If You Take Care Of Your People, Your People Will Take Care Of Business

A long, long time ago, in a city so very far away, I was an afternoon shift nursing house supervisor. In the course of my shifts, I would receive call offs from midnights, and attempt to discern that point at which nights would be short, and I would have to attempt to backfill their staffing.

One such evening, I had determined that nights would, indeed, be short. I started on the unit that was short, and called up. The first nurse I spoke with was the recipient of my stock spiel.

“Ms. Smith, golly, have I got an opportunity for you!”

She was amusedly skeptical. “Oh, you do? What sort of opportunity might that be, Mr. McFee?”

“Ma’am, I have the opportunity for you to make eight hours of time and a half, right this very night! What a deal!”

“What might I have to do, to earn this time and a half?”

“Why, simply keep your same assignment, and ride home in the morning glowing in the satisfaction that comes from a job well done!”

“Suppose I don’t have a ride home in the morning? I carpooled with Ms. Diaz, and she is completely uninterested in OT.”

I had an answer to that problem. “In that case, I’ll trot up there with a cab voucher for you!”

She was surprised. “Can you do that?”

“It certainly appears that I can, as I have the cab voucher right here in front of me!”

“But, I did not bring anything to eat later!”

“No problem. What would you like? We have KFC, pizza, Burger Biggie, and others not so far away.”

“But, I did not bring any money!”

“Who asked you for money? You’re working over, I will be sure that you eat, and have a way home. Any other concerns?”

“But, who is going to pay for the food?”

“Not you. Beyond that, not your problem!”

She sighed. “OK, let me call my husband. I’ll get to keep my assignment tonight?”

“Yep! I will so advise the night supervisor!”

“Thank you, Mr. McFee!”

“Ms. Smith, you are welcome. Thank you for being flexible!”

I caught up with the security supervisor, and asked him if one of his officers could make a chow run. I handed him a $20 dollar bill, asked for my change and the receipt, once Ms. Smith had her food.

The next day, I took my receipt to my boss, explained how I had negotiated coverage for night shift, and presented the receipt. She wrote out a petty cash voucher, and sent me to the cashier to get reimbursed.

Interview Skills

A long, long time ago, in a Galaxy not so very far away, TWWWBTP (The Woman Who Would become The Plaintiff) had graduated LPN school, and was starting her LPN-to-RN studies, and I was seeking a change of employment. I was looking to add ICU to my resume, since the grad school I had my sights on required it. This one hospital was recruiting, and proclaiming that nurses who accepted positions in their ICU, would receive a $10,000 sign on bonus.

I investigated, and learned that one half of this bonus would be paid upon completion of one year of employment, and the second half would be forthcoming after completion of the second year of employment. Sounded good to me, and so I arranged an interview.

Since TWWWBTP, at that point TDW-Mark I, thought that it would be problematic should I accept a job requiring me to drive halfway across the state, as this position would, perhaps she should investigate employment (and schooling) opportunities there, as well.

Sounded good to me.

On the appointed day, she and I arrived for our interviews. I learned of the position, and they told me, “You do know, don’t you, that we require a two year commitment from nurses in order to qualify for this bonus, right?”

I acknowledged that I did, indeed, comprehend this aspect of the arrangement, and stated, “Yep, I expect that I can wait two years before going to grad school!”

They acknowledged my comment, and we proceeded.

So, we concluded our interview, TDW-Mark I and I, and we sat in the lobby, awaiting their offer(s). We were summoned, and received the news: TDW-Mark I was offered a PART TIME, LPN job. As for me, well, I did not receive an offer. They informed me, “We are looking for nurses who want to come here, and settle down here, in our community. With your grad school plans, well, you do not appear to be a good fit for that sort of longevity.”

Cool story. We drove home, TDW-Mark I composing her “Thanks but no thanks” letter in her head, and I remarked, “Ya know, honey, I believe that I have figured out what I did wrong!”

She replied, with some side-eye, “Oh, really? What was that? Other than being truthful about your higher education plans, I mean?”

“Well, you see, I should have walked in there, paused just inside the door, and, James T. Kirk like, spread my arms in an all encompassing gesture, slowly turned, taken in a deep breath, and declaimed, “I…I..feel, I feel as if I have come….HOME! I….I want my children…to grow, TALL, under these…these Blue ! Skies!…I want to spend my days….Breathing! This! Clean! Air! I…I want…my..bones, to rest…to, REST…beneath …these green hills! I…I feel as if…I am…at..HOME!”

I looked over at my bride. She smiled, and responded, “So, you are telling me that you should have lied your ass off, right?”

“Of course, right!”

Questions Above My Pay Grade

A long, long time ago, back in Da City, I had left EMS, and was employed as a nursing house supervisor. In the course of my rounds, I stopped by ER. The staff chatted with me, revealed that things appeared to be under control, and they needed for nothing at that time.

One of the staff nurses drew me aside, and murmured, “Check out the ER doc that they sent us!”

I asked, of course, “Why?”, and was told, “Never mind! Once you chat with him, you will know!”

I approached him, introducing myself, and asked how his night was going. I was struck by the fact that he appeared to have several freckles about his face, each with a glint as of metal. Each, in fact, about the size of a pin head. I figured that was odd, concluded my conversation, and moved on.

I subsequently encountered one of the ER nurses in the cafeteria. “What did you make of Dr. Pins?”

“Couldn’t tell you. Never seen anything like it, before!”

So, a little later that night, I cruised through ER, again. (part of my “management by wandering around” strategy). The doc asked me if he could speak to me, in private. That was odd, but, sure, whatev’s.

So, back in the physician’s office, he began to describe a patient. I mean, as in how a resident (or a midlevel) would staff a patient with an attending. He wound up with his query: what did *I* (remember: the NURSING supervisor, with no provider chops whatsoever at this time) think that the patient ought to have done?

I tried not to stutter: I really, really did. I suspect that I failed, but I did manage to observe that other physicians had ordered this, or that test, and not uncommonly had discharged the patient with a prescription for this, that, or the other thing.

The following afternoon, my boss, the afternoon Nursing Director, and I had a chat. A lengthy chat. About Dr. Pins.

Above and Beyond

So, TINS©, TIWFDASL©…. Well, OK: REALLLLYYYYY!, I was holding up the counter, and awaiting my next patient, when one of the registrars came up and informed me, “Reltney, I’ve got this sick lady out in the drive up, and I really think you need to see her! Like, right now!”

To set the stage, my urgent care has (surprisingly!) urgent care patients, as well as folks who arrange to be tested for Da Rona. This latter group makes their appointment, drives up, telephones in to announce their arrival, and my registrar gowns up, registers them (now, THAT is a surprise, amirite?), and one of the MAs gowns up, strolls out, tests them, and hands a sheet of instructions (prominently featuring the admonition to quarantine for ten days, or until negative results are forthcoming) to the patient.

This particular soul had not made it past the whole “registrar registers them…” part. This particular registrar, let us call her Eloise, has been doing this for several months. She is one of those quiet, efficient, takes-care-of-business folks that make things in general, and our agency in particular, run. She is not a nurse, not an MA, may not have any “medical training” whatsoever.

Nonetheless, Eloise had appropriately identified that this patient, nominally here for coronavirus testing, was way, way, way sicker than (a) coronavirus testing was gonna help in a clinically relevant timeframe, as well as (b) way, way, way, way! too sick to be driving around. So, she came and got me.

I went to the patient, shortly afterwards followed by an MA who had overheard Eloise’s pronouncement. I was impressed by the fact that this woman reported chest pain, nausea. left sided neck pain, left sided jaw pain, as well as being unable to tell me her allergies, or medications, or medical history, and could not state the name of her boyfriend (whom she wanted called to retrieve her vehicle) as I shortly had determined that this nice lady was going to shortly be the recipient of over 50 years of pre hospital emergency care wisdom and experience, as well as diesel therapy. (ambulances nowadays generally run on diesel).

I told Eloise to get an ambulance, and the MA hopped in, to clear a room for this patient. Eloise evidently had delegated that task, as she returned promptly with a wheelchair, and I noted another MA on the phone to dispatch, as Mrs. Chestpain was wheeled in.

As I assessed this soul, engaging in conversation all the while, it struck me that her ability to track the conversation was deteriorating before my eyes. Not a good thing.

Soon EMS arrived, packed her up, and set about their own part of her care.

I called report to the local ED, explaining the above.

I then went in search of Eloise’s supervisor. I informed this worthy that, in my opinion, Eloise had saved this woman’s life. Had she not had her head in the encounter, had she not noted “chick don’t look right” (the fundamental item of nursing assessment), had she not sought me out and had she not compellingly made her case that this was a SICK person, well, Mrs. Chestpain might have driven off, to die from (her heart attack)(her stroke)(a collision from her impaired ability to navigate), or (all three).

For some reason, I had occasion to speak to my physician supervisor around that time. I repeated the foregoing story, as well as the foregoing analysis, to her.

“Well, you know, Reltney, you also saved her life!”

“Ma’am,” I responded, “I have dozens of years of schooling, decades of emergency and clinical experience to enable me to do that sort of thing: it’s kind of what you are paying me for! Eloise, on the other hand, has none of those things. You are congratulating me for doing my job. I’m applauding Eloise for thinking outside of the box, outside of her job description, and acting effectively to get this woman the help she desperately required. Thank you, but Eloise went above and beyond her job. She is what made everything else happen.”

As a side note, here’s what the preceding paragraph looks like, when your cat helps you:

“Ma’am,” I responded, “I have dozens of years of schooling, decades of emergency and clinical experience to enable me to do that sort of thing: it’s kind of what you are paying me for! Eloise, on the other hand, has none of those things. You are congratulating me for doing my job. I’m applauding Eloise for thinking outside of the box, outside of her job description, and acting effectively to get this woman the help she desperately required. Thank you, but Eloise went above and beyond her job. She is what made everything else happen.”pppppppppppppppppppppppppppppppppppppppppppppppp

Thanks, Kitty. i do believe that I have this under control.

“Reading the Room”, or, Situational Awareness

So, TINS©, TIWFDASL© as an ED RN. At this point in time, the ED employing me (which was Middling Freestanding ED (MFSED) was an entertainment subsidiary of Enormous Hospital System With Delusions Of Grandeur (EHSWDoG).

My subsidiary hospital had the system’s psych ward upstairs, and therefore we appeared to be the psych intake for the three or four county area at which we were the center. So, this one night, an enormous dude, dressed in a three piece suit, perfectly buttoned etc, and BACKWARDS appeared. There were no police accompanying him (so I assume he was not a police psych hold). For some reason, Mr. backwards Suit had decided that he needed to go for a stroll.

As I became aware of the excitement, I noticed a cloud of nurses, as well as several security, negotiating with him to lay back down for assessment, and so forth. Somebody had given him a pen (for Ghawd only knows what reason), and he was appearing to become more excited as time passed. I noticed him only paying attention to the officers, with his (pen holding) hand behind him. He was standing in a doorway from one hallway to another, and I was down the one hall to his right. I strode past him, as if going down that hallway, and, as I passed, I snatched the pen from his hands, and continued down the hallway, as if that were the only reason for my passage.

Mr. Backwards Suit soon de-escalated, was assessed, and (unsurprisingly) admitted for psych evaluation. And, nobody else gave him a pen.

“From the mouths of babies…”

Last week I worked with a resident. She had recently completed a rotation at The Big Pediatric Hospital, in the ED. One of her stories involved a child with a fracture. She related that, as she was showing this child her fracture on the x ray, the child exclaimed, “That’s the broken part, isn’t it?”

This stimulated me to recall a tale of my own (for, does not nearly EVERYTHING, stimulate me to recall a story?). Long ago and far away, I was working urgent care at a distant clinic. In this facility, my MA was an x ray tech, going to school for MRI. One day, a family brought in the matriarch, who had hip pain after a fall. Indeed, this elderly woman was pained by the movement elicited by the cracks in our flooring (our flooring was in very good repair!) Well, (let us call my MA…) “Ashley” determined that there was an x ray in this lady’s future, and figured that one movement onto the x ray table might be superior to a move into the room, an exam, another move into the x ray room, and THEN onto the table. Good call.

Ashley took only one image, before exiting the x ray room, at speed, and summoning me. “Reltney, you need to see this film”.

“Oh? Is it interesting?”

“Well, I believe you will be irate if you delay another minute before you see this film. I think that it will have a serious impact on your medical plan of care!”

Well, alrighty, then!

I had previously casually mentioned the concept of “the ophthalmologic fracture”. That is a break so obvious, so lacking in radiologic ambiguity, that should an ophthalmologist happen by, that physician would stop in his/her tracks, do a double take, and exclaim, “Hey! That looks broken!”

This lady had a ophthalmologic fracture of her hip. I had Ashley copy this image on a CD, and had my clerk summon EMS. I called The Local Trauma Center, and described the events to the attending physician. Once EMS had arrived, I invited them to view the film. They were, as well, impressed. She was backboarded, and transported to the hospital for further evaluation and care.

My physician colleague (remember her? She led me into this tale, after all!) nodded. I concluded, “You, doctor, have just introduced me to the concept of “the pediatric fracture: a break so obvious that a child can identify it”!

Dad’s Blood Infusion

So, TINS©, TIWFDASL©…well, while This Is (indeed) No Shit, I was NOT, in this tale, Fighting Disease And Saving Lives. Rather, years ago, I was in The Un-Named Eastern State, visiting the Momette and my father. Dad had had a cardiac arrest something on the order of a year and a half prior, and had, miraculously, recovered entirely intact. Subsequent to that, he was found to have cancer, and THAT had NOT had a miraculous outcome. He had undergone several surgeries, and finally had been referred to hospice.

Let me say this about hospice. These folks, in this corner of that state, were a Gift From Heaven. No shit, honest-to-God, straight up. If I were to be found to have a heart, they certainly warmed it.

Today’s lesson concerns one of Dad’s surgeries. I had taken some time off, and was in The Un-Named Eastern State. Dad had come out of surgery, and we were there to visit him: Mom, My Brother The Accountant, and myself, who, at this point (yeah, my stories sort of jump from one point in time to another, don’t they?) was an actively licensed paramedic, as well as an RN, and nursing supervisor. I had been an ED RN for something on the order of 5 years at the time of this story. In anticipation of there developing a need for me to make a longer term presence in my parents’ home, I had obtained a Nursing license in the Un-Named Eastern State.

So, we were standing at Dad’s bedside, and I noted that he had blood running. As a nurse, we all learn, early on, that from the time that the blood departs the blood bank, until the last drop of hemoglobin rich goodness leaves the bag for your patient’s veins, no more than four hours must elapse. Anything not infused at the four hour mark, will still be in the bag as it is returned to the blood bank.

Idly, I observed that the bag appeared to be half full, and dropping sluggishly. I looked at the blood bank tag, which documented, among other things, the time the infusion had started: approaching three hours previous to my inspection thereof. I inspected the tubing, looking for closed clamps, kinked tubing, or other impediment to flow. On Dad’s hand, just upstream from the IV catheter, I observed a tight bend, something resembling a slight kink in the tubing.

I released the tape, opened the loop a bit, and re taped it, and gave things another looking over.

My mother reproached me. “Reltney, I don’t think you should mess with that. You should call the nurse.”

I was surprised. “Mom, I *AM* a nurse! In fact, I’m even a nurse, in *THIS* state!”

She replied, “Oh, you know what I mean!”

PROFESSIONALISM, PART II

So, Carmen, my grand daughter, had a couple of additional Magical Mystery Tours of Peds ICU. Brenda, her mom, wound their way through the maze of physicians, and specialists, treating, and attempting to diagnose, what was underlying our recurrent Monday-evening-Grandpa-visits.

Eventually, one of the specialists determined that a surgery would mitigate Carmen’s breathing difficulties, and so a surgical date was set, in a distant Big City Medical Center. Brenda told both of her parents, and her conversation with me went along the lines of “Dad, so Carmen is going to have surgery on (date), at Big City Pediatric Hospital.”

(Dad): “uh huh. I’ll be there.”

(Brenda): “Uh, Dad? So, Mom is gonna be there, too.”

(Dad): “Uh huh. Why would there be any question about that?”

(Brenda):”Well, I know you guys are going through that divorce, and things might be…tense..if you were both in the same room.”:

(Dad):”Well, Honey, your mom is a grown up professional, I flatter myself that I am a grown up professional, and while we are there with you, for that time, what I think about your mother, or what she thinks about me, well, nobody cares. This is about you and Carmen, and nothing else is on my plate for that time. I don’t anticipate any drama coming from either of us. I know I won’t cause any drama, and I am confident that your mother will not, either.”

So, we met at the appointed time, and greeted each other. Carmen received her IV, and was pre medicated, and rested on her mother’s lap, soon falling asleep. I have a photograph, somewhere, of Carmen, relaxedly asleep, on Brenda’s lap, Brenda appearing fatigued herself.

Carmen went for her surgery, and returned, post operatively. Carmen had an uneventful post operative course, and Brenda took her child home. Today, a dozen years later, Carmen is newly adolescent, The Big Sister, and perfectly healthy.

Oh, and my pre and post op interactions with The Plaintiff? Benevolent, professional, and child (and grandchild) focused. No drama.

Guardian Angel, Working Overtime

So, TINS©, TIWFDASL©, working a weekend gig in a very, very rural corner of The Un-Named Flyover State. I was a mid-level in, completely out of character for me, a very, very rural hospital’s (VVRH) walk in clinic. I was working with an LPN, a woman of sense, alertness, and industry. Sometimes, Blessings are not obvious.

So, mid morning, she gave me report on Our Next Contestant. Late 20’s fellow, had complained of back pain for a week or two, and he attributed this pain to “I pulled my back, working out doors”. So, this was long about February, and in VVRH’s catchment area, it was mighty freaking cold. Snow, long about hip deep, lined the roadways, and the roads, themselves, had been plowed, and, in keeping with Flyover State Rural Road Commission Operating Procedures, had *NOT* been salted. Since everybody got their water from wells, and most of us thought that salting our water was ill advised, the roads had some sand applied, “upstream” of intersections.

I listened to the vitals, and noted her assessment that “this guy doesn’t look right”. I entered the exam room, introducing myself. He told me that he had started to hurt a couple of weeks prior, the pain in his back, described as “Like something tearing”, had increased with time, despite his employing the ever popular intervention of “ignoring it, hoping it would go away”.

Having concluded on this beautiful sunny 8º F day, that is was *NOT* going to get better, he had WALKED three miles into town, by his estimate, seeking help.

He had muscle spasm in his back, true enough, but something about his story sounded several degrees out plumb. I palpated his belly, and felt something therein pulsing away. He also reported that my pushing on his belly, made his back pain worse. I was not certain what it was, but I was pretty sure that this was way, sway above my pay grade.

I phoned the ED physician, spun my tale of oddness, and he accepted my patient. My nurse wheeled him down the hall to Emergency, and we plodded through the rest of our day.

Nearing the end thereof, the ED physician walked in my door, and told me a story, featuring my long walking friend. He, the physician, had also thought that the examination, along with the back pain, was odd, and so he, the physician, had CT’d my patient. That study revealed a honking big, seriously dilated abdominal aortic aneurysm (a dilation of some part of the aorta, in this case in my patient’s abdomen).

For those in the studio audience who are not medically inclined, the aorta is the single largest, highest pressure, artery in your entire body, running about 2 cm in the area just below your diaphragm, about at the level of your renal (kidney) arteries. Those of us who have studied the US Military’s tactical trauma care course, or have had some sort of “care under fire” training”, will have learned that, should the aorta be penetrated, either by projectile or through a rending of it’s wall, the entire blood volume of an adult male (running around 5 quarts) can empty out in something approaching a minute, plus or minus. One thing that places you at risk of experiencing that, besides the projectile-through-your-aorta thing, is having a large aortic aneurysm abruptly rupture.

Of course, in VVRH, there was no abdomino-thoracic surgery service. My friend the ED doc attempted to arrange a transfer for this fellow, only to be SOL (Surenuff Outa Luck). The roads in our corner of the state were being snowed in, and therefore ground transport to pretty nearly anywhere was not going to happen.

Doc cast his net more widely, and more widely. Adjacent State Big Time Medical Center would accept him, but, alas, we would have to figure out how to beam him up transport him there. Middling Outstate Medical Center could not accept him, since they had no vacant ICU beds, which our new friend would certainly require, assuming he survived (a) the trip, (b) the surgery, and (c) the post op period. Any one of which could end him.

Next Up Upstate Medical Center, alas, similarly had no ICU vacancies, and so, finally the physician negotiated a transfer to Downstate Academic Medical Center, who, miraculously, sent a fixed wing aircraft and critical care transport team to our little single runway county airstrip.

A couple of weeks later, I was working a weekend as was the physician in question. He made a point of strolling over , and relating the above to me, both because it was remarkable that the patient had not only survived the trip, as well as the surgery, and the recovery, into the bargain, but was home, and evidently neurologically intact. The doc knew this, because this fellow had come into ED seeking care for a sprain or some such thing, that he had newly acquired, working outdoors!

“Show Me Some Teeth!”

One afternoon, I came in to my shift as a nursing supervisor, and the director of nursing had, it appears, JUST finished receiving a phone call asserting that somehow, the hospital staff had lost some patient’s dentures. Of course, I was the High Value Target in that particular free fire zone, and I caught the assignment. “McFee! You find out what happened to this patient’s dentures! Do not rest until you find them!”

I promised my best efforts, and was reprimanded. “I do not want your best efforts! I want you to show me some teeth!”

Uh, Ok. Yes ma’am!

I inspected the patient room, freshly cleaned by housekeeping. No dentures. I went to billing, the keeper of the valuables, and searched for property that had remained unclaimed. No dentures.

I interviewed our laundry folks, and inquired regarding foreign objects in the washer or drier. No dentures.

I inspected the patient intake form, cataloging the patient’s property at arrival. Of course, there was indeed a notation that the patient had brought her dentures with her to the hospital.

I took a break, and visited the security supervisor. We chatted for a bit, until he asked why I had not been wandering around, and had not been in evidence that shift.

I told him the Story Of The Missing Teeth, and my efforts to transition that tale into a dental retelling of The Prodigal Dentures: “Rejoice! My teeth, that have been lost, have been found! Kill the fatted calf, prepare the feast!”

Along with my, thus far, horrible fail in accomplishing it.

He sat back, and a thoughtful look crossed his face. “So, Reltney, do you need to find THE teeth, or just any teeth?”

I observed that the patient in question might feel a little, well, odd, wearing somebody else’s teeth.

My friend the security supervisor opened his safe, and extracted some ancient dentures. He then clarified things for me. “See these green teeth, here? Now suppose they were inadvertently dropped outside the door here, in the driveway, and some inattentive security officer, like, say, me, were to accidentally run them over, like, six or eight times? I doubt that anybody would put the shards into their mouth, you could show your boss teeth, albeit broken teeth, and so she would be happy, the complaining patient would get new dentures, so they would be happy, and your boss would stop breathing down your neck, and so you would be happy. How many opportunities do you think you will get to make that many people happy, all at once?”