Wednesday, February 26, 2014

Dear Miss Management

Once again, it's time for your semi-annual review. We continue in our hopes that you may someday achieve a grade of barely adequate, but we won't hold our breath or get our hopes up. Based solely on your documented performance to date, flying pigs and a winning powerball ticket are more likely to be in the near future for me.

First, we need to correct a mis-impression on your part: when it was suggested to you (and if we find out by whom, the phrase "heads will roll" won't be melodramatic hyperbole as much as an anatomical description of fact) that Nietzsche had suggested God has died, and left you in charge, it was a metaphysical jest. Yes, we do note that you are possessed of a shiny clipboard, and a disposition that would pucker a sour apple tree, thus perhaps leading you or any number of guidance counselors to think they had directed a round peg into a round hole, but we note with some firmness that as observed by John Cleese, the first prerequisite for a lion tamer isn't "Has he got a hat?" Thus mayhap you could rethink your career choices, or at least notch down your delusions of personal competency at this one.

For your rather bankrupt fund of personal information, all those rather curious-looking and odd-speaking folks down on the lower floors moving to and fro rather rapidly are what we in the trade refer to as "medical professionals". They all have advanced training and degrees which, unlike yours, required actual passing grades in actual scientific fields of study, in things like physiology, chemistry, and such. They have all sorts of rather specific functions, none of them interchangeable to any great degree, arrived at by literally thousands of years of trial and error in the medical arts. (Stop me if I'm going too fast at any point. I realize that when I'm talking to you about science, history, and medicine, I'm speaking ancient Greek to you; in no small part because the ancient Greeks had a lot to do with, well, science, history, and medicine, thus this is the first time you've heard any of it.)

Consequently, we tend to look at what we do with a certain bit of prejudicial pride, because we have this quaint notion that the measure of our success is two-fold:
how many of our patients we don't kill; and
how many of our patients actually improve when we do what we're supposed to do.

Shocking as it may seem to you and your colleagues, neither of these things (I believe you refer to them as "metrics", yes?) has any remote relation to how long they waited outside, how distressed they are at having to wait, their personal emotions about anything, nor their feelings about how well we do our jobs (which, once again, are not to kill them, and to make them physically better to the limits of our powers. Perhaps you're noting a trend here?)

Hereabouts, there's an additional complication, because in its wisdom (owing to no small number of 2x4s applied to the back of the state legislators' heads, both serially and liberally), one small subset of medical professionals known as "nurses" (perhaps you've heard of them) are limited by the state's nursing practice act (we call that "the law"; by a strange coincidence, so does the state's Attorney General, and every court from Oregon to Mexico in between. Perhaps someone in Risk Management could catch you up on this concept another time?) regarding how many, and of what severity, patients we are allowed to assume responsibility for at the same time. Just as a refresher, here in the ED, that would be 4 regular patients, or 2 serious ones, or 1 critical patient. (Funny, huh? It seems that both legislators and people with medical degrees and nursing Ph.D.s came to the incredible conclusion that someone who's a 1:1 patient when they go to ICU isn't somehow less serious before they get there. Close your mouth, dear, flies will get in.)

Consequently, in a colorful turn of phrase, we really don't give a damn about how that makes people outside with hangnails and kids with runny noses feel when they have to wait longer while we foolishly chose to save the lives of the acutely critically ill or injured. (That was acutely, not cutely. Don't worry, it happens all the time in your department.)

We also don't tend to give a damn about meeting farcical illusions about how long a visit here takes, or how long the wait is to be seen. We observe daily the overwhelming number of persons who elect to leave before being seen should have made that decision before coming in the first place, borne out by years of not finding their decomposing corpses littering the freeways they drive to get home, ever, at any time in history. (Curiously both the police and fire departments have told us the same thing about a lack of cat skeletons in trees. Crazy, huh?) We further note that most of their histrionics occur once placed in a room, mainly to fulfill their inner child's need for attention before they huffily depart in their bid for the award for Best Actor Or Actress In A Dramatic Departure.

Personal anecdote here: among a baker's dozen (sorry, that would be thirteen for you. Public school grad too, huh?) of eclectic hobbies, I enjoy competitive shooting sports. Coincidentally, one of my best friends is a world-class shooter. And he's even younger than you are. The way he got good, was to get fast, then work on accuracy. It worked, to the point that he's faster than everybody, and he doesn't miss much now. Hardly ever, even on multi-day competitions. It's rather scary to behold. Thing is, that's a fine way to learn shooting, when you're talking about wasting a few rounds outside the target's bullseye. They hit the dirt with a thud, rather than the target with a clang, so nobody minds all his previous misses in practice.

But (pay attention, this is where that literary meander hits the target, so to speak!) that method of improvement doesn't work nearly as well with actual lives, unless you apprenticed under Dr. Mengele. (M-E-N-G-E-L-E. You should look it up on Wikipedia, 'kay?) Because the optics of those metrics - a little management lingo I've picked up - are a truckload of corpses, and a courtload of lawsuits. Good for Risk Management's job security, but conversely, less money for management bonuses. (Got your attention there, did I?)

So it's far better that we focus on getting everything as near to flawless, and then slowly increase speed, to just short of the point where we start making any mistakes, rather than listen to you and your clipboard, and try it the other way around.

So let's talk turkey: You have the exact same staffing matrix in place in terms of nurses and doctors now as you had here ten years ago. Conversely, we see every 24 hours some 300% of the number of patients as we did ten years ago. (And by the way, they're one helluva lot sicker, person for person.) I've been watching my paychecks, and yet strangely, I don't seem to be making 300% of the money you paid me when you hired me a decade back. In fact, you can't even be bothered to fully staff the nursing positions such that there is a nurse everywhere we're supposed to have one any night in living memory, and the lowest paid workers in the department, the techs, without whom patients don't get to such petty things as X-ray, CT scan, ultrasound, or admitted to surgery or the wards, are so short-staffed we could count them on our thumbs most nights.

So here's another historical anecdote, and a wee suggestion:
In 1864, General Ulysses Simpson Grant, Commander of all Union Army forces, and future president of the United States, noted that cavalry saddles chapped his ass. Which occasioned him to do nothing but tolerate the distress. I bring this up because if a great man such as that could bear up under adversity, perhaps the folks crybabying to you on the surveys could sack up and learn to tolerate their petty inconveniences like something other than offended oil sheiks at a strip club. (Who, unlike a respectably large number of our patients, actually pay for the services in question, and reportedly tip better. Just saying.)
And instead of feeding those pigeons by polling about how they feel when their whiny little complaint (that should have seen them in an Urgent Care or their doctor's office during business hours, rather than the ED when we have enough patients for 10 hours out of every 12 to fill 320% of the available beds) isn't seen as fast as they order fries at the Burger King drive-thru, how's about you stop responding to your Press-Ganey happy gas imperative, reach down between your knees, and pull really hard until your head pops out?

Think of trying it as leaving your personal comfort zone.

When the oxygen rushes to your head, and the light breaks because your eyes are outside for the first time in several years, maybe you could toddle over to Human Resources, and ask them why, with EMTs by the score within the range of me swinging a dead cat are looking for better jobs, you can't find us an on-call pool of 40-80 folks with excellent work ethics and a functioning brain who'd like a 50% pay raise over what they get paid to ride on an ambulance, a shot at benefits and normal hours, and an employee assistance program that would help them transition to becoming nurses, physician assistants, and doctors. You know, the one you pimp on the company website, that I have to listen to for hours on end while I'm on phone hold as my ear goes numb, trying to get one of the over-worked floor nurses to take report on my sick-as-hell ED patient, so I can help keep the meat moving down here in the hell you never visit until the JCAHO clipboard commandos dither by every few years with more stories about the Tooth Fairy and the Easter Bunny, and demands so ridiculously irrelevant to actual patient care as to be unthought of nor unseen by Florence Nightingale amidst a war in the Crimea when nurses still had to boil the patients' linens themselves.

Failing that, you'll perhaps understand why getting your head out is going to get a bit harder if you're still talking to me five seconds from now, after I shove that clipboard so far up your ass it impinges on your cardiac preload. I'm sorry if that negatively impacts on your workplace karmic harmony, but perhaps you would be better served by a transfer to either the retail sales or fast food service industries, where things like how long it took to get your Whopper, whether you liked the toy in your Happy Meal, or what color things come in, are all far more germane to what's important than they are anywhere within shouting distance of the Emergency Department.

Are we clear?
M'kay, B'bye until next time!

{Also, my apologies if I used too many "S"es in your title, to the same degree that the hospital's board of directors seems to put too many "asses" in your department. My mistake is because I was raised by people who were both courteous and wise, whereas the board manifestly was not.}

Friday, February 7, 2014

Mini Mental Status Exam: The Bathtub Test

During a visit to the psych unit, a visitor asked the director how they determine whether or not a patient should be institutionalized.

"Well," said the director, "we fill up a bathtub, then we offer a teaspoon, a teacup, and a bucket to the patient and ask him or her to empty the bathtub.

"Oh, I understand!" said the visitor. "A normal person would use the bucket because it's bigger than the spoon or the teacup!"

"No," said the director. "A normal person would pull the plug. So, would you like a bed near the window?"

Courtesy of Sean Linnane at Stormbringer