurse practitioner in Grove, a city of 6,600 in northeast Oklahoma. More than 1,200 doctors in Oklahoma are supervising about 1,000 nurse practitioners, according to data from the state medical board.
Cox said he saw a need for a medical professional to help treat people, and he felt like supervising a nurse practitioner would be a way of doing his part to address the provider shortage in his area.
“The No. 1 reason I see people in the ER is because they can't get into a doctor's office,” Cox said. “There just aren't health care providers to serve the need, but our nurse practitioners have liberal prescribing authority.” Nurse practitioners in Oklahoma are not allowed to prescribe certain drugs, including oxycodone, a strong pain medication, and Adderall, a drug prescribed to children with attention deficit hyperactivity disorder.
Tulsa nurse practitioner Mindy Whitten said such restrictions regularly create a problem at her job.
Whitten works at an urgent care medical office, a setting where health care providers regularly prescribe Schedule II drugs like oxycodone. If a medical doctor isn't at the office when a patient who is allergic to codeine and hydrocodone comes in suffering pain, there aren't many other options for her to prescribe.
“I don't have a pain medicine I can write for them because the next one is oxycodone, and that is a Schedule II drug,” Whitten, the legislative chairwoman of the Oklahoma Nurse Practitioners, said. “I have to tell them, ‘I'm sorry, I can't write a prescription for you. You'll have to go over to the ER.'” Another obstacle that nurse practitioners face is in paying physicians for signing off to supervise them, she said.
For example, some physicians charge nurse practitioners between $2,000 and $3,000 each month, she said. It's a charge they wouldn't have to pay if they lived in states like New Mexico.
“Nurse practitioners are starting their own clinics in rural and underserved communities,” she said. “If I'm going to pay $24,000 a year, I can live in New Mexico and not worry about it and own my own practice.”

Dr. Gabriel Pitman, a trustee on the board of the Oklahoma Osteopathic Association, said if a doctor is playing a role and is available to a nurse practitioner, they deserve compensation for participating in the nurse practitioner's practice. Under Oklahoma law, a physician supervising a physician assistant is required to be on site at the clinic for a certain amount of time each week, whereas with nurse practitioners, a physician isn't required to be at the clinic.
Pitman, an Oklahoma City neurologist, said a physician is necessary to supervise a nurse practitioner or physician assistant because they aren't as rigorously trained as medical doctors and doctors of osteopathic medicine. In Oklahoma, nurse practitioners are required to have a master's degree along with clinical hours. Requirements are expected to change in 2015 to require a doctorate.

The Oklahoma Osteopathic Association supports nurse practitioners and physician assistants in the roles they serve in the health care system — just not without supervision, he said.
“We feel that a physician must always serve as the team leader, as they are the only comprehensively trained health care professional prepared to make a diagnosis and establish a treatment plan,” he said. “We feel direct access to nonphysician health care professionals endangers patients' health. We feel direct access also puts the patient in the unfortunate and confusing position of being forced to choose among the series of health care professionals, not all of whom are adequately trained to make well-informed diagnoses.”

Sunday, September 29, 2013


Because of school a bunch of people I would never have been friends with in the real world, I now consider friends. However, reality is only a few of us will stay in touch now that it is over and most go on their way with family and professional life.

Still studying and jumping through hoops of paperwork, verifications and government regulations so I can finally sit and write my boards. After a vacation I should be able to write the boards by the end of October.

This blog helped me get through school and in its current form I think this blog has run its course. I have other ideas to explore, like Twitter which seemed interesting for about 2-weeks. However, other sites and platforms will work better for what I am thinking.  


Sunday, July 28, 2013

Kaiser Permanente Profits versus Patients

Kaiser Permanente the largest private managed care organization in the U.S. and only second in size to the Veterans Administration.  Over the past decade Kaiser Permanente has also gone from a reasonably priced alternative for health care to one of the most expensive in the country.  KP offers no explanation for the increased costs, only that this is part of doing business. Decades ago Kaiser was a non-profit that helped all people, then they changed to a for profit model, using wording that still claims non-profit status. Although, KP did reported almost $3 billion in non-taxed profit last year, and CEO George Halvorson’s annual compensation was $6.7 million.

Here is the problem; Kaiser Permanente is a private company owned and run by doctors. This is not unusual many hospitals and health systems are owned and run by doctors. But companies like Southwest Airlines are also owned by their employees, but Southwest tries to keep their costs to the customers low.  However, at Kaiser it is only the doctors getting annual profit sharing. So when making a decision about a patient’s medical care does the doctor also think about saving money, costly procedures, and those annual profit-sharing checks. Face it, the more profitable the company, the bigger those bonuses. Sounds like a big conflict of interest when your doctor is deciding between patient care and their bank account.            

Monday, July 15, 2013

Next Chapter

Clinicals are completed and my final project handed in.  Which means I am finally done with school, well unless I go back for my DNP or PhD, and that will not be happening this year.  Board certification and a resume will be the next projects.  Now that I have started looking at jobs, it feels good to see so many available. I have physicians and NPs that I worked with willing to give me references.  You always want doctors you worked with for your references, but always wonder what they really thought about your skills. The medical and nursing models are different ways of working and caring for patients.  
One doctor is trying to get me a job where she works, but I don't know if that is a good fit. I would like to stay here, but the other day Las Vegas sounded good, now that Nevada has passed the bill for NP independence. The only bad thing about Vegas is I do not like the desert climate.  

Anyway, maybe for the next chapter in life I should start a new blog. Especially one not connected to the Google platforms. Although nothing is going to happen for a few weeks while I rest first.   

Sunday, June 23, 2013

AMA Decides Obesity is a Disease

The American Medical Association (AMA) decided, and it is their opinion, that obesity is a disease. Like every profession the AMA is an association that can be joined by doctors and medical students, but they have absolutely no authority to officially classify a disease. The World Health Organization and CDC can actually classify a disease, but so far they have not agreed that obesity is a disease. 

So, at the AMA’s annual convention this year, and against their own counsel’s advice, the majority voted to say obesity is a disease. Even after the AMA Council on Science and Public Health, which had examined the subject over the last year, declared that obesity should not be classified as a disease because the measure that is used to categorize obesity is flawed.  However, at their meeting the majority of physicians voted to say obesity was a disease. Therefore, it is now their opinion that 78 million or 1/3 of the US population has a disease.
Is calling a disease less of a stigma than telling a patient they have a serious risk factor they can influence.

Instead of doctors pushing for lifestyle changes does this open the door to more surgery, medications, and insurance reimbursement for obesity treatment?

For many years the CDC has recognized that the two biggest preventable causes of death are using tobacco products and obesity. Obesity is not a disease, but a risk factor for other diseases, like cardiovascular disease, diabetes, hypertension, metabolic syndrome, etc.  

Should we now say smoking is a disease or is it still the cause of a disease? 

I am waiting for my first primary care patient to tell me they have the disease obesity. 
Yes obesity is serious, but instead of running for the knife lets first try:
Dietary changes
Exercise and activity
Behavior change
And if needed prescription weight-loss medications.  

Wednesday, June 12, 2013

Graduation and summer

Graduation week, but that does not mean the work is done. In grad school you can still walk, even though they give you a little extra time to finish some requirements. Like a 30 page paper and clinicals until the end of the month. I will miss my primary care clinical site. However, it is starting to feel strange that this school part of my NP journey is over in 3-4 weeks.  

But come mid-July it will be time for me to mentally and physically clean my house and mind after years of school dictating life.  

So many stacks of papers, references, Power-points and lecture materials that I thought I might need one day, will be placed with love in the recycling bin. I will keep the important books and notes, but literally there are stacks of paper feet deep. Yes, I still prefer taking notes on paper and reading books with pages instead of e-books. So much easier to write in the margins and highlight in a book.  

Then I will need to take care of, boxes that are rarely opened and need to be evaluated and items tossed or donated.

Electronics and cell phones not used for years need to be recycled.     
Clothes still with tags that I will never wear. They were gifts from my Mother, and sometimes her taste is good and at other times it is not my style, but I still love her for sending them and so will the Goodwill.       

After a good mind and house cleaning the rest of the summer will be studying for boards and working on a resume. Although, no hurry in looking for work yet before September. 

Saturday, June 1, 2013


Another reason I was never interested in pediatrics.  

The other day a friend’s 8 years old, rationalized and told us that we are old because we were born in the "nineteen hundreds".

Their reality is so different from mine. 

Thursday, May 9, 2013

Affordable Care Act

A lot of people don’t know that if you are insured you should not be paying a co-payment, deductible or anything for any of these services. But the doctor’s office or insurance company will not tell you that.

Direct from the website:

"Preventive Services Covered Under the Affordable Care Act

If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a co-payment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider.
15 Covered Preventive Services for Adults
  1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  2. Alcohol Misuse screening and counseling
  3. Aspirin use for men and women of certain ages
  4. Blood Pressure screening for all adults
  5. Cholesterol screening for adults of certain ages or at higher risk
  6. Colorectal Cancer screening for adults over 50
  7. Depression screening for adults
  8. Type 2 Diabetes screening for adults with high blood pressure
  9. Diet counseling for adults at higher risk for chronic disease
  10. HIV screening for all adults at higher risk
  11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
  12. Obesity screening and counseling for all adults
  13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  14. Tobacco Use screening for all adults and cessation interventions for tobacco users
  15. Syphilis screening for all adults at higher risk

 22 Covered Preventive Services for Women, Including Pregnant Women

The eight new prevention-related health services marked with an asterisk ( * ) must be covered with no cost-sharing in plan years starting on or after August 1, 2012.
  1. Anemia screening on a routine basis for pregnant women
  2. Bacteriuria urinary tract or other infection screening for pregnant women
  3. BRCA counseling about genetic testing for women at higher risk
  4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  5. Breast Cancer Chemoprevention counseling for women at higher risk
  6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
  7. Cervical Cancer screening for sexually active women
  8. Chlamydia Infection screening for younger women and other women at higher risk
  9. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
  10. Domestic and interpersonal violence screening and counseling for all women*
  11. Folic Acid supplements for women who may become pregnant
  12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
  13. Gonorrhea screening for all women at higher risk
  14. Hepatitis B screening for pregnant women at their first prenatal visit
  15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women*
  16. Human Papillomavirus (HPV) DNA Test: high risk HPV DNA testing every three years for women with normal cytology results who are 30 or older*
  17. Osteoporosis screening for women over age 60 depending on risk factors
  18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  20. Sexually Transmitted Infections (STI) counseling for sexually active women*
  21. Syphilis screening for all pregnant women or other women at increased risk
  22. Well-woman visits to obtain recommended preventive services*

Tuesday, May 7, 2013

Medical Marijuana

First, I live in one of the medical marijuana states. I believe for a few individuals it could be a useful medicine. It helps cancer patients, glaucoma patients and some others. But let’s get real most people who claim they use it for medical purposes are just getting stoned.

I was thinking about this again today because I heard on the radio that San Jose had 70 pot club or medical marijuana dispensaries and only 41 Starbucks. They want to regulate and close many of them. So a quick Google search revealed this is common in many big cities like Denver and LA, where medical marijuana is legal. They also have almost twice as many pot clubs or medical marijuana dispensaries as Starbucks. Funny they use Starbucks as a gauge, because we all know they are everywhere. 

If you have ever seen or been in a pot club or medical marijuana dispensary then you know 95% of them are a joke pretending to be clinics selling medicine. Remember the Speakeasy’s during prohibition or the 1800’s traveling snake oil salesman, that sold alcohol tinctures to cure everything from your libido to the mother-in-law visiting. Well probably cured both of those at times.

Anyway, most of these medical marijuana clinics and pot clubs are nothing more than bars with pot instead of booze.  They have counters, menus of different way to smoke or eat your marijuana, and tables to hang-out with your friends.  Does this sound like a clinic or an Applebee's. 

Two states have now legalized marijuana and a bunch more pretend that it is only distributed as medicine. In addition more than twenty states will fine you less than $100 for getting caught with less than an ounce or growing a few plants. Not even a slap on the wrist.

Outside of a few cases, people need to stop pretending it is some kind of wonder drug for everything from hangnails to gonorrhea,  and the states need to just legalize and tax the shit out of it, like alcohol.

Tuesday, April 30, 2013

Nurse Practitioners are not Medical Doctors

There is a national bill in the House of Representative called "Truth in Healthcare Marketing Act of 2013," (HR 1427). This would clarify for patients’ who someone is in healthcare.

Even if they have a doctorate or PhD, a nurse practitioner, chiropractor, physician assistant or psychologists is not a medical doctor. If you are treating someone in my family I want to know your background. I am proud to be a nurse practitioner and we have a lot of power as NPs. We perform physical examinations, diagnose and treat illnesses, order and interpret tests, prescribe medications in most states, and plan and implement therapeutic interventions.

On the other hand, I am not foolish enough to put myself in a class with most medical doctors, and patients should not guess who is wearing the white coat. I have met only one NP who was narcissistic and insisted she be called doctor by staff. Beside setting herself up for a lawsuit, I won’t tell you what the staff called her behind her back.  

This is a relevant topic because to be blunt, many patients are not educated enough, and have no clue to know the difference between the people in white coats. I wear a white coat now, but even in my nursing scrubs with my RN badge on, patients regularly call me doctor, and probably only because I am a male. Talk about confused.

Truthfully, anyone with a PhD or doctorate can call themselves a doctor, but that does not make them a medical doctor. In fact there are a lot of people out there in the world with PhDs and doctorates who like to be called doctor, and that is fine. However, I would never have them touch or get close to a real human being.  Thousands of people have Honorary Doctorate degrees like Stephen Colbert or Bill Cosby and can call themselves doctors. Do you really want them, a psychologist like Dr. Phil or the guy at the gas station with a PhD diagnosing your intracranial bleeding or cardiovascular disease?  

Thank God I know some doctors well enough to ask them medical questions, and I do so often. I am not a fool and will not pretend that I have the same education as a medical doctor.
MD's learn the medical model and as medical students they spend 10-15 years in higher education, medical schools and residency, and if they specialize add more years to that.
A nurse practitioner learns the nursing model and may spend 6-8 years in school.

 However, nurse practitioners are better and more equipped to deal with patients in several ways. We were trained to treat people more holistically and not just in a narrow allopathic or western form of medicine. We communicate better with patients and their families. We see the big picture more often. In most hospitals I have worked and research papers I have read, nurse practitioners consistently have a higher overall patient satisfaction score.  

Most docs love us and as NPs and PAs we are part of the solution to the primary care shortage. But a few bad apples can ruin it for a lot of people when it comes to trust and working together.  

Monday, April 22, 2013

Nurse Practitioner Scope of Practice Grades by State

NP's scope of practice varies widely from state to state. I know where I live and many states have current bills trying to improve NP scope of practice. Primarily because of the new Affordable Care Act, the shortage of primary care doctors and an aging population.

The state ranking below are from the Pearson Report. The most interesting thing I found was that only 24 states restrict Doctorate and PhD NP's from calling themselves Doctors. This is a pet peeve of mine, because as an NP you should never imply to a patient that you are a doctor without clarifying you are a NP. (more on that another time)

Hopefully change happens sooner rather than later in more of these states.

2011 Pearson Report
NP scope of practice laws

Alabama:  F                       Alaska:  A                      Arizona:  A                     Arkansas:   D
California:   C                    Colorado:  A-                 Connecticut:  B               Delaware:  C  
Florida:   F                        Georgia: F                       Hawaii:  B                      Idaho:  B
Illinois:   D                         Indiana:  D                       Iowa:  B                        Kansas:  C
Kentucky:  B                     Louisiana:  D                    Maine: A-                     Maryland: A-
Massachusetts: D              Michigan: F                     Minnesota: C                 Mississippi: C
Missouri:  F+                    Montana: A                     Nebraska: D+                 Nevada: C
New Hampshire: A+         New Jersey:  B                New Mexico:  A             New York:  B
North Carolina: F             North Dakota:  A             Ohio:  C                       Oklahoma:  C
Oregon:  A+                     Pennsylvania:  C               Rhode Island:  A          South Carolina:  F
South Dakota:  D              Tennessee:  C                   Texas:  D                         Utah:  B
Vermont:  C                      Virginia:  D                       Washington: A+           West Virginia:  C
Washington DC:   A          Wisconsin:  C                   Wyoming:  A

Sunday, March 31, 2013


 In early 2009 when the economy tanked and unemployment was over 10% I decided this was a good time to go back to school while things recover. The plan then was to graduate, get experience and settle down. Now the economy is recovering and I will be graduating, but I do not know where I want to settle. I am torn because I like my current location and everything about it. On the other hand my mother is getting older and I do want to be closer to her. 

I'm attracted to the west coast and it feels like I still have unfinished business here. But in the end I guess any job offers will still be the biggest influence of where I end up. Hopefully it does not take as long for me to recover from school as it has the economy. 

Sunday, March 10, 2013


 I’m assuming most NP programs are similar to this one and that we meet weekly with our instructor to discuss patients, clinicals and any concerns. For our primary care we are all located in different large busy clinics throughout the metropolitan area. These clinics are not in any way upscale or suburban; they provide services to the inner-city and underserved populations. But this is also where we get the best experience, because many of these patients are train wrecks with extensive problem lists.
Nobody has dropped out, so my cohort remains the same ten people after 18 months. We now know each other all too well. These weekly sessions lead by our instructor is a chance for us to decompress from the stresses of everything going on. Of course our favorite topic is patients and their comorbidities.

Everything we talk about is confidential. But we laugh at our patients, we feel for our patients, we get frustrated with our patients and we really care about them. It helps because we know we are not alone in the decisions and mistakes that we make. They are learning points. Our instructor with her decades of experience has some of the best and funny stories about patients and mistakes from her past.   

I want to blog about some of my patient encounters, but it still feels uncomfortable to post anything outside of the classroom for fear of being recognized. Even without identifying points in a post, all those confidentiality, HIPAA and ADA laws make me overly cautious while still in school.

Tuesday, March 5, 2013

Take what I can get

Feel so mentally beat up lately that even a card in the mail from Southwest Airlines made me feel better.  I Luv you too Southwest, now take me the #%*+ away.  

Sunday, March 3, 2013

Paths of Life

As I continue to walk the bigger path of life, it is hard not to look back at the smaller paths and exit ramps taken along the way. People, places and experiences are what shape your life.
And many times I have wondered how one decision, made years ago, along one of the numerous side paths, would have changed everything.

Would I be walking this current path of life to become a nurse practitioner, probably not. And who knows where I would be if one of a thousand decisions had been made differently. Honestly, life’s little journeys can have positive and negative effects, but they are only part of the aspects that make you who you are.

As easy as it is to look back at paths not taken and decisions that could have been made differently, so it is with looking forward on my current path. Sometimes I think that I should never be here, but yet the path is still beneath my feet.

Even though the end is close and I think I will see it just around the next ridge. There waiting for me is another creek to cross or hill to climb. So I will keep walking. Sometimes on a smooth trail, sometimes on a path that is overgrown and strewed with hazards. Life is just that way, and there will be a day when I will look back and wonder if I should have made different choices I have yet to make.  

Wednesday, February 20, 2013

Sick and Tired

Sick for 10 days or so, but since then I have been unbelievably tired. After school and clinicals all I wanted to do is sleep. So now it is catch-up mode for presentations and papers due.  

But it made me think, why don’t nurses get sick more often?

My sister the teacher always says she gets sick from being around the kids, and granted kids can be like little Petri dishes of germs. And at the clinic patients often say they must have caught something at work. Maybe that is true.

But what other profession depends on a business model that involves their staff having direct contact with sick, infectious and injured people. Clinics and hospitals rely on and persuade the sick to visit them. In fact they relish the various and obscure contagious diseases. Nurses and healthcare professionals must be hardy, because we get exposed to this daily. Next time I hear my sister talking about catching something at work I'll have to bite my tongue.

Tuesday, February 5, 2013

Gargle with Salt Water

Tried to avoid it, but to no avail. Some little virus or bacteria found its way inside of me and then kicked my ass, and left me wandering between my couch and bed for three days.  Most of it was in my respiratory system with accompanying throat pain, coughing and phlegm. The occasional headaches and muscle pains were just bonuses. 
The generic OTC cold and flu medication in my cupboard that expired six months ago can attest that I do not get sick often. Probably not the flu, but I will never know. Because like any good nurse I will try to avoid a doctor or urgent care visit, and self treat first. FYI, hermetically sealed expired medications still work fine. So I prescribed alternating acetaminophen, NSAIDS and Robitussin DM that seemed to keep things tolerable. 
However let’s be honest, the true secret weapon was gargling with warm salt water. Why does this always work so well on a throat that feels and probably looks like ground beef?

The holistic approach is still the best, because besides my salt water gargling, drinking hot tea with fresh lemon and honey was a good thing. Sympathy from others was appreciated, but not as much as a comforter on the couch, time and the occasional bowl of warm chicken soup with saltine crackers. Those things probably helped me as much as any over the counter medications. Chicken soup and saltine crackers no lack of sodium there.

Monday, January 14, 2013

McDonaldization of Healthcare

McDonaldization is a term coined by George Ritzer, when he wrote about the McDonaldization of Society. Basically, you rationalize a task and break it down into smaller parts to make it more efficient, faster and cheaper. Think of a time when a craftsman took time to manufacture a piece of furniture from start to finish. He would take a piece of oak and measure, cut, plain, chisel, border, stain and a dozen other step to make something of quality. Or a chef making something as simple as a good hamburger, there are a lot of steps. Start with good quality meat you have to grind, form and fry or grill properly. Fresh tomatoes, lettuce, onions and other produce to selected, washed and sliced. And fresh baked buns. Now think the opposite, McDonald's and IKEA. 

To increase production and profits companies turned to the McDonald's or assembly line method. A product comes down the line and a person does one thing. No thinking involved.

Most fast-food places operate this way. Frozen preformed burger, fries and food is delivered from a large factory somewhere. On the same truck comes, pre-chopped lettuce, tomatoes and onions in something that looks like a clear garbage bag. No real cooking going on, only the timers and beeps that tell the worker when everything is ready. One person takes your order and money, one person drops the fries, one person flips the burgers, one person assembles the food, and one person puts it in a bag and gives it to you. Efficiency without deviation or thinking. They even figured out how to have the customers work free, by filling their own drinks and clearing their own tables. IKEA has you pull and assemble you own furniture.

Yes assembly lines have their place and make things cheaper. Can’t imagine making millions of a cars or computers without an assembly line.
Healthcare has been McDonaldized. CEOs and bean counters see patients and care as products to streamline. Get them in and get them out. Like a fancy restaurant, the more times they can turn over a table during a shift, the more money made. Hospitals use beds instead tables. Healthcare has been broken down into small parts, like an assembly line of care. 

In any hospital, on any unit, you cannot avoid hearing the charge nurse, staffing and the shift manager referring to and arguing about the Bed Board. It keeps track of all the hospitals beds and who is in them. We shuffle patients in the hospital 24/7. A doctor orders a bed on a particular full unit, or a new patient needs a bed on the already full specialty unit. The shuffle begins. The people ordering the patients to be moved at midnight never see the patients. The shift manager says take the 35-year-old male on B5 to CVPCU. Then take the new admit to A3, because we are moving a patient from there to the med/surg floor. The ER patient on hold can then go to the neuro ICU, and the semi-stable ICU patient from neuro ICU can go to B5. . . checkmate. 

In the hospital, you will see every specialist there is because nobody deals with the whole person anymore. Chest pain cardiologist, a little confused neurologist and trouble peeing, a urologist or nephrologists will see you. They all specialize, one flips, one assembles and one hands you the order. Try to get a patient discharged and you need 3 different specialists to agree and sign off.

In the hospital, like Target, everything is computerized and bar coded, and we will scan patients, medications, supplies, equipment and staff.

I am in a large clinic now and it is the same. A person will check in, see a nurse for triage, see a practitioner and then the discharge person. If they need labs, pharm, x-rays or behavioral health, they can see from 4-8 people during their visit.  

In some clinics the provider has a set schedule and every 15-minutes they have to see a patient; 10:00, 10:15, 10:30, etc.  Unless you are a new patient and I am doing a complete history and physical, but those are only on Tuesdays. A regularly scheduled visit and you are limited to one problem. If you have another problem, you will need to make another appointment. You came in for a cough I will treat that. So the sore leg or mole you want me to evaluate. Sorry, no time. I will make sure it is not life threatening and can refer you to dermatology or orthopedics.

In my surgical rotations to observe, they have their own unique spins on assembly lines to make things quick and efficient.

Yes, again there are times when it is productive and makes sense to use some of these methods. However, people are not products to be flipped and hurried along to the next station in the assembly line.  

Monday, January 7, 2013

Escape Fire

I do not have the solutions, but just about everyone in healthcare knows there are problems, and we will not be fixing them anytime soon. One of my clinical rotations has me working with many homeless and uninsured individuals. Another clinical rotation has me working with an upscale rural population. None of that is the problem. The problem in this country is we do a horrible job educating and preventing disease in the first place, e.g., Primary Care.