No new orders.

I'm waiting with bated breath to see how Nurse K responds to HH's "no new orders" post.  I have the gauze, adaptic and tape ready for his inevitable blistering.

I did stop to think a moment about why I document this.  And I'll admit it is primarily a CYA measure.  Since the docs at my hospital are not employees, they are not subject to the HIPAA/JCAHO/DHS bullshit that the rest of us are.  They can blissfully "look at the whole picture" while not signing telephone orders, chitchatting about their patients in the middle of the hall, and generally flaunting their immune status.

I am intelligent.  I've been doing this a number of years.  I've developed an ability to size up a patient and determine which needs are critical and which can be addressed later.  But I am required to call you for things that Those-Who-Do-Not-Practice have deemed critical or noteworthy.  I understand a K of 3.3 probably won't kill my patient, nor will an INR of 2.3, in the absence of other mitigating factors.  And when I call you and inform you of something we both know is not truly critical and I receive "ok" as a response, I have to document what the result of my call was.  You guessed it, no new orders.

BUT, when I call you for a Hct that has dropped significantly, the patient's belly is so hard you could bounce a quarter off of it and the IAP is 32, the NG output is > 1L/shift, and I'm having to increase my pressors I want answers.  If, given this information, you are still unsure of what our plan is, I will document specifically what I told you and that you gave me... wait for it... no new orders.  Because I'm not allowed to document "Physician Cavalier was notified of all s/sx of incredibly bad process, requested surgical consult.  Physician said "what can you do for a belly?"  Physician is incredibly dense or incredibly stubborn, either way he's risking this patient's life and my license and I will not have it supposed that I failed to understand the gravity of this situation."

But I will also document that I have called you prn with the patient's deteriorating status and lack of new orders until you give me what I want.

You can document my assessment lacks substance (unlikely BTW) or that the IV pole was beeping or that the patient was sitting in stool when you rounded.  That's ok.  Those things are directly controlled by me and I have an acknowledged responsibility.  But pull your head out of your ass long enough to see that I've walked into the room with you, answered your questions, then sent my aide off to get another full bed change for this patient while I head to the med room to replace the empty bag.  Or look in my other room to see that the stool ranks as low as you being called for a Tylenol order when my other patient is unstable or actively coding.  Or don't.  Just realize that those things do NOT affect your practice or licensure in any way but I am ultimately responsible for every single individual, department, and substance that interacts with my patient at any time.  If PT drops the patient, my responsibility.  If the patient has a med reaction because you ignored a cross-allergy, my responsibility.  If my patient has a low RBS because you've made him/her NPO and I haven't reminded you to throw some dextrose into the IV, my responsibility.  

Recognize it or not.  Either way I will keep calling you.

Dear Dr.Halfway

You are indeed halfway there.  The problem is, you can't seem to go all the way.

1) You can write orders but you can't remember them.  If I get chewed out one more time in front of a patient and family for following your NPO orders instead of feeding them we're going to have a problem.  I don't just starve people because I have a fat phobia.  

2) If you're going to treat a really really sick patient that's out of your depth, you MUST listen to those around you who know what they are doing.  Rigors that look like seizures with a temp of 40C unresponsive to Tylenol with a HR of 160's is not ok.  There's a reason God made vecuronium.  

3) If you're going to do the right thing and feed the gut, do not blow off the dietician who spent over an hour reviewing your extensive list of useless medications, calculating the kcal in the propofol I'm infusing at over 80mcg/kg/min and backtracking through our cumbersome charting to find that patient's dry weight.

4) It is good that you have actually provided us with contact information.  It only took you two months.  But now you must answer your pages.  

5) I, along with most of the other RNs around you, do not care who your partner is.  And we do not want to see you googly eyed when you talk to that hot neurologist.  He bats for my team.

6) Most men buy overpriced, loud, shiny cars to make up for their shortcomings.  You admitted you drive a hybrid so you must have decided shoes were the way to compensate.  Hint: if they're slipping totally off your heel when fully tied they are too big and you look ridiculous.  Watching your size 9 self kalump around in size 11 shoes is annoying.

Dude, you're killing me!

I've been having some increased discomfort in the tolerance region of my brain.  It all started with the moving of gastric bypass patients to the unit I was working on some years ago.  It was like trying to put the same poles of a magnet close together; impossible.

**** I will allow that 0.00000000001% of the population genuinely has some physiologic reason why they are morbidly obese*****************

That said.

If you won't take care of yourself before you get to me, why the hell am I obligated to take care of you in a way that will injure myself and/or my coworkers?  If you can't put the damn cheeseburger down, why should I pick up my compassion card?

I've been watching this show called "Obsessed" where people with OCD are given exposures to the ideas or things they fear most.  It's not for lack of exposure that my obsessively negative thoughts are nurtured.  We have a couple of superfat nurses on the unit along with the odd assortment of chubby, middle aged spread, or post baby nurses.  One superfat nurse is loud, abrasive, and has no regard or respect for others.  The other is loud, abrasive, has no regard or respect for others AND is pregnant AND wears skin tight clothes in lieu of scrubs.  Always has.  I'm not sure why management allows this to continue.

I do not want to see your mooseknuckle.  Ever.

Then the mooseknuckle option is removed because now they're in the bed.  Nekkid.  And I have to push the rolls of fat over, up, under, around to get the ECG electrodes on.  Hold the arm up to get a BP cuff on.  Fat people, you may never have seen the numbers the scale brings up, but let me give you something to chew on (pun intended).  I have to stretch before and after lifting your dead weight arm up just to put a cuff on it.  I has to weigh 50lbs.  Watching your face go purple as you're having the fat that's normally supported by your thighs/knees now actually on your abdomen as I try to get a foley in is absolutely not one of the highlights of my shift.  FINDING the place the foley goes through the abdominal and thigh fat requires an extra two people and a minimum of one flashlight.

I just read that in Kansas (I think) an ambulance company is going to increase the costs for caring for and transporting those over 350lbs.  I found myself startled initially reading it, not because I had any opinion either way, but because I'm so freaking inundated with those >400lbs that 350lbs seemed a pittance!  I reframed my thinking and found myself cheering!  What if nursing did the same thing?

1. Q2h turns requiring > 3 people: $50/person/turn
2. Bathing >  qshift r/t offensive diaphoresis or odor: $50/person required to assist/bath
3.  Foley placement: $100/person required to place
4. Isolation: $5/hr more for the nurse assigned, $10/hour more if airborne and the nurse has to wear the hood.