Archive for February, 2007

Just got back from my (former) OB’s office. Seems that they still have not released over my medical records to the midwife. They’ve had three weeks to do so. They told me that I had to fill out their form (rather than accepting my midwife’s form which I had already submitted to them) and then wait 10-14 days. I requested if there was any way to speed things up in light of the fact that I was already 36 weeks pregnant.

The reply: “Nope. And all of this was made clear to you in your welcome packet.”

SNOO-TEE!!!! Despite the fact that I wanted to slap the receptionist, I politely filled out the form, handed it back, and thanked my lucky stars that there really wasn’t anything in my pregnancy record that would have deviated from the normal. Well, except for that one extra pound I gained back at week 25 but I think everyone’s just going to have to work around that.

At any rate I was thinking how nice it would be to have all my medical records on a customized website (like MDVIP provides).

My dream is that someday everyone will have access to their medical records without having to deal with snooty receptionists.

I have been asked to review a product, “Concierge Medicine” offered at MDVIP.com. This is rather timely given my last post, expressing my less than satisfying experience with my OB practice.

So on to this concierge medicine. What does it offer me as a patient? There are some things that I found appealing. First of all MDVIP doctors limit their practice to 600 patients. (The site claims that the typical physician had 2500 patients.) Because of this limit they are able to spend more time with the patient, and the patient can make same-day or next-day appointments. You also have your doctor’s cell phone number, eliminating the need for busy signals, answering services, and annoying medical receptionists who can’t really tell you anything useful. And it’s nice to be able to make the appointment when you are actually sick.

Another thing they offer is the MDVIP physical. This includes:

? an extensive risk factor assessment that incorporates family history, patient history and lifestyle analysis
? screenings related to mental status
? screenings related to exercise, nutrition and sleep
? screenings related to vision and hearing
? pulmonary function testing
? comprehensive laboratory testing
? EKG

Okay, I could probably do without a mental status assessment, but I like the comprehensiveness of this. As someone who sifts through medical data on a regular basis for my patients, I am always curious about what my data would show. (Are my electrolytes in order? Is my pulmonary functioning normal? What does my EKG show?)

One of my favorite things about this service is the personalized website. This gives you the ability to organize all of your health information and health data from the physical all in one place. I hate trying to chase down lab results from doctors. I remember one time a doctor ordered a CBC on me and I requested that she send me a copy of the results. I told her that I sometimes had a low hematocrit and so was interested in following up on that. After she received the CBC results she sent me a letter in the mail that said this and only this:

“Your hematocrit was normal.”

Um, yeah. So you went to all the trouble of actually sending me a piece of mail and yet you can’t tell me what the actual number was? Totally frustrating.

So what could be the downside to this nirvana of healthcare delivery? In a word: Price. I called the 800 number and was told that for the physicians in my area there would be a yearly annual fee of $1500. This could be paid quarterly. It could also be paid with a health savings account (meaning it’s tax-free). I think this price is a little steep and probably wouldn’t pay it myself. I asked the customer service rep what the fee pays for and his reply was the lab work and diagnostics that you receive at your MDVIP physical. He also said that part of this fee goes to the doctors, because they have to offset the cost of limiting their practice to 600 patients.

My overall impression? I would consider Concierge Health to be a luxury item. It sounds like a good product but only if you can afford it.

(Discloser: this post is a paid review)

It’s kind of late in the game, I know. But I’ve switched teams. I’ve gone from an OB practice to a nurse midwife practice.

At around 30 weeks I started to thing about taking a birthing class. I procrastinated because (a) I don’t have much spare time and (b) I’m just not a classroom kind of a learner. So I decided to start doing some research on the labor process, in order to come up with some sort of birthing plan.

First stop, the bookstore. Not too many books on labor, but most of the books that I did find recommended another book: “Ina May Gaskin’s Guide to Childbirth.” So I bought it and started to read it. Ina May Gaskin is, from what I can gather, one of the US’s leading mid-wives. She has a place in Tennessee called “The Farm Midwifery Center,” that has been in operation since the seventies. The first one-third of this book was composed of Gaskin’s clients telling anecdotes of how the birthing process went. I was hooked from the beginning…I love a good birth story.

In her book she talks about the midwifery model of care vs. the medical model of care, which, in a nutshell is this:

Midwife = birth is a natural, instictive process. Your body already knows how to do it.

Medical = birth should be in a controlled environment (the hospital), supplemented by medical interventions.

For some reason the midwife model rang true to me. I remember not too long ago, visiting a birthing center in nursing school. I though it was the coolest thing. It was like someone’s house. You could get up walk around while laboring. You can eat and drink while in labor. After the birth the woman was given a chance to recover, the family shared a nice meal, and were on their way home within hours of the birth. I found this very appealing, but unfortunately the flip side of the coin - What if something goes wrong and they can’t get you/the baby to the hospital on time - got the best of me and I forgot all about birthing centers and midwives.

So why the change of heart?

For one, I wasn’t quite satisfied with my OB practice. It consisted of 7 practitioners, and at that point I had only met about half of them. So it was becoming quite possible that a complete stranger would been have attending my birth. Also, this practice was very over-crowded. The waiting room was always like a zoo. The phone number was always busy. Not busy as in, leave a message busy, busy as in an actual busy signal. Haven’t heard one of them since the 1990’s.

And the “get em in, get em out” feel to it - “Ready?? Go! Pee on a stick! Blood Pressure! Weight! Doc listens to fetal heart tones, and YOUR DONE! Who’s next?”

After a few visits I was like, “Man. I could be doing this over the phone.”

Don’t get me wrong - I really liked the physicians there, at least the ones that I had met. But there was one in particular that just kind of rubbed me the wrong way. I can’t say anything really that bad about him except this: At 25 weeks he said to me, “I see that you’ve gained 4 pounds in two weeks. You should be careful about that.”

I said, “”Really? So your telling me I’ve gained too much weight this week?” Then he glanced over my chart and saw that I had gained very little weight in my first trimester. “Um, well, it’s probably not a problem.”

I didn’t think it was a problem. At 25 weeks, some of my colleagues couldn’t even tell I was pregnant yet.
Then a friend of a friend told me about her recent experience of delivering with this doctor. He would come in to the room, check her cervix and say, “You’re going to have to do better than that. I need you to get 4cm more dilated by 12 o’clock.” And so on and so until finally he did a C-section because she wasn’t dilating fast enough.

To me that’s kind of like being constipated, sitting on the toilet, and someone coming in and saying, “C’mon. You’re going to have to poop faster. Please produce two turds within the next 20 minutes, or were going in after them…”

So I knew that I couldn’t leave things up to chance.

I did some research and found a midwife practice with a birthing center that was on the hospital campus where I am to deliver. This, to me is the best possible scenario. If any thing goes wrong - there you are, just a stone’s throw away from the actual hospital. So I called them at 31 weeks, and they had me in by 32 weeks. Now I’m 35 weeks pregnant and so far I’m very satisfied with the care I’m receiving there.

Except for one thing: At the last visit the midwife told me that the OB practice still hadn’t sent over my medical records (even though they are in the same building). I offered to go get them myself but it was late in the afternoon and the office was closed.

“You’re might have to start calling them and bugging them to send over the records,” she said.

I told her about the busy signals, and how it’s one of the reasons I left the practice.

And besides, I’m not in that much of a hurry to get the records over. What if they find out that I gained 4 pounds at week 25? I’m hoping it won’t change the course of my care.

I feel great this week - I’m motivated, I have energy, my mood is good… “Sounds like she’s reached the nesting phase of her pregnancy,” many of you might be thinking.

Actually it’s more like, “I called in sick twice this week and now I realize just how much working in the MICU strips me of my mental health and physical well-being.”

Thanks to the previous post, I’ve been doing some serious thinking about my health and well-being. As a result I made the decision to call in sick for two of my night shifts this week. As many of you know, this is not an easy thing for a nurse to do. We seem to have this work ethic and sense of duty that makes us crawl into work or else feel eternally guilty for not making it in. And for those of us who have no sense of guilt or work ethic, we have the on-call system.

The on-call system dictates that I am required to sign up for 2 on-call shifts every six weeks. If two nurses call out, they bring in the on call nurse. I’ve always believed in the “on call kharma” …meaning if you call in sick too much you can be sure to be called in soon enough. The evidence doesn’t really support this, though. I’m about to reach my 2 year anniversary at Ghoat and I have only really been called in twice, yet, I’ve called in sick many more times than that. However, the majority of these call-outs have been during my pregnancy, which everyone seems to agree, is a good excuse.

And yes, my guilt for calling in sick was eating away at me for a few brief moments, but you know what? It’s worth it because I FEEL FANTASTIC THIS WEEK.

But am I really nesting? Let’s explore this question…

Is my nursery set up?

No, the finishing touches of paint are still being applied by the wonderful husband of pixelRN. All the baby stuff that’s thus far been acquired is sitting around in boxes and bags…

Am I cleaning my house? No, there are tumbleweeds of dog hair everywhere, thanks to the wonderful dog of pixelRN.

What can I say? I’m usually a big fan of vacuuming (really - I am), but not while pixelRN junior is sitting on my lower spine causing this nagging (but not really severe) lower back pain.

So what have I been doing?

Surfing the net, dude. (OMG that is so 1997)

Resdiscovering my love of graphic design + the internet.

Rediscovering blogs.
And working on my swanky new gift shop.

Where you can buy these fine products…

Nothing like a little art therapy + capitalism to get me back on track.

Warning: this content may be somewhat disturbing.

On a more positive note, maybe I should try auditioning as a story developer for “House.”

These are some actual nightmares that I’ve had recently:

I have this patient. I know that he is extremely sick and dying. I have a sense that his insides are decomposing even as he looks up at me and blinks his eyes. The doctors are approaching for AM rounds. I know they are expecting an update from me and I haven’t done anything for my assessment. I don’t want to lay my hand on this patient; I’m afraid I will somehow harm him. What can I do to quickly to produce some data to report to the docs? I decide to take his tympanic temperature. As I push the probe into his ear I realize that it’s gone in too easily, to quickly. His brain is mush. Much to my horror, I pull out the probe and realize that it has grabbed my patient’s eyeball and pulled it out, much like an apple corer. I drop it on the bed and walk away from the room.

Then I notice lots of people in my patient’s room. Visitors - two angelic pale looking ladies dressed in white. Other visitors with military uniforms on… then a crew comes by to do a bedside CT scan. I realize that everyone is going to see that eyeball lying there on the bed…

“What’s wrong?” asks another nurse. I tell her what happened with the eyeball.
“Just go in there and put it back in!”
“I can’t go in there. I’m too freaked out.”
“Okay, then. I will.” She then proceeds to the room and sticks they eyeball back into the patient and no one is worse for the wear.

Then, last night:

Before I went to sleep I was talking to my husband about a theory I was developing. I was thinking that skin breakdown as a stage of sepsis is perhaps an accurate predictor of death, and yet it is often ignored by doctors when deciding if a patient will make it or not. I’m talking about when a patient is in multi-organ failure and their skin is continuously oozing out bright yellow serous fluid onto the bed. You can’t keep up with keeping dry chucks pads underneath him. When the patient reaches this point only the nurse seems to notice or care. The doctors will go on telling the family that “the numbers look good” and “we still have hope.” But as a nurse you instinctively know that this type of skin breakdown almost always leads to death. The skin is an organ that can fail just as well as your kidneys or lungs can fail.

So then I dreamed this:

I took over care of this patient. I looked at his documentation from the previous shift and realized that no one had been able to obtain on O2 saturation on him, nor could they document a pulse. From what I could figure this patient had been PEA arresting for 12 hours straight. He was basically dead. And all of his serous fluid had leaked out onto the bed. I told the attending and this is what he said:

“Here’s what you do. Grab a large pillow and take 90% of the feathers out of it. Then put the patient’s body in the pillow, seal it up and put it in the dryer for one hour.”

I woke up horrified.

Some of you might be thinking that these are pregnancy-induced bizarre dreams (supposedly a lot of women experience strange or vivid dreams during pregnancy). I don’t think that this is necessarily true. Case in point: this is what I dreamed two years ago as I was starting my orientation to the the unit:

As new nurses, we were sent to the morgue. They decided that this would be the best place to practice our assessment skills because we couldn’t really do any harm to dead patients. We started unzipping body bags. There were all shapes and sizes of corpses and some of them were dismembered. As we practiced on them some of the corpses suddenly began to sit bolt upright, scaring the living crap out of us.

Perhaps I should have quit while I was ahead. At the very least I think it may be time to find another type of nursing to practice.

I’ve been tagged by Shane over at nursingjobs.org. I am to tell you the the 4 things I can’t live without, followed by the thing that I covet. I immediately thought about material things (my scrubs? my stethescope? my clogs? The latest Prada bag?), followed by things of sustenance (Hazelnut latte? Donuts? Toasted Onion bagel? An icy cold Kettel one gimlet? well, not so much these days), and I realized that everything I need to do my job is either all in my head or out there in the ether. So here you go…

1. Good Assessment Skills

Good assessment skills are what makes a good nurse, in my opinion. This reminds me of something that happened to me when I was a nursing student on my unit. I was in my patient’s room doing all the normal things that I considered to be part of the assessment. My preceptor came up from behind and said, “Hey, do you notice anything strange here?” He then pointed out to me that my patient’s right breast was roughly three times the size of her left breast. She had a chest tube on her right side. It turns out that the breast had blown up like a balloon due to subcutaneous air.
In my defense I would say that the patient was placed on her left side, so that it was hard to see the asymmetry of her chest area, but still. Her breast was humongous! We confirmed that it was sub-q air because it had that crunchy rice krispy feel to it. I felt rather foolish that I had missed it but in the end I saw it for what it was: a valuable lesson. I was so busy looking at the monitor, testing her lines for blood return, checking placement of her NG tube, confirming vent settings, that I had failed to take a step back and really look at my patient and get the big picture.
2. The Internet

We come across so many different disease processes, infections, and medications. It is impossible to keep it all my head. With a computer terminal at every bedside, I can have answers within minutes. Not to mention access to every single protocol that I would ever have to use, which leads me to…

3. Protocols

Okay, I will admit it. I’m a protocol wonk. In the beginning we all use to joke about them, as in “Here at Ghoat we have a protocol to tell you how to blow your nose.” But I’ve come to love the protocols. One of my pet peeves at work is having to inform the resident about every little lab value that is out of wack, and then wait while they sit there, thinking out loud and trying to figure out exactly what to do. I’m not sure why they do this. I sometimes feel like saying, I don’t really need to be enlightened by your thought process. Just figure it out and get back to me with your course of action. Thankfully I have protocols that save me from making any breeches in professional courtesy. The protocol usually goes something like if the lab value equals “A” and criteria “B” and “C” have been met, then take course of action, “E”. This saves me so much time. We have protocols for electrolytes, insulin drips, heparin drips. We even have an ARDS protocol that tells respiratory therapists what vent changes to make according to the latest ABG.

4. Danskos

Okay, shoes are a material object. But I really can’t live without my danskos. For me there really is no other shoe (except for lately I’ve been wearing crocs because my feet are a little large). I can do 12 hour shifts for 3 days in a row wearing Danskos and not complain of foot pain. Now if only they would make an odor resistant model…

The One Thing That I Covet:

The chance to watch patients get better.

Especially the potential liver transplant patients. We take care of them when they are at their worst. They turn the color of mustard and you can hardly believe that they could have survived this far and then “poof” a liver appears and they get whisked off to the OR. And we never see them again.

I am so tired of seeing my patients die. It really wears on you after awhile.
And now, I officially tag May at about a nurse, and a fellow MICU RN at talkingRN.blogspot.com

What else could it be? It’s the new Change of Shift.

I love change of shift. It means I get to go home and put my feet up and make my cankles go away.

Warning: this change of shift may make you crave pink frosted cupcakes.