Saturday, February 26, 2011

Government Medicine

This isn't meant to be a rant or political diatribe, rather a point of view from a medical practitioner about our current and potentially future medical world.  So here goes..

I work for an institution where a majority of our patients are covered by either Medicare or Medicaid - the federally funded health insurance programs.  The rest are either private insurance or self-pay.  With that being said, any changes in federal funding or reimbursements have a HUGE impact on our budget, operations, and bottom line.  It affects how many new staff can be hired, what kind of benefits can be offered to staff and even what products are available.  

There has been a lot of talk recently about federal budget cuts and what programs would be affected.  After all, we are in a recession right?  And no matter what the analysts say, the country is not exactly bouncing back quickly.  This means the government is trimming "the fat" and cutting funding across the board.  Well within the last week, it was announced that cuts would be made to Medicare and Medicaid reimbursements.  For my institution that relies so heavily on these federal insurance monies to pay for services offered to patients, these "small cuts" can mean hundreds of millions of dollars of losses.  That money has to be made up for and that means cuts in the operating budget.  

Not a week goes by that I get an e-mail about cost-saving measures or the institution's attempt to balance the budget.  It's pretty stressful being the new person in a place that's talking about cost control and hiring freezes.  It has been said and said again that they are doing everything they can to prevent lay-offs and luckily I believe them.  But it makes me think.

Our government has offered to extend health insurance coverage to millions of uninsured in our country. But when it comes to paying healthcare providers, hospitals, etc they decrease what they are willing to pay.  In other words, we are expected to do more (see more patients in an efficient way) with less money while jumping through the seemingly hundred of hoops the government requires in order for them to pay the bills.  And private insurers quickly follow federal reimbursement guidelines, which means even less money.  Oh, and then I get patient families who ask me to write a prescription for an over-the-counter medication so medicaid will pay for it.  Seriously?  No, I will not pay for your $4 bottle of tylenol (because, yes, I, as a tax payer will be paying for it).  If you can afford your fancy bag and your pretty earrings, you can pay for your child's medications.  No, not everything is about a dollar sign.  But when it comes to affecting how patients are cared for, it becomes an issue.  Have I seen things that affect quality patient care?  No, not yet.  But it worries me because eventually something has to give, right?

Do I have a solution?  Unfortunately, no.  I'm not sure anyone has the cure-all.  But there's got to be something better than the status quo.  I don't know.

Okay, now I'm off my soapbox.  

Thursday, February 24, 2011

New Kid on the Block

After 3 months on the job, I'm no longer the new kid!  Well, that's not totally true because I still consider myself new, but we have a newer team member now.  I worked with her for the first time a couple days ago and it was a strange feeling giving her advice and answering her questions.  While I am by no means an expert (let alone feel comfortable in my every day practice) it showed me that I have learned so much in my first 3 months as a PA-C. 

So far a lot of what I've learned deals with institutional things.  By that I mean, the way things are done in my specific hospital.  As any of you who have ever worked in medicine, things are done differently based on region, city and indiviual hospital.  And it includes anything from how you admit patients to the hospital from the ED to what first line antibiotics are for pneumonia or cellulitis.  It also includes what numbing medicine is used for different procedures and what the phone numbers are for lab, radiology, the radiology reading room and the pharmacist (definitely my top 4 people I call!)

While I've managed to get a pretty good grasp on the way things are done at my facility, I've also learned alot of medicine.  When I first started I felt like I knew absolutely nothing about anything.  My PA program (as I'm sure every other one the country) focused on adult medicine.  I only had a 4 week pediatrics rotation and one pediatric course.  I could tell you everything you wanted to know about diabetes or high blood pressure.  I could give you a long list of differential diagnoses for chest pain, shortness of breath or abdominal pain.  And I knew about flu, strep, ear infections and well-child visits, but that's not the kind of patient I see in my emergency department.  We see the kids with chronic medical conditions like type I diabetes, kidney disease, cancer, or those that have had organ transplants.  I've seen some medical and genetic conditions that affect only 1 in 10,000 live births and some even more rare than that.  I'm not saying I haven't treated many kids with common things like flu, asthma, RSV and stomach bugs (see previous post about that, ugh) because I definitely have.  I just get to see some really interesting things interspersed. 

Along with all the medical knowledge and what I consider system "know-how", I've also learned personalities.  From fellow mid-level practioners to residents, attendings and nursing staff there are alot personalities to work with.  And luckily, most are fantastic people and super easy to work with.  Others are a little harder to work with, but that comes with any workplace. 

My confidence is slowly on the rise.  No to toot my own horn, but I've gotten several compliments from a few different attendings over the previous week or two and it feels great.  These past 3 months I've been trying so hard not to make a fool out of myself.  So it feels great when my attending compliments me in front of the residents.  Last night an attending mentioned "we need more people like you in the department."  Talk about making me feel great!

The best part about feeling more comfortable in my role and with my abilities?  Walking to my car at night and not feeling like I may have screwed something up.  Sure, I still worry about my patients when I go home at night, but more because of their disease process, not what I did to mess things up.  I still have good and bad days, but the good days are starting to outnumber the bad.  It's a process and I'm taking baby steps (haha get it?) but I'm getting there!

Friday, February 18, 2011

The proverbial $%*& has hit the fan

Yep, this post is about poo....I know pretty gross and totally inappropriate, but heck, I work in an ER.  I'm good a being gross and inappropriate.

My last two shifts I felt like every patient I saw had the pukes, the runs and fever.  Initially I felt sorry for them, then I freaked out worrying that I just might come down with it.  After the first patient it wasn't a big deal, I just soaked my hands with alcohol gel and moved on.  The next patient I was a little more cautious, after using the alcohol gel I washed my hands.  Finally, after seeing my 3rd patient in one shift with the same stuff, I scrubbed my hands and disinfected my stethoscope, badge and pen.  Then I started freaking out, I swear I could feel myself getting nauseous and my forehead heating up.

Luckily I made it through the shift without complications and made it to my next.  And guess what?  Three more patients with the SAME thing!  Yikes - are you serious??  So I started where I left off - cleaning everything the patient may have come in contact with that could safely and effectively be cleaned with alcohol pads.  And I'm glad to report, thus far, I have not come down with anything (knock on wood).

And if I didn't deal with enough poo over the previous couple days, today I was reading some articles in order to stay up on my knowledge.  Take a wild guess what two of them were?  Emerging treatments in gastroenteritis (aka the stomach bug) and etiology, presentation and treatment of constipation.  Oh yeah, apparently I'm a $#&* magnet.

I know, my life is pretty glamorous.  Try not to be jealous.

Monday, February 14, 2011

Shift Work

In the ER, there is no such thing as 9 to 5.  It's open 24/7 which means it is staffed 24/7.  Since I started my medical experience in the ER in college, I quickly grew accustomed to strange hours and working weekends.  It wasn't too bad, and my college body easily handled flipping back and forth between days, nights and school.  In PA school, I got used to the 9 to 5 schedule again because with the exception of a few rotations I was up in the morning heading off to school or the office and home in time for dinner.  When I applied and interviewed for my current job I emphatically told the team that I could definitely handle the long hours and odd shift times, after all I had done it previously without any difficulty!

Now, in my mid-20's, I apparently don't have that college body that quickly adjusted to nights/days/whatever was thrown at me.  Pretty pathetic, no?  But I have discovered I need my 8 hours of beauty sleep each night and I'm just not getting it anymore.  Even on my days off I'm having a hard time sleeping in or getting to bed at a decent hour.  In my position there is no night or day shift.  We work morning, noon and night and alternate throughout a couple different shift times each 2 month schedule.  One week I could be working 7a-7p one day, noon-midnight the next and 11a-11p.  The next week I could be working several overnight shifts in a row.  We also work every day of the week.  Lately I've been working a decent amount of weekend shifts meaning Corey and I don't get to spend lots of quality time together on his days off (especially with all the house stuff lately!)

Not only does shift work mean no set hours, it means you don't necessarily go home at the end of the 12 hour shift.  Take, for example, last night.  I was scheduled to be off at 11pm, but just as I was getting ready to discharge a patient and hand my last patient off to another provider, my soon-to-be discharged patient threw a kink in our plans.  I ended up staying until almost 1230 in the morning trying to get things wrapped up enough to hand them off to another provider.  After a 13 1/2 hour shift I was exhausted on my drive home.

But its not all bad.  There's actually some really great stuff about it.  For instance, I only work 14 shifts in a 4 week period.  Meaning I get just as many days off as I work.  Not many people can say that.  Also it means I get random times off.  I get to do my grocery shopping on a Tuesday afternoon when hardly anyone else is there.  I can go to the mall and not have to deal with crazy crowds.  I can be at the house for the cable guy, the heater repair man and I get to spend lots of quality time with my pup.  I also can meet friends for their lunch break.  It also means I get to spend two wonderful days off with my husband today and tomorrow.  He took two random vacation days and we are celebrating Valentine's Day together.  Lucky me :o)

Monday, February 7, 2011

It's Finally (Almost) Over!

Despite the crummy weather last week and the threat of our move getting post-poned we actually made it into the house with our stuff Saturday night.  In order to ensure the movers would arrive and take our stuff as promised we pushed the move time back to early evening (start time window of 4-6pm) and I spent over an hour crouched over a sheet of ice at the bottom of the apartment stairs salting and scraping it til my hands bled.  Oh, yeah, tons of fun, let me tell you! 

As with all services that give you an arrival time window, the movers didn't call until just before the latest time they were scheduled to arrive.  They finally showed up around 6:15 and got started right away.  Unfortunately, we didn't get the best moving company because these guys were slow as molasses in February.  We finally had the apartment packed into the truck around 11pm and we were off to the house.  They worked a bit faster unloading and finished at 1:30am.  We promptly fell into bed because I had to get up the next morning for work.

While unpacking/moving boxes to their respective rooms yesterday, Corey noted that I had probably more kitchen boxes than anything else.  Well, I was curious to find out if this was in fact true.  Yes, I counted each and every box in an attempt to prove my husband wrong...I'm not competetive or anything.  So, what did I find?  We had about 60 boxes of stuff (yes, we have far too much junk - we'll be working on purging some things) and 27 of those are kitchen related items such as dishes, cookware, glasses, silverware, gadgets and the like.  That doesn't include the 3 boxes of cookbooks I had as well!  Yes, I am addicted to all things cooking.  The first step to recovery is admiting you have a problem, right?  Too bad I'm not interested in recovery - its a fantastic addiction to have!

The kitchen drowning in boxes

Lacey seems to be settling in well and loves running up and down the stairs.  She has also found the perfect spot to sun herself near the front door and has spent most of the morning there. 

I've decided we picked the absolute perfect place to live, which is a good thing because Corey told me we aren't ever moving again.  His actual words were "you'll have to drag my dead body out of this house."  The commute is not bad for either of us.  The neighborhood is nice (and no HOA - thank goodness!).  And the location is great!  We are within 5 miles of everything you could want: the mall, Target, Costco, grocery stores, restaurants, even a movie theater.  Two major highways are very close, but not so close that we hear traffic or have to worry about safety issues.  And finally, as I was driving today within 2 miles of our house I passed a field with horses grazing, another with a few cows relaxing and finally a parcel of land with a herd of buffalo - yes, buffalo!  I like that we are so close to everything, but there's still pockets of land around as well.

Now, I must wait for the satellite people to show up and set up our TV stuff so I can go grocery shopping.  The only items in our fridge are water, milk, an apple, a kiwi, wine and rum.  Oh yeah, and Corey's leftover pizza from last night.  Sounds like a bachelor's fridge to me! 

Friday, February 4, 2011


Buying a house has been super exciting mixed in with stressful.  The novelty and fun of it all has worn off at this point.  Why?  Because the movers are (hopefully) coming tomorrow.

Packing sucks.  We only have a 2 bedroom apartment, but it feels like we have enough junk to fill an 8 room mansion!  Okay, not really, but where did all this stuff come from??  Just when it feels like we are making a dent, we realize how much more needs to be packed.  It is absolutely awful and one of the most stress-inducing activities I can think of.  And to top it all off, we had an ice storm here earlier this week, have been in the teens all week (for the high temp, mind you) and today we got about 4 inches of snow dumped on us.  The combo of all this has made the roads pretty ugly and resulted in the delay of the delivery of our new living room furniture.  We now have to wait until Thursday to get the sofa and loveseat that was supposed to arrive today.  After the phone call from the furniture delivery people, I thought it would be prudent to call the movers.  Long story short, we are scheduled for moving late tomorrow afternoon if the snow/ice/slush melts enough for them to deem is safe to move/drive.  Please keep your fingers crossed and say a prayer that they show up!

On a happier note, we got some new hardwood floors installed this week and they look great!  We also were able to get the dingy upstairs carpet cleaned before moving all our stuff in.

Entry before - ugly white tile and dingy white carpet

Entry/study now
Also, we took Lacey to the house for the first time this week and she loved it!  She loved it even more today with all the snow in the backyard.

Pouncing in the snow
 As inconvenient as the weather has been, the snow covered house and yard were absolutely beautiful this morning.  Much prettier than a sheet of ice over everything!

Winter wonderland

Some sort of animal was lurking around the house - these tracks were in the front then between our house & the neighbor's

Keep us in your thoughts and prayers as we move this weekend.  Hopefully we won't strangle each other before it's all said and done!

Tuesday, February 1, 2011

The Big "C" - Closing Day!!

This past weekend was filled with activity for us but mostly packing and organizing.  We were overwhelmed with just the thought of packing up our apartment, but found once we started it moved pretty quickly.  There's still lots to pack, but we've definitely made progress.  We also finalized utilities, the movers and the mortgage/down payment stuff.  Sunday we got a little house teaser - we did a final walk-through and I fell in love all over again with the house.  It was pretty hard to leave that evening without our keys!

Sunday night I was so excited about closing on Monday that I couldn't sleep.  Okay, not really.  I couldn't sleep because I worked the overnight shift.  But I decided that I probably wouldn't have slept very well anyway, so might as well get paid, right? :)

Once off work Monday morning, Corey and I headed into the title company office and signed away our life to the various entities handling our home.  After what seemed like a hundred signatures, dates, initials, our realtor handed us the key.  In all honesty, it was pretty anti-climactic.  I was expecting confetti and balloons raining down from the ceiling with trumpets heralding our big moment.  Perhaps that's a bit of a stretch, but it wasn't at all how I expected.  I blame it on the fact that from the title company Corey headed off to work and I went back to the apartment and promptly fell asleep.

We did meet up at the house last night to drop a few things off and introduce Lacey to her new home.  She wasn't quite sure what to make of it because there was nothing in the house.  After some sniffing she started running around and quickly explored every nook and cranny.  She also made herself comfortable with the backyard, which I'm pretty sure she's gonna love!

What is this place?

Now that we have the house we can't wait to start putting our own touches on it with paint, light fixtures and eventually furniture, decor, get the idea.  And now I can start officially planning our housewarming party - hooray!