Observations from the Trenches

March 13th, 2011

By Brian Bagent

The trenches of health care delivery, that is.

Recently, I had three ladies in my care at the hospital where I work.  One of them was just post-op for a prolapsed bowel (where part of your bowel goes inside itself, not unlike what your socks look like just after you take them off), a second was just post-op for 2 hernia repairs, and the third was what we call a “frequent flier.”

Abdominal surgery is tough on a patient, even when done laparoscopically because we all have four layers of abdominal muscle — one layer that runs up and down our abdomen, one that runs across out abdomen, and two layers that form an “X” from the ribs on one side to the hip on the other.  Nearly all movement of any sort makes demands on abdominal muscles, which for my post-op patients meant that they couldn’t really move or their abdomens, injured by incision, would cause them pain.

Yet troopers they were, only once in a while asking for their narcotics.  It is to care for people like these two ladies that I became a nurse.

My other patient…I don’t even know where to start except to say that on that day I was very lucky because she was the only malingerer in my care.  She came in complaining of generalized chest pain, as she frequently does.  Her labs were normal, her EKGs were normal, but she was asking for Dilaudid and Xanax every couple hours, no matter how many times she was told that she could only have them every 6 hours.  Oh but she was in horrible, non-specific pain.

For those that don’t know, Dilaudid is a synthetic form of morphine, and much more potent.  But she claimed an allergy to both morphine and Demerol, so our only options were Dilaudid or Stadol (Stadol being another heavy hitter like Dilaudid).

The frustrating thing about an allergy to morphine or Demerol is…almost nobody has an allergy to opioid analgesics.  Perhaps 1 person in millions upon millions might develop anaphylaxis when administered a narcotic (and this is a town of about 8000 people).  No, this lady, like so many other patients getting “free” health care, had learned to game the system.  Unfortunately, she isn’t the only one of our frequent fliers that has developed an “allergy” to the milder narcotics like hydrocodone (the narcotic in Vicodin) and Demerol.

When narcotics are pushed through an IV, good form is to mix the narcotic with about 5-10 mL of normal saline (regular IV fluid) and then administer the drug over about 3-10 minutes, depending upon the narcotic and the amount being pushed.  Push a little at a time, then wait 30 seconds or a minute and push a little more, and repeat until done.

Another one of my little jewels, getting “free” health care, when I was pushing her Demerol told me “Oh, you can go faster than that, I can take it.”

I’m sure she could, but pushing faster gets people high, and can result in respiratory arrest, to boot.

Another one of our frequent fliers, we’ll call him “Bob,” comes to our ER about every 2nd or 3rd day (no kidding — an audit of ER records recently revealed that Bob had been in our ER about 60 times in a 90 day period).  He gets admitted to the hospital about once a month (it sort of depends on who the ER doc is when he comes in).  And he gets morphine every few hours.  At least he doesn’t claim an allergy to morphine.

In any given shift, I have at least one of these, and frequently 2 or 3 (out of 6 or 7 total patients).  After some non-scientific polling of other nurses in other facilities, I’ve discovered that this is not unique, and almost without exception, these patients are MedicAid patients.

These people gobble up scarce resources, and my time is the most scarce resource of all.  In a 12 hour shift, everything that I do is measured in seconds.  It takes about 30 seconds to get clean prior to and following every patient contact.  If I have 6 patients, and have 8 to 10 contacts with each one of them in 12 hours, I spend an hour a shift just washing my hands.  Time is the one luxury no nurse has, and what time we do have needs to be devoted exclusively to the sick and/or injured.

When I’m having to take 5 or 10 minutes to push morphine on one of these folks (and they’ll ask for it 3-4 times a shift depending on the doctor’s orders) while one of my post-ops is headed south or a patient with pneumonia has a change of condition or somebody with actual chest pain is starting to have trouble breathing (you can always tell because they get blue around the mouth and other such easily observed signs and symptoms)….

I love helping people get better, and knowing that I’ve made a difference in just one person’s life is incredibly rewarding.

Gee, gosh, and golly, I’m so looking forward to the day when everybody gets free health care.  I’m all a-tingle in anticipation of taking care of even more narcotic-dependent malingerers while people who actually need my attention have to wait.

Ah well, who is John Galt, anyway?

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One Response to “Observations from the Trenches”

  1. Tom Carter |

    I guess all this just proves a point that hardly needs proving — people will always take advantage of things that cost them nothing. Problem is, the costs are always paid by someone else, either in taxes or abuse of scarce resources.

    I think we have to have Medicaid, or something like it, to provide a reasonable level of health care for people who have no other access. But I can’t understand why abuses can’t be controlled — for example, why doctors will continue to prescribe drugs for those who are abusing the process.

    And by the way, I admire you for the work you do and the profession you’ve chosen. I don’t think I could do it.

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