After this week’s post where a fellow nurse reported my so-called (in her opinion) poor patient care, I got a surprise email telling me that I am being promoted, effective Saturday. This was a huge surprise, being that I was just promoted in August. While I am sure that this was not related in any way to my argument, it just feels like icing on the cake.
I am waiting to see what kind of raise comes with this.
No, it isn’t a management position, but it does mean more money and prestige.
I am going to take this time to explain how strokes are treated in the hospital. I am going to make this understandable to the layman, so there will be some things that get simplified, or even omitted to make this easier to understand.
Strokes are the fifth leading cause of death in the US, so treating them is an absolute must. When people have signs of a stroke in the Emergency Department, the rules say that we have to get them a head CT within 10 minutes. The CT is looking for bleeding in the brain, which is called a hemorrhagic stroke. About one in eight strokes is caused by bleeding in the brain. The other seven are called ischemic strokes and are caused by blood clots.
Immediately after the CT scan is done (the patient is still in the CT imaging room), they are interviewed by a neurologist to see if they are showing signs of an ischemic stroke, meaning one caused by a blood clot cutting off oxygen to the brain. The nurse does the evaluation at the same time, and each of them come up with what is called an NIH score. They then compare scores and, if different, they discuss why. The idea is to give the score that is most advantageous to the patient. An NIH score measures the likelihood and severity of a stroke through a score that ranges from 0 to 42. The higher the score, the more severe is the stroke. A score of eight or higher means that the patient gets screened to see if they are a candidate for TPA administration.
TPA is a miracle drug. It breaks up blood clots, and allows blood to again flow, saving brain tissue from death. If administered within the first 4.5 hours of a stroke first beginning, the patient frequently leaves the hospital with no permanent disability. Sadly, many people with stroke symptoms wait too long to come in and are not candidates for this therapy.
If they are having a stroke, but are outside of that 4.5 hour window, they are admitted and we see just how much brain function they have lost. Then they are discharged to be rehabilitated and taught to live with their new disability.
In 84% of cases, patients who have just had a stroke will see their blood pressures greatly increase as the body tries to use this pressure to force blood past the clot that is cutting off blood to the brain. This process actually reduces the amount of damaged brain tissue in an ischemic stroke, reduces the amount of permanent disability, and decreases patient mortality due to ischemic brain tissue.
The risk of this is that the large increase in blood pressure greatly increases the chances that a blood vessel will rupture, causing a second, hemorrhagic stroke, and that second one is often fatal. I believe that a hemorrhagic stroke is what killed my mother last year.
Since 2019, the American Stroke Association and the American Heart Association both recommend that a patient with an ischemic stroke that isn’t a candidate for TPA administration be permitted to have high blood pressure for the first 24-72 hours after the stroke while being closely monitored. The only high blood pressure to be treated in these cases is a blood pressure higher than 220/120. In those cases, the patient should be medicated to reduce blood pressure by 15%. This is called permissive hypertension and is the current way that hypertension in stroke patients is being treated.
The problem is that this is not received well by older medical professionals, who have spent their lives thinking that “high blood pressure is bad” and want to reduce blood pressure no matter what. They just haven’t remained current in their clinical knowledge, and secure in their ignorance, will violently defend what they have always done, even when that has been shown to be the wrong thing to do.
I recently had a stroke patient with a BP of 263/152 and had formed a plan in conjunction with the doctor to lower her BP slightly to 220/110 using medication. Another nurse (who used to be a charge nurse) came over and started a loud shouting match, telling me that I was being dangerously lazy in not controlling the patient’s blood pressure. She accused me of being a shitty nurse and reported me for poor patient care.
I produced all sorts of studies showing that I was right, so I won’t be getting in trouble, even though the QA department agreed with her, trying to tell me that blood pressures of over 200 are too dangerous. They pointed out that the units on the floor have a policy of not accepting patients with a blood pressure that high. I told them that maybe the policy should be revisited in light of current literature.
Why? Because medicine is evidence based, and the evidence and current literature is on my side. I presented my nursing plan and the current literature to my department head, and she agreed that my treatment was in keeping with current AHA and ASA guidelines.
That required me writing a long dissertation to support my position. It wound up being a 460 word essay, complete with references to the AHA and ASA guidelines, as well as referencing multiple studies carried out since 2020, showing that patient outcomes are better under these guidelines.
It’s cases like this that show why good nurses make a lot of money for the level of education that they have. I’m probably going to present my case to the hospital’s clinical standards council (one of whom already spoke with me and thinks its a great idea) and try to get the policy changed. It’s a stupid policy that is likely killing people. The bonus is that, if I am successful in forcing the change, I get a raise and I also get published.
The reason that posting has been lacking a bit is that it’s been a busy week. Let me recap it for you:
There are seven days in a week, of course. Three of them were spent at work this week. The first day this week turned out being a 14.5 hour shift because of a stroke patient, a fellow nurse who used to be a supervisor trying to bulldoze me, and a little thing we will talk about in a future post called permissive hypertension.
The second day this week was a 14 hour shift because I had some relatively sick people and the nurse taking my patients was late doing so due to her trying to find a sitter for her Baker Act.
The third day, they cut me an hour early because the census was low and they didn’t want me to slide into overtime.
Then my days off wound up being filled with personal details- the house that we used to live in is now under contract. We first listed it for sale back in early March after replacing the floors and the air conditioner. We tried selling by owner, no luck, only one showing that never called us back. We tried one agent who didn’t even get us a single showing. The second agent had multiple showings, and we finally sold. Now I can use the money to get a pool, an outdoor kitchen, and pay off half of the mortgage on my current house. Speaking of mortgages-
We have been trying to refinance the house we live in, because our original loan was for 8%, and we got a refi offer for 4.8%. We close on that this week.
I have also been working on the network of the house. If you will remember, I wanted to put a UPS on the network. The one that’s in the house as built was supposed to have a 28 inch media panel. It didn’t- it had a 20 inch panel, and that was too small to fit all of the stuff I needed. So I pulled out the old one, put in a 30 inch panel, and wired the network in the house with a MOCA system. That 30 inch panel let me put in the modem, the MOCA converter, the master mesh node, a couple of network switches, and the UPS.
While installing the MOCA system, I had to use a cable tracer to see which cables went to which rooms. There are 8 cables coming into the house- one for each bedroom, one in the living room, one to the media panel, one to the bonus room upstairs, and one that I still don’t know where it goes. I put a cable tracer on the lines, and three of them were showing open circuit. I started investigating, and this is what I found:
The one in the master bedroom was hidden behind a phone jack:
The one in the upstairs bonus room was simply not connected. An inspection camera revealed that the cable was stapled to the studs above and below the box.
Still, I have it all done, and the MOCA system is now installed, so my mesh network now has an Ethernet backhaul, which increases network speed and reliability.
Then I spent a day this week going to my grandson’s soccer game.
All of those things have taken quite a bit of time, and left me quite sleep deprived. There was one night that I had to make do with only three hours’ sleep. So Sunday is a day off. I am going to get caught up on sleep, head to a diner and get a rib sticking breakfast, then spent the day with my bride doing nothing.
With all of that, there was precious little time for blogging or even reading the news. I am looking forward to vacation. I have a vacation coming up, where I am spending a week in Bimini for some well earned time off. Until then, life goes on.
This week has been pleasant in Florida, with temperatures being typical for a Florida Autumn. The highs have been in the high 70s to low 80s, lows in the upper 50s and low 60s. Pleasant breezes carrying air that is, for the gulf coast, rather low in humidity.
It has triggered some strong, pleasant childhood memories. I remember most vividly a fall day spent watching my mother decorate the house for fall with expanding paper pumpkins and other assorted fall and Halloween decorations, the windows open and cool fall breezes blowing through the house as dinner cooked in preparation for my father coming home from work. It is one of the more pleasant memories from my childhood. I still fondly remember those decorations to this day, 50 years later.
Now, the child is gone. My mother and father are gone, the paper pumpkins are gone. The country that I grew up in is gone. All that remains are the memories of a time that no longer exists in the head of a man who now is old enough to get free coffee at Denny’s and has grandchildren who are older than I was in those memories of an autumn long gone.
I had a tough week at work. Because the weather has been so mild, people haven’t been coming in to the ED for the stupid reasons that they usually do come in for, so we haven’t been as busy as usual. I have been in the critical zones, and my patients have been truly sick. More than half of my patients have been admitted to the ICU, and that makes for a heavy workload and a lot of thinking about life and death.
Combine the battles with death and the upcoming anniversary of my mother’s death and father’s birthday, and you have what I suppose is the reason why I am feeling a bit- nostalgic.
My wife, without even knowing the memories and thoughts in my head, has decorated the house for autumn. It makes me content. I don’t think of myself as an old man, yet. I’m not old enough to be a boomer, but I still feel older every day.
It’s a perfect metaphor. I am in what is probably the October of my life, and missing the time when I was a child. I can feel the chill of an approaching winter, can you?
Our highest wind gust last night was 78 mph. We had several hours of 40-50 mph wind. We wound up getting 4 inches of rain in total. There were a couple of instances where I heard something hit the house.
At first light, I went out and surveyed the damage. We had no damage to our house, but a neighbor had a couple of trees topple. I helped him do some chainsaw work. Another lost his roof. All in all, it was relatively painless. Once the breezes calm a bit, I will get the drone up to look at the area.
I set up the propane stove on the back porch, and we are cooking breakfast. Once the clouds are gone, we will go back to cooking on electric. I am just trying to limit electric loads while we are on battery.
We have plenty of food, water, and supplies.
Update- The winds are now running about 45 mph. A weather station nearby just reported a gust of 120 mph, far more than we were supposed to get in this area. There was a momentary glitch in the power about an hour ago, which caused me to lose Internet connectivity as the modem reset. About 5 minutes after that, there was a bright flash outside and the power went out again, but didn’t come back on.
The power is out throughout the area, all is dark. We are now running on our fully charged Powerwalls. We have enough battery power for more than 24 hours at current consumption- I have turned off the upstairs air conditioner, the water heater, and all other large loads with the exception of the downstairs air conditioner.
I am sitting here watching the back door bow under the pressure of the wind. I’m sure that I won’t sleep well tonight.
From three years ago. I figure this is needed since there is a lot of misinformation about the hurricane response.
Many people see FEMA as some sort of large Federal organization that responds to emergencies. They aren’t. What FEMA is, is a guy with a Rolodex (Remember those? If you don’t, ask your parents, snowflake.) and a checkbook. There isn’t some magical team of Federal Employees sitting around, waiting for “the big one” so they can swoop in and save everyone. That isn’t how it works.
No, this FEMA guy’s phonebook is filled with the contact information of local and state resources that can be called in an emergency. Those resources respond, tracking expenses and man hours used, and the FEMA guy then breaks out the checkbook to reimburse the states involved. The Governor doesn’t call out FEMA for shit. If you want to get technical, FEMA can’t do a thing unless the President tells them to. (Didn’t Trump catch hell for that recently?) FEMA’s largest contribution is writing the check to pay for it all.
After 9/11, the US government came up with the concept of Urban Search and Rescue Teams. They follow a set of guidelines in equipment and training, so that all of them nationwide operate on a similar set of procedures. This makes them interoperable across state lines: a person qualified for one could easily fit into any of the others. A USAR is equipped with everything from power generators to food trailers and rescue equipment. They have medical supplies, fuel, and all other equipment needed to fulfill their mission. Each USAR maintains over 5,000 pieces of equipment and has 140 or so assigned personnel. They can operate independently for 2 weeks, longer with resupply of fuel, food, and other consumables.
While there are some variations in the mission for each team (a team in Florida doesn’t need to be equipped for blizzards, for example) the teams are remarkably similar in training and equipment.
Florida doesn’t need FEMA resources for a building collapse. The state has eight Urban Search and Rescue Teams, all of whom are trained and equipped for that. Each one is centered on a large city, and draws its personnel from surrounding first responders. These first responders volunteer for the team, are sent to special training, and then become qualified for the team. Specialists are trained in HAZMAT, trench rescue, building collapse, confined space, water rescue, dive rescue, high angle, and vehicle and machinery rescue. Every member is certified as an EMT or Paramedic. It takes 2 to 3 years of training to fully qualify for a USAR team, on top of the extra training that they do on a constant basis. Most USAR members are the best of what their employing agencies have to offer. They are the most motivated and able of emergency responders.
To be honest, I loved deployments. Not because deployments meant people were suffering. No, mostly it was because they were a test of all that you had learned. That, and a FEMA deployment usually pays pretty well. I was deployed to Katrina for 12 days and was paid more than $5,000. You want people who bring years of expertise and thousands of hours of training to come save you? You want people willing to live on 3 hours’ sleep a night without bathing while shitting in a bucket and eating old MRE’s for two weeks? It’s gonna cost ya. That kind of expertise and dedication isn’t cheap.
When talking about libertarian theories of government, someone always comes forward with the example that fire departments be privatized. When I point out that private fire departments were already tried in this country and didn’t work, someone always points to volunteer fire departments as an example.
And they are wrong. Fire departments are a subject in which I consider myself to be an expert, having functioned and worked in half a dozen of them over a three decade period. I have been a volunteer with at least four different volunteer fire departments. Three of them are no longer staffed by volunteers, and the fourth is in a VERY rural area.
The problems with running a volunteer department are many. Let’s start with the reason why libertarians want to use them- money.
While cheaper than a full time, paid department, volunteer departments still cost money, and in most cases those departments are nowhere near as effective as a career department. There are only two ways that a fire department can be funded: Through tax dollars, or through voluntary donations called “membership fees.”
The tax dollar funding model is self explanatory, so I will spend some time discussing membership fees. In order to become a member of the fire association, each property owner pays a voluntary membership fee, with these fees ranging from $30 to a couple of hundred, depending on the particulars. If a member’s property is responded to by the fire department, their membership fee is all that they pay. If the fire department responds to a nonmember’s house, there are two possibilities:
All fire departments require large amounts of funding. There are fire trucks to be bought, a fire station, firefighting equipment, insurance, utilities, fuel, and a myriad of other expenses like training that all must be paid for. The larger and busier the department is, the more that costs.
Let me explain:
Volunteer department D: This was a very busy volunteer fire and rescue squad in a large city (over 400,000 people) that had been in operation since the 1950s. Over the years, more and more career firefighters were added to staff the station during periods when the volunteers were unavailable. When I was there, one fire engine and one ladder truck in the station were staffed 24/7 by a crew of 8 career firefighters, while several EMS units and a second fire engine were staffed by volunteers. There are no longer any volunteer firefighters there. While I was there, it was volunteer, but it still was funded by tax dollars and had an ISO rating of 4/9.
Volunteer Department H: This is a volunteer department in a very rural area of the Ozark mountains. It’s staffed by untrained volunteers, and while they work hard, they have almost no money for equipment. The fire engine that they had was a 1950’s era fire truck. In the year that I was there, they had exactly 5 fires: 2 brush fires, 2 chimney fires, and one house fire that saw the house burn to the ground. It had an ISO rating of 9. It is funded through mandatory fire fees that are collected through the county tax office, and has an operating budget of about $50,000 a year, even though there are only about 500 residents.
Volunteer Department B: This was a busy volunteer department that responded to approximately 4,000 calls per year out of two stations that contained a total of four engines, two brush trucks, two ambulances, a pair of tankers, and a rescue squad. The ambulance at each station was staffed by two career firefighters, and the fire engines were staffed by volunteers. The requirement was that one fire engine at each station was staffed 24/7 by two volunteers. Each volunteer was required to be in the station for four 12 hour shifts per month. The funding for this department came from tax dollars. Eventually, the department went to a full time career staffing model. When it was volunteer, it had an ISO rating of 5/8.
Volunteer Department M: This was also a busy volunteer department. It responded to about 1,500 calls per year out of one station. It served a small town of about 12,000 people until the late 90s, when the population (and 911 calls) exploded, with the town going from a population of 12,000 to 70,000 within just three years. The volunteer system collapsed under the weight of increased call volume, and it was taken over by a career department. The station had a rescue squad, a tanker, a fire engine, and a brush truck and was supported by tax dollars. Its ISO rating was a 6/9, but the station is gone and there is a gas station where it used to be.
There are some very successful and large volunteer fire departments. The Thibodaux Volunteer Fire Department is one such department. It boasts 500 volunteers responding to calls out of 10 fire stations, with 150 of those volunteers being active in responding to calls, the rest of them doing fundraising and other services. The department has an ISO rating of 3. However, the city of Thibodaux provides nearly half of the department’s $2 million in operating expenses from tax dollars. This is a great example of the best in Volunteer firefighting, but it still needs to be funded through taxes.
The additional fact is that volunteerism is declining in this country, and has been for decades. A lot of factors go into the reasons for that. The demands on volunteers’ time is one- training, maintenance, and increasing call volumes are big reasons for this. Not to mention, it’s easy to get people to show up to the “exciting” calls like plane crashes, fires, and auto accidents. It isn’t nearly as easy to get volunteers to show up to EMS calls, because it isn’t “fun” to show up and deal with the demented old lady who is covered in her own shit. Firefighters, especially volunteers, are adrenaline junkies, and EMS runs just aren’t exciting.
Trust me- I was in charge of retention and response at department M during the end of my time there. We tried a mandatory staffing model like Department B, but there weren’t enough volunteers to do it. We tried paying a volunteer $5 an hour to staff it during the day when the other volunteers were at work. Then we tried paying volunteers $4 each for showing up to EMS calls, but that didn’t work either. The demands on people’s time was just too much to bear. The number of calls that went unanswered climbed steadily, until almost 10 percent of non-fire calls went unanswered. People just didn’t want to run the “boring” calls. As one volunteer told me- “I am here because I like putting out fires. I give the time I want to give, that’s what volunteering means. I am not about to come in at 2 am just to wipe grandma’s ass or deal with some homeless junkie.”
Another demand on firefighter time is training. Everyone likes to do live burns. Those are fun. Where people don’t like to train is in the more dry subjects- classroom time in HAZMAT, medical training, and the hundred other topics that are required to run a fire department. It’s getting more and more difficult to get people to come to things like training. Even paid firefighters hate training- and there is a lot of it. To become a state certified firefighter and EMT in Florida takes nearly 2,000 hours of training, and then another 250 or so hours of training per year. It’s a lot, and volunteers just don’t have the time to engage that much.
It’s tough, and it’s getting tougher, to recruit, train, and retain volunteers. It’s tough to fund their operations without using tax dollars- in fact, it’s almost impossible to do so without some form of mandatory, tax funded source of income.