Me

As I said last month, we are searching for a new location to be closer to my wife’s job. I am also tired of things where I work:

• I was suspended without pay for a week because of a pending investigation when a delusional patient accused me of trying to kill him.
• An incident just after New Year’s day where a patient threatened violence.
• Three different incidents in January where patients either attacked or threatened to attack me.
• My hospital claims to want 4 to 1 nurse to patient ratios* in the ED. That is rare. Now it’s usually 6 to 1. On one recent shift, I had 5 patients, but 2 of them were on ventilators. One of the other three was a sepsis patient who went into cardiac arrest just after EMS brought him in. The work load there is just too high.

So I also want to change jobs. Career specialists say that you should change every 2 to 3 years, so I think now is a good time to do so. I think we are close to answers on both.

We found a builder that will build us a 5 bedroom, 4 bath, 2900 square foot house for less than $190 a square foot. The place is gorgeous. Here are a couple of pictures from the model:

Construction should take a bit. In the meantime, my wife’s job is moving in the fall, so if the house isn’t done by then, she will have a 45 minute commute. We are negotiating terms now.

On the job front, I just negotiated with a potential new employer. I spoke with people I know who work there, and they say it’s a good place. It looks good:

• Patient to nurse ratios in the ED of 3:1, with occasional jumps to 4:1. I confirmed with friends that they aren’t blowing smoke with this claim.
• Better neighborhood, so less of the violent psych and druggie patients.
• A $12 per hour raise over what I am making now
• Getting a $10,000 recruitment bonus for a 2 year contract doesn’t hurt (payable in 4 semi annual installments)

The downsides are twofold:

• Because this hospital is properly staffed, there are no shift bonuses for pulling extra shifts. Of course, my hospital stopped paying them in September, so no real loss.
• I can’t be PRN at the new place. I have to work full time for the time being. That’s OK, this will enable us to pay for this new house in 8 years and still keep the one we live in now as a rental.

The new hospital has sent the offer, and I have conditionally accepted for an August start date. (when the wife’s new job location starts) I should get the actual contract to look over some time in the next week. If it looks good, I will sign on. Hey, closer to the new place, less workload, and more money.

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Explanation of the importance of patient/nurse ratios:

For those who don’t know, each patient needs to be assessed at intervals, plus needs medications, tests, and other related things coordinated. For “routine” patients on a medical floor, a nurse can handle as many as 6 or 7 patients at a time. The more things that are wrong with the patient, the more time it takes to care for them, so task loading becomes an issue- a nurse can only do so much without increasing the risk that they will miss something important, or make a mistake because they are pressed for time and rushing high risk tasks like selecting and dosing medications. For this reason, the sicker the patients, the fewer that a single nurse can effectively handle.

Some patients are so sick that they take up all of your time. A patient on a ventilator is one of those. In general, having two patients on a ventilator is all a nurse can handle, because those patients are also usually receiving a list of medications that are high risk, and this combination means spending a lot of time with that patient. This is why the more acute the unit, the lower the ratios need to be. In the ED, patients in general shouldn’t be more than 4:1 to the nurses, unless you want to compromise patient safety by not monitoring the patients closely enough. For that reason, the ICU is usually 2:1, the “step down” unit is normally 3 or 4 to 1, and so on.

This is why the ED usually has a unit called “fast track” where patients are less sick with things like toothaches or broken fingers. In fast track, you will see ratios of 6:1 because the patients require far less of the nurse’s time. Fast track is usually a separate subunit within the ED, usually staffed with a nurse or two and a midlevel practitioner (a PA or a nurse practitioner), and the goal there is to clear out as many low acuity patients in as short a time as possible, thus leaving the sicker patients (who take up more time and resources) for the doctors and the nurses with lower ratios.

My wife’s job is moving. She will be working about 30 minutes farther away from the house than she is now. She wants to move closer to her new work location. I have been working on changing hospitals. If I want to do that, it would be easier if we move. If we move about 30 minutes south of where we are now, it would put us closer to my wife’s work and would make it easier for me to find a new hospital.

So we have been looking at houses. We had a few must haves, and some wants.

• We want a one story house.
• We need at least three bedrooms and three baths. This is so we have room to care for an aging parent if it comes to that, plus room for a guest.
• I would like natural gas service
• We would like a pool.
• We need more storage space. Either a bonus room, a large garage, or room to build a storage structure on the property.

So we began looking.

The first community we looked at wanted $400k for a 2000 square foot house. Hidden costs included a $45,000 bond. A bond is an invention here in Florida that requires each owner of a residential property to pay for roads, fire stations, and other infrastructure costs that are not part of the property. In other words, it is a cost of building a neighborhood that is passed on from the builder to the buyers of the homes. This raised the cost of the house to $455k, or about $225 a square foot.

The second and third builders did not have houses and floor plans that we liked. We went to a late lunch out in the country. While we were there, I happened to see a nearby community that looked interesting, so we headed out there. They had 2950 square foot home plan that they think we can get built with custom options for $525k, and no bond. That brings the cost to $178 a square foot. Admittedly, it’s at the upper limit of what we wanted to spend, but it’s a really nice house with a large kitchen. The best part is that it is within a 30 minute drive of 5 different hospitals, which gives me a lot of flexibility in changing hospitals. It’s one of those small Florida towns that only have a population of about 2,000 people, but still have stuff nearby.

The only real catch is the current lead time for construction is 12 months, meaning that we will be in late 2023 or early 2024 before we can move. We are looking at all of the numbers and facts, but we will likely be paying earnest money within a week or two. That means when the school year starts next fall, my wife will have to commute a bit. It also means that I can start looking for new work, expecting to start somewhere in July or August. There is a hospital that is only 15 minutes from the house we are looking at that is a good place to work and is offering a $10,000 bonus to work there. By all reports, the pay is good and I hear lots of good things about them. There are other hospitals that offer larger bonuses, but there is a reason for that.

So change is coming. It will be easier working where I am, knowing that my days there are numbered.

Speaking of expensive hobbies. One of the things that I do to stay busy is work on making my house a smart house. It all began about 8 years ago, when I installed a SmartThings hub. Our house is automated. I use our cell phones as presence sensors, and the house changes modes when we leave, come home, and go to bed.

My wife was very understanding, and has now come to love the automated features of the house. When we go to bed, the thermostat changes to make the house cooler, the lights turn off, and the smart locks on the doors all lock themselves. The landscaping lights change colors depending on the season. There is purple, gold, and green for Mardi Gras; Red, white and blue for Independence Day, that sort of thing. The hot water heater turns off when we go to bed or leave the house. It’s geeky, fun to do, and pretty bad ass.

But 8 years has gone by, and technology is evolving. I have always been bothered by the fact that SmartThings is a cloud based processor. I want local processing, and now that we are thinking about moving next fall, I have a chance to try it.

I am thinking of switching to Home Assistant. I just bought an Odroid N2+ processor and a 128 GB eMMC card to use as a server. Now I am going to learn how to program it and integrate it with all of the devices I am planning on using. So I will spend the next few months playing with it. I am planning on using smart switches that can control scenes as well as individual lights.

It’s good to have a tolerant wife.

Oddly enough, I posted the other day that I am thinking of changing to a different hospital and that same afternoon, I got two emails. The first was from my job, spelling out that all employees need to be aware that, should we decide to wear a shirt under our scrub top, it has to be white. We also have to wear white socks that cover our ankles. If we choose to wear a sweater or coat, it must be the same color as our assigned scrub color. This seems odd to me, since they can’t find shift coverage and are back to offering shift bonuses most days and are still understaffed.

We are a 50 bed ED, and we had 123 patients the other day. All of the rooms were filled, plus we had 50 patients on beds in the hallway and another 23 patients being treated in the waiting room. But our administration is worried about what color tshirt I wear under my scrubs.

The second email that I got was from a competing hospital chain. They are inviting a bunch of nurses to a free meal where cocktails will be served and we get the opportunity to meet the leadership team and learn about the advantages of coming to work for them.

Dude. Looks like I at least get a free meal out of the deal. I told my wife that I am not working that day, so I think I am going to go and at least hear the pitch.

The hospital where I work has all sorts of issues. There is a nursing shortage, there are problems with long waits, patients holding in the ED waiting for space on the floor that isn’t available due to a shortage of nurses. Turnover has been enough of an issue that they can’t keep staff.

There have been multiple administrators that have come and gone, and each of them has addressed it in a different way. One way was hiring contract nurses at $200 or more an hour. That was too expensive. Another administrator tried paying large bonuses to get nurses to work more days per week. Still another tried bringing in foreign workers.

One thing that all of them have had in common was the dumbest, least effective action. They changed the colors of the scrubs everyone wears. When I was hired, you could wear any color except black, denim, camouflage, or pediatric prints. Six months later, the colors changed. Since then, we have cycled through at least four different colors. In less than two years, I have bought at least five different collections of scrubs.

Effective tonight at midnight, we all have to wear a new scrub color. These scrubs have to be embroidered with the logo of the hospital and your job title “Nurse,” or “Doctor,” or what have you. We have to buy them from one approved vendor. That vendor is owned by the wife of one of the administrators. I am not sure how that is legal, but there it is.

So I had to buy two sets of scrubs in the new color, complete with the logo of the hospital affixed to it. I’ve learned not to buy more than that, because we will just have to buy a new color within a few months anyway.

The managers are mostly assholes and treat staff rather poorly, although I can say that I like the ones in charge of the ED. They are mostly cool, and I don’t blame them for my recent suspension. That came from risk management, and wasn’t their decision. Still, this place has begun getting on my nerves.

I am giving serious thought to switching hospitals. I’ve been here for two years now, and one of the nice things about this profession is the ease of finding a job. I know one nurse who shows up to interviews in casual clothes and says something to the effect of “Here is my license. We both know that you need nurses badly enough that you are going to offer me this job. So let’s cut to the chase- what are you willing to offer me? Don’t waste my time with useless back and forth, give me your best offer,” and they present her with her options.

Maybe it’s time for a change of scenery. There are a couple of options:

• I can go back to being full time. There are a couple of places that are offering $10k bonuses and more per hour than I currently make for full time, which is three shifts a week. The downside is I am on a fixed schedule, and I hate begging someone for time off.
• There is also an offer of $7500 bonuses at a couple of places. The downside is that I have to work two shifts a week, and still have to beg for time off.
• I can also take what’s called a seasonal position, which pays $65 to $85 an hour, depending on what unit you wind up in. The downside is that you get you no bonuses, no benefits, no shift differential, and have to work every holiday. You sign a contract that has to be renewed every six months, so you can take a few weeks off (without pay) between contracts.
• Or I can look and see what PRN contracts there are and at what pay level. These allow the most freedom- you generally have to work 4 days per month, but can work as much and whenever you like. The only benefits you get are shift differential, shift bonuses (which most hospitals have done away with), and the freedom to work whenever, as little, or as much as you want.
• The last option is travel. A recruiter just contacted me about working in Boston. Ten weeks, $3400 a week for three days per week. They pay the cost of your hotel. That works out to about $90 an hour. It costs $200 round trip to fly between Boston and Orlando, so I would be making $3200 a week for ten weeks but would have to pay Massachusetts taxes, plus would have to actually go to Massachusetts. I don’t think that’s in the cards for me.

I think I am looking at leaving this place in June or so, when my wife’s school year ends. I don’t need benefits, because I get health insurance from my wife’s job. Maybe I will take a month or so off, then look at my options.

Christmas day saw me work 13 hours in the emergency department. It was a fairly quiet day. Then came the 26th. Things were pretty quiet until 3 in the afternoon or so, then all hell broke loose. We had drunks and crazies galore.

One guy came in as a Baker Act*. He was screaming that he was a CIA trained assassin and said he was going to kill (pointing at four of us, me included) those guys as soon as EMS let him off the stretcher. My manager was standing next to me. The same manager that had to tell me that I had been suspended for the last time I had to wrestle a patient. Next to that manager were two of our doctors.

Sotto voce (so the patient couldn’t hear) I said, “How good of an assassin could you be? Killing yourself even seemed to be beyond your capabilities.” Coffee immediately shot out of the doctor’s nose. My manager said, so let’s let him off the stretcher and see what happens. I said, “Do you really want to do that? Last time that shit happened, you suspended me for a week.” The manager even laughed. We gave him some Haldol and some Benadryl, which did wonders for his attitude. After an hour or so, he was telling me that I was the smartest man he had ever met. Love that Haldol.

We also worked four codes, some other kidney and blood sugar problems, half a dozen sepsis alerts, and a stroke alert or two. We are also seeing a lot of flu and COVID. We actually had our first COVID death in quite a while. It was legit. He came in complaining of shortness of breath and had an O2 saturation of 65% and a blood pressure of 70/40. We did all we could, and even managed to get his O2 up into the 90’s with some BIPAP, but even Levophed couldn’t keep his BP up. He died about an hour after we sent him upstairs to the ICU.

Yesterday was no better. We had all sorts of craziness. A homeless woman who wanted to fight, three codes, and a dislocated hip. Conscious sedation, one nurse leaning on his pelvis, me pushing on the hip joint, and the doctor up on the bed with the patient’s knee on his shoulder, pulling. We pulled several times, then a loud pop. Nope, didn’t realign. Instead, the hip fractured. So now he’s off to ortho for surgery. Another patient had been prescribed Januvia and Novolog and the combination meant that we couldn’t keep her blood sugar up without a constant D10 drip.

Thus ends my work year for 2022. Now I don’t work again until a few days into 2023. I worked 38 hours in three days, which is why there hasn’t been any posting here to speak of.

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A Baker Act is a law in Florida that says a person can be held under involuntary psychiatric observation for up to 72 hours, if a Law Enforcement Officer or Physician feels that the person presents an immediate threat of death or serious bodily harm to themselves or others. It’s generally used when a person either attempts or threatens suicide. Every state in the US has a similar law.