Five days ago, I posted about the hospital where I work trying to save money by cutting out the shift bonuses that were being used to entice the staff to work 50 and 60 hour workweeks. Today was the first day where I worked and there were no overtime people. Where a 50 bed ED normally needs 14 nurses to operate? We had 10 for most of the day. Meaning that we should have 5 patients to each nurse.
Nope, we were too busy for that. We tried to tell EMS agencies that we couldn’t take any more patients (it’s called being “on divert”). It didn’t work. At one point, we had 90 patients. For ten nurses.
I work a swing shift, which is supposed to be 11am to 11pm. Most of the ED works 7-7. By 9pm, my patients were:
- A 37 year old female who kept having seizures. She had 6 of them the first 2 hours she was my patient.
- A 26 year old male fentanyl overdose.
- A 76 year old with a bowel obstruction that is vomiting coffee grounds.
- A 35 year old who came to our facility two weeks ago complaining of chest pain and went into cardiac arrest. He is complaining of chest pain and has elevated troponin levels.
- A 78 year old woman with perforated diverticulitis.
- A 56 year old intoxicated woman who is with us for altered mental status and is covered head to toe in her own feces.
For those of you who don’t know, most of those patients need to be in a unit that offers a higher level of acre than what we can provide in the ED. The problem is that all of those units are already full.
In the meantime, there are 22 people in the waiting room, waiting for us to have room to treat them. At one point, there were 7 ambulances lined up at the door, waiting to drop off patients. So I wound up ordering Wendy’s through DoorDash at around 8pm, and eating it at the nurses station while I wrote notes on patient’s charts.
Needless to say, everyone was getting testy, patients AND staff.
As 11 o’clock approached, the charge nurse asked me to hold over because we still had more than 60 patients, and three of us were scheduled to go home at 11, which would leave her with no techs and only 8 nurses. Because I like her and she always does me favors, I agreed to hold over for a couple of hours.
Right at 1, when I was planning to go home, all hell broke loose. An intoxicated woman was brought in by EMS, who claimed they were unable to get an IV. Ten minutes after they dropped her off, she vomited about a 1.5 liters of blood.
So a third of the remaining nurses spent the next 45 minutes trying to keep her alive. All of their patients were getting ignored in the meantime.
One nurse remarked, “As long as we keep doing this, they will keep making us do it, until it becomes the ‘way we have always done things.'”
I finally left the place at around 2 am, having worked a total of 15.5 hours. But think of all the money they are saving by not having to pay those bonuses.
18 Comments
joe · September 25, 2022 at 5:46 am
it took me 15 years to realize no one gives 2 fucks how hard you work, how many times you volunteer to do this or that, work a weekend/holiday until the day comes when you aren’t there for some reason… not that I ever did it for favor or brownie points, just the way I was raised… up until I had kids, I had used maybe 10 sick days in nearly 15 years… this ain’t 1940 when people worked at a company/business their entire adult life and retire and still feel welcome and get invited to the company picnic every year… like you mentioned the other day DM, it’s business…I don’t volunteer for shit any more…I give 110% the hours I’m there and that’s it…
Jerseygirl Angie · September 25, 2022 at 6:35 am
You are , like so many in the front lines of health care , a victim of your own competence . You have proven to the administrators that previous staffing levels were grossly bloated – after all , things are working perfectly well ( from the administration’s POV ) , and no need for those silly bonuses for the peons ( that money can go into the bonuses for the administrators ) .
Any issues , up to and including serious injury or death of patients ( or staff , for that matter ) will be lamed as obviously the fault of the front line worker bees . Administration NEVER has to face the consequences of their mistakes .
DMLMD · September 25, 2022 at 6:57 am
“But think of all the money they are saving by not having to pay those bonuses.” Also think about who gets the blame when something goes very bad, anybody but the those that received the bonuses for “managing” the costs. Can be very scary doing the right thing.
Nolan Parker · September 25, 2022 at 7:21 am
What a frikken nightmare, for everyone.
mike · September 25, 2022 at 8:03 am
>>A 37 year old female who kept having seizures. She had 6 of them >>the first 2 hours she was my patient.
Drugs or Vaxx??
>>A 35 year old who came to our facility two weeks ago complaining of >>chest pain and went into cardiac arrest. He is complaining of chest >>pain and has elevated troponin levels.
Vaxx?
Sounds like it is beyond the breaking point now. I wouldn’t put up with it for mere money, but that’s me. I don’t think the prepping world has considered or weighted properly how easily the medical system could completely break down and the ensuing chaos that would unleash. It seems like there is great potential for that at any given day ,independent of any other collapse factors.
Divemedic · September 25, 2022 at 10:54 am
Not everything is always the vax, all the time. In the case of chest pain guy, he is a long time abuser of drugs. Although he has been clean for the last couple of years, the damage was done.
Seizure lady has a long history of them and has been on lamictal/keppra and other drugs for years.
Michael · September 25, 2022 at 8:12 am
The bean counters are never working the floor.
It’s hard to tell a good boss that works beside you no, I cannot do an extra shift (usually hidden as a couple more hours until the surge is over?). I too have been called in when not on call because the situation was crazy or the On Call wasn’t responding. Code Mom is always going to get my support.
And then folks cry that Nurses and Techs should not be allowed to Unionize or strike. While I tend to agree, what happens when the bean counters keep pushing the envelope on our sense of decency and or physical limits?
Big Ruckus D · September 25, 2022 at 10:20 am
I’m pointing out the obvious here; but the conditions DM has described in the ED he works in are one of the myriad reasons healthcare will collapse. Those “running it” don’t care, and just keep squeezing costs (read: cutting staff/level of service) while the health of average Americans further deteriorates. I’ve told people around me for years to get healthy (insofar as not doing stupid stuff to damage their own health with things they can control like being poor diet, smoking, drinking, drugs, needlessly risky behavior, etc.) The consequence of so many bad habits over the long term is damaged health, and ultimately more reliance on healthcare services.
The upshot is that at some point those services will not be readily available when they are most desperately needed because of the way corporate medical systems operate. The quality continues to decline alongside the precipitous drop in the baseline health of most Americans. There will be a convergence point where those two realities destroy any chance of receiving acute care in a timely manner, and eventually it will find it’s way into non-emergency care as well. That is already here, really, as I know many people who already in their 30’s and 40’s have serious chronic conditions (some are self inflicted, others just drew a bad hand in the genetic lottery), and wait literal months for an office appointment with a specialist who they see to try and manage various problems.
This is not going to get better, as the talent to fill demand is not being cultivated. Rather, staff is being imported from countries with lower standards, or the ranks are being filled by affirmative action dieversity candidates who frequently lack the competence and disposition needed to do the job. Either way, the trend is less access AND less quality right as the demand for ever more is exploding on account of an aging and increasingly unhealthy population at large.
All this is steering is towards the inevitability that there will be far less access to healthcare services in general, and poorer outcomes will become the reality even for those who can get access to it. We have largely done this to ourselves through personal carelessness, and a long running collective lack of concern about how the healthcare business has turned into a monster (from a corporate management standpoint) that seeks to consume every dollar it can extract, even to the detriment of the larger economy in general.
Those like DM, who have the skills and character to do the job well and go the extra mile, are themselves victims of a fucked up and abusive system they have to operate within. Their collective efforts will not prevent the collapse, and unfortunately even those individuals who benefit from the care they receive from the dwindling number of staff who put in that sort of extraordinary effort, will take it for granted until it’s no longer there.
It is a problem, like so many others in modern society, whose only apparent solution is destruction. Just like many of the patients DM described, death is already assured because the damage done is too far along to be reversed, and almost nobody wants to do the hard work to change the outcomes anyway. So, here we are, watching the wheels fall off.
Aesop · September 25, 2022 at 11:45 am
You can keep filling the lifeboat until it only has an inch of clearance from the gunwale with the surrounding ocean, and it will work– until it doesn’t.
Then everybody dies.
Administration isn’t checking the wave height, or the clearance height, they’re just looking at how much they saved by not buying more lifeboats.
And guess who’s the first to call in and say, “Hey, my mother is having chest pains, can you hook us up when I bring her there in about half an hour?” with absolutely no sense of irony.
why · September 25, 2022 at 2:17 pm
The death ratio is 1:1, you’re born, you die; only a matter of when.
We, as a society, deemed that some lives are more valuable than others – the cocaine addict will receive multiple extensive cardiac workups for chest pain, the dementia patient in the nursing home who lives in the fetal position unable to respond or care for themselves is kept a full code by family, or the morbidly obese patient (BMI> 40 or 35 if has diabetes) who comes in routinely for chronic pain.
Yet, admin continues to make money, while actual care-givers make less. Medicare continually cuts re-imbursement and insurance finds multiple ways of not paying. So the only way to make more money (outside the fed govt giving subsidies like during COVID) is to see more patients.
I’ve got NO answers except that society determines priorities, i.e. chest pain more important than cocaine abuse. IIRC, it was TN (or OR??) that did the same, with each year determining how much money was available then stating they’d pay up to diagnosis #121 one year or maybe to diagnosis #200 the next. Anything after that isn’t paid for, so sorry.
Primary issue DM discussed is the difference between ED and ICU. While both are considered critical care, there are some fundamental differences. For one, ED is used to developing the diagnosis, versus the ICU already having a working diagnosis. The ED is used to dealing with a critical patient for short-time and rapidly identify abnormals BUT not necessarily good at identifying concerning changes that are still “normal”, i.e. pulse going from 62 to 96 over the shift. The ICU is used to looking at trends over a 12-hour shift. The ICU is also used to working 1:1 (RN:patient) or 1:2. Depending on severity of illness, there may be 2 RNs per pt.
When you’re talking ICU and having a patient on multiple drips (medications), you’re constantly checking the vitals and those drips. In the ED, if you get pulled away for an emergency, your ICU patient becomes at risk as who is watching those vitals?? And depending on monitor alarms are a joke. It’s called “alarm fatigue.” After having an alarm go off multiple times, and each time because the patient had their arm bent, eventually the alarm is either turned off or ignored.
Hospital admin can talk out their ass all day long. The VAST majority of the ones I know have ZERO clue of what’s really going on.
A Few Good Men sums it up – with Jack Nicholas on the stand being grilled how he gets the job done.
anonymous coward · September 25, 2022 at 3:44 pm
The problem – that EVERYONE see’s, isn’t just related to health care – although that is probably the most important business/service to everyone. All companies have this disfunction to some extent.
It’s driven by the decision makers not being a part of the work, instead they are the cloud people – professional managers brought in to tell you how to do it, even though they are long past (if they ever did that thing thing in the first place) of getting their hands dirty doing the job.
Decision makers don’t work in the trenches.
Eric Wilner · September 26, 2022 at 8:10 am
“It’s driven by the decision makers not being a part of the work”
That’s a large part of it. Modern corporate executives, like kings, are fungible. Just as a king’s pedigree is more important than any connection to the land he rules, speaking the local language, and such, the executive must have the correct background and social connections, which are not obtained by working one’s way up from mail-room assistant.
The newfangled ESG rules accelerate the decline, by requiring appointment of executives with special characteristics unrelated to (or even at odds with) the qualifications needed to do the job.
Consider also what happens when an airplane company moves Corporate HQ away from the factory to be closer to a big financial hub. The executives get to attend better parties, and the airplane business falls apart.
The execs have all the wrong incentives: they get to party on somebody else’s dime, while having no understanding of, nor loyalty to, the companies over which they rule. Impressing members of their own class is what matters, and that’s not accomplished through the long-term success of the company.
It doesn’t help that the pay structure seems to be oriented around quarterly performance, rather than the long term. I’ve long throught that executive bonuses should be mostly in the form of stock options that vest a decade or more out.
Anonymous · September 26, 2022 at 12:10 am
Suppose you took the moral agency for this system of hurting patients and split it into twenty pieces, then gave it to different corporations, industry organizations and government agencies. Would people recognize these 5%’s as a team member of Team Evil(TM), assigned 5% of the Evil(TM) checklist but with plausible deniability? Can people recognize evil anymore which is more subtle than an Austin Powers parody of a Bond villain?
At some point, healthcare workers who continue to obey/participate/vote for authorities who demand this situation will become accomplices or accessories.
Aesop · September 26, 2022 at 11:11 am
Right.
Because shooting the kid with his finger in the dike is easier than tracking down the sumbitch who built it wrong and then failed to maintain it.
Brick-in-the-head subtle hint: You cannot assign moral agency to people who have no vote in the system. Responsibility without authority is an oxymoron. And you can’t justify launching no lifeboats, and letting everyone drown, just because there aren’t enough lifeboats for everyone.
The suggestion is asinine.
Anonymous · September 27, 2022 at 10:03 am
This attempts to put all the blame on the political leader, and none of the blame on people who first voted for and then continued to work in the politician’s organizations and obey the politician, no matter how awful the commands from the politician got. I’m sure every healthcare worker is a small-government cultural conservative who wrote in Ron Paul for president, and then having made that utterly ineffective bleat of protest went back to following orders and injecting the notvax.
Divemedic · September 27, 2022 at 1:14 pm
So what are you saying? That we should all quit our jobs? That we should start stacking bodies?
Anonymous · September 28, 2022 at 12:00 am
There are more options than those two, and I want to avoid the false dilemma fallacy. Here are some ideas: All hospital corporations are not identically awful; you could switch to a better one, or a smaller one. You could find a sympathetic doctor who shares your views on controversial medical subjects (covid/notvax/masks/lockdowns, cholesterol/low fat/statins, fast carbs/obesity/diabetes), then do emergency service housecalls under his telephonic supervision, and don’t report it when the customer who fell off the roof is an illegal alien working on a non-permitted project for cash under the table. You could be the nurse-plus version of a lodge doctor. You could get your patient stream from a health crowdfunding, religious healthcare sharing ministry, or surgical facility. You could be entrepreneurial and create one of those organizations in your area.
Anonymous · September 27, 2022 at 10:08 am
https://en.wikipedia.org/wiki/Accessory_(legal_term)
An accessory is a person who assists in, but does not actually participate in, the commission of a crime. The distinction between an accessory and a principal is a question of fact and degree
[…]
In some jurisdictions, an accessory is distinguished from an accomplice, who normally is present at the crime and participates in some way. An accessory must generally have knowledge that a crime is being committed, will be committed, or has been committed. A person with such knowledge may become an accessory by helping or encouraging the criminal in some way. The assistance to the criminal may be of any type, including emotional or financial assistance as well as physical assistance or concealment.
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