Advocates Of Excellence

Blood, Sweat, and Tears of an ER Nurse

7/14/2016

By
Ryan Nolan

image provided by http://thewholesystem.co.uk/

I am blessed beyond measure to live surrounded by so much beauty in spite of living in a world that can be so damn ugly. I'm not voting republican this November..... yet I still love so many people that will. And I defend their right to do so, even if I disagree.
I'm not voting democratic this November..... yet I know many that are. And I love them.... no matter if we disagree politically.
I have friends and family that have had abortions. I love them. I have friends and family with drug problems. I love them.
I have taken care of law enforcement killed in the line of duty...... black and white.... and mourned with the community they served. I have taken care of gang members shot and killed for no reason other than poor choices...... and I wept with their surviving mothers and fathers. Their child made mistakes.... but they were still their child.
I work in the ER shoulder to shoulder with a team made up of white and black, rich and poor, gay and straight, Christian and non-Christian and all points in-between..... and we make an AWESOME TEAM. We laugh together, we eat together, we bear each others' loads, we cry, we bitch and moan, and we get the job done. And you know what??? I love that team.....
I have friends in the ministry serving God..... I have some that believe there is no God. I have some that aren't sure what's out there...... some that pray to other gods...... and yet we have lunch and laugh and be friends together.
I don't own a gun. At this moment......I have no desire to have one. But I will do whatever I can to make sure those that have them and want them has the freedom to do so. It is their right to own what they want.... just as it's my right to not have one. I have held the hands of the dying. Sometimes of old age, sometimes of trauma, sometimes of a disease that someone in their family thinks they "deserve" because of "God's Judgment". I tried my best to comfort them all equally.
I've also hugged complete strangers as they received devastating news that crushed their soul, changed their family's destiny, and gave them grief so profound they could no longer stand on their own strength. I've felt that pain before..... and if I can lessen it one bit for someone else.... then I will. Just this week alone..... I've given loving embraces to whites, blacks, Asians and probably some that fall in between. Not because I felt obligated.... but because I care who they are.... I value them. I love them as my friend, colleague, acquaintance, best friend, family.
ALL THIS TO SAY THIS...... Why are we making this so hard? Loving each other isn't hard. Just make your mind up to do it and DO IT. Race, creed, color, religion, sexual orientation, nationality, political affiliation, social status, educational levels, ....... IT DOESN'T MATTER.
We don't have to agree on everything. We don't have to even like each other all that much……But we must love each other,…respect each other. Do this..... and I promise you..... CNN and FOX and all that stuff will have nothing to talk about but Hollywood gossip and weather reports.
Hug someone..... and tell them you love them. Like a friend of mine quoted..... BE THE CHANGE YOU WANT TO SEE.

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My Journey to Finding Patient AND Provider Satisfaction

5/13/2016

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What is customer service in healthcare? Who defines it? Better yet who propagates and sustains it? Over the years I have been involved in this industry, I've been searching for the next best process, “key words” to excite and motivate my team, or other "secret weapons" of employee engagement. Each initiative, I've found, starts full steam ahead with large buy in and outstanding results, only to fade as the quarters pass. The initial motivation is simple, but the sustainability is complex. As with most industries, we tend to over-complicate the simple and avoid the obvious that is often staring us in the face. Personally, I found the answer in the evolution of my practice.
The evolution of my personal customer service journey or patient experience quest began at home. It started with a brief conversation with my wife after returning home from a very challenging shift at one of our emergency departments. The details are somewhat blurry, but I remember my wife saying in passing “I wish you could bring some of that cheerful customer service stuff home.”
This comment sliced deep, unleashing regret and frustration. Shouldn’t something that motivates or inspires also energize? The essence of a person shouldn’t be defined by his location or current situation. I should be the same person at both the hospital and home. I shouldn’t feel “spent,” after a long shift, leaving my family the scraps of my emotions and time. Why had I gotten into medicine in the first place? What motivated me in the areas of customer service or patient experience? What had changed?
It all started a few years back. I was a concerned physician who often went the “extra mile," following up on discharge ED patients or with the families of the lost. There was an inner motivation, a flame that was not easily quenched with long shifts, difficult patients or the perilous navigation of healthcare. Being respectable was easy because it simply came with doing the right thing. Doing the right thing quickly catapulted me into a position of leadership in the area of customer service.
In my expanded role, a difficult-to-describe, innate process now had to be replicated for the masses in the name of core measures and ACA benchmarks. It was like asking a guy that loves to fish to “teach everyone what you know and make sure they like to fish when its over.” As a motivated young physician, I took the bull by the horns, focusing on best practices, 5 step processes, and key words. The innate became less innate as the focus shifted more on the process and less on the patient. It was an exhausting journey with many short lived triumphs, and at some point I found that I had changed paths. My path no longer focused on the patient, but instead on numeric goals and initiatives.
Sometimes brief moments have a huge impact on the trajectory of your life. I was fortunate to have had my encounter on that warm summer evening in East Texas. My wife’s words in passing had re-adjusted my focus in the blink of an eye. It was as if I had been sitting in a dark room and someone turned on the lights, illuminating the obvious. What had motivated and inspired my patient care had not been the process, but the patient.
This is true of any good nurse or physician: what motivates us to stay late and hold the hand of a dying patient, or go to the store and buy socks for the indigent in need is never the process or the numbers … it’s the patient. The process is only there as a tool in our arsenal of healthcare. A focus on the individual we are serving and on looking for opportunities to make a difference fuels and invigorates healthcare workers rather than creating fatigue and frustration.
In an ever evolving metropolis of healthcare, one thing holds constant: that pillar in the center of our industry is the patient. Vital to our success is the ability to centrally focus on the simple, while understanding the adjunct power of the process.

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Simplicity....An Innovative Approach

4/12/2016

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I’m a physician, part of the enormous all consuming “machine” called modern healthcare. This machine is driven by value based best practice and end results. Literal life and death decisions are required daily, so naturally I become impatient when my son can’t decide between chocolate and vanilla or which movie to watch. My cultivated “Achilles heel” of impatients has a tendency to interfere with daily interactions or decisions because of the dreaded “decision fatigue” that sometimes surfaces as a result of my chosen profession. I’ve wrestled this demon time and time before, not wanting to allow my profession mold my personal interactions.
My natural evolution as a physician, husband, and father has included complex searches focusing on areas of self help, personal growth and maturation. I’ve read literally thousands of pages focusing on communication, employee engagement, and managing the patient’s perception. Complex processes have given way to “key words”, 5 step programs, and management initiatives. It’s ironic how in healthcare, we have accomplished so much in the way of cardiac bypass, organ transplant, and early goal directed therapy while neglecting the obvious. We have become so sterile in the area of emotion and empathy, that interactions as innate as sitting at bedside or eye contact have to be taught or scripted. Casual conversation has been replaced by the cold and innovative. I’ve been a victim of this “machine” we call healthcare, and unfortunately I’ve perpetuated the process.
In Western society we have become professionals of complication. We create vast processes and complex algorithms, later returning to the obvious and simple calling it “revolutionary or inspiring.” The innovations of the 70’s have been replaced by free range chickens, grass fed cattle, and oxygen therapy. Butter is back in favor over margarine and paleo has replaced many complex processed diets. Healthcare has come full circle, now focusing on patient centered care and communication with less emphasis on the process at hand. Basic human interactions once lost to the machine of innovation have started to resurface, shedding a new encouraging shade of a previous vibrant light. I’m cautiously encouraged about our future at hand, feeling that innate and basic will triumph if not overcome by the “need to innovate or mass replicate.”
Through my travels and educational quest to become a physician I’ve been many places. I’ve lived in the center of the world, and trained in highly innovative and cutting edge medical complexes. I’m fortunate to have been exposed to opportunities and experiences that would have seemed impossible when considering my humble beginnings. Ironically it was those long summer days in Southern Arkansas that may have taught me the most. It was on the back of pick up trucks or on the small town square where my education began. It was the life lessons of my father where I learned the value of saying thank you, expressing true empathy, and truly being able to listen and appreciate the words of others. It wasn’t until thirty years later, after being swept up by the ”machine" that I understood the momentous power of simple sincerity and good communication.

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Simplicity….A Revolutionary Idea

2/23/2016

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   We are fortunate to live in an era where innovation and rapid expansion has become almost a daily occurrence. Over the past 100 years travel has evolved from wooden carriages fueled by equestrian means to literal footprints on the moon and rover exploration on Mars. Healthcare has evolved from tincture of opium and bloodletting to miraculous transplants, stem cell research, and bypass surgery. Technology and innovation are all around us, the complex becomes mundane or the norm at lightning speed, only to be surpassed by the next “breakthrough.” Limits in healthcare no longer dictate our destiny, as we are constantly reaching for new horizons.
            With innovation and expansion have we neglected or overlooked the basic? This was a question that hit me like a ton of bricks. Can you build and maintain a skyscraper while neglecting the foundation? Better yet, can we maintain our rapid expansion and improved outcomes in the healthcare industry while neglecting the basics? Or, can we catapult the level of patient care to unforeseen levels by redirecting our focus to what matters most. The patient.
            Over the past decade, a “new and innovative” industry has emerged in almost every arena of society. This industry focuses on the consumer rather than the “through put” or “final product.” Healthcare has not been immune to this industrial storm, focusing on patient centered care and Studor principles. Somewhere along our journey we discovered the direct correlation of patient communication and patient outcomes. Simplicity has become a revolutionary idea and literally a multi-million dollar business.
            As a father, healthcare provider, and entrepreneur I often reflect lessons from my past. What is it they say about history being destined to repeat itself? This is a pattern that I’ve hoped to grasp prior to the inevitable cycle, but unfortunately it has yet to occur. I remember lessons from my father of respect, common courtesy, and how to treat people. I recall observations of artful conversation that included non-verbal affirmation and the simple ability to listen. These observations or lessons were filed away deeply and forgotten as side notes or outdated practices while perusing my dream of innovation, growth, and revolutionary change. Fortunately I’ve discovered that this personal interaction is the yeast in our loaf of exponential healthcare discovery.
            Our horizons are limitless with unforeseen miraculous innovations. Technology is expanding at unforeseen rates that are hardly imaginable. The key to our success and implementation is to remain focused on what matters most, the patient. The “revolutionary” concepts of good two-way communication between providers and patients combined with our advanced technology will catapult healthcare and patient outcomes to levels of unimaginable heights.

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My Two Coats

1/20/2016

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            I walk out of a room filled with emotion and despair. A battle lost but the war rages on. I’ve seen miracles, often only a daily basis. Life is precious but peculiarly fragile while resilient and strong. Every emergency provider understands the feeling after a patient has passed. It’s the unexplainable reverence and daunting silence as I put on the white coat. It’s the echoing footsteps that never go away on my path to the consultation room. It’s the faces that we never forget as we have to deliver the news of a passing loved one. As doctors and nurses we must inform family and loved ones of untimely deaths and or an anticipated passing. These moments etch eternal impressions and memories on the hearts of families and healthcare providers.
            In training, I was instructed to keep these conversations “short and impersonal.” It was almost a scripted event based on anticipated reactions and emotions. Patient Care 101 says, “Never say you’re sorry for your loss.” If a doctor does this, the family could misinterpret it as “all was not done or improper care was administered. “ I have to admit that this was part of my practice in early years. I kept it professional…….and kept on my white coat.
            Somewhere through my journey, I took off the white coat. Maybe it was the birth of my children or loss of my grandmother that made the difference. Somewhere on my journey I took off the coat and held the family members hand and felt tears of my own. Every loss I can see the face of my child. Every passing I understood and hurt for his or her loss. Empathy is universal, transcending words or expressions. Empathy is essential in healthcare. It’s a component that can’t be taught or scripted but must be present. Patient care goes well beyond the IVs and drips. It goes beyond the last heartbeat.
            As I walk home, leaving the ER after an exhausting night…..the battle wages on. I put on my other coat; the one I wear when I hug my kids, go to ballgames, and attend my local church. In this coat I throw balls and read bedtime stories. In this coat I encourage my friends and grieve for their loss. It was wearing this coat that I became a physician.

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The Hallway

12/20/2015

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We walk down the halls, time and time again, each encounter a new discovery, mystery, or typical presentation. As ED providers, we see new faces, entwined with “frequent flyers” that have become in a weird way part of the family. Our job is often loosely entangled with our identity and existence. It becomes hard to have dinner conversations without discussing therapies, changes in healthcare, the Obama Care fiasco, or “unusual cases.” We feel their heartache and rejoice in their victory. We are frustrated by lack of responsibility and ownership in personal health but invigorated when a patient is triumphant.
            Emergency medicine is a unique specialty in that we see it all. Each ED room a new encounter, a new adventure. A typical night may include anything from the common cold to calling child-protected services for suspected abuse. We treat broken bones and STDs like a work of art. Our specialty is an unusual one in that we are asked to walk from a room full of hurt and pain where a loved one has met an untimely death and enter a room where an acute case of gastroenteritis is in full force. We must keep our game face on, as each new patient deserves our best and should be oblivious to what is happening down the hall. How do we do this? Why do we do this? How is this sustained?
            A mentor and good friend once told me “Jeff, everyone has a need. It may not necessarily coincide with the chief complaint. Our job is to find out what this need is.” I’ve learned through the years, that people are complex and life can be hard. Models and schematics are a rough outline and life can be messy. It was the realization that has made me a better emergency provider, human, and hopefully friend. I see patients for what they are………people. Chest pain has evolved to now include anxiety and apprehension. A psychotic outburst now includes a lost person looking for a reason.
            Why do I do what I do? Why will I do it until my last breath? It’s because in the midst of the chaos, I’ve learned to care. I feel their pain and rejoice in their victories. I take home part of their loss and am encouraged by their triumphs. I see my grandmother in the eyes of the ailing old and feel the parent’s pain when a child is ill. I’m an emergency doc and somewhere in the midst of the storm I’ve become human. It’s okay to care…its okay to give your patient a hug when need most. Sometimes we are their only advocate.
            I look down the long hallway, lined with examination rooms and trauma bays. What use to be chief complaints and “interesting cases” has evolved. I now see people for who they are………people. I guess the deeper question is who has evolved? This is why I’m an emergency doctor. This is why I do what I do.

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Forged in The Trenches

12/14/2015

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I’ve read a lot about great men and women who changed the world. Humble servants, visionary leaders, and dedicated crusaders have left their mark, forging unfathomable evolutions of society. I look back at moments that still resonate loudly in the hearts and minds of people from all walks of life. Lincoln’s Gettysburg address, Churchill’s “This was their finest hour,” and Dr. King’s “I have a dream.” These words of inspiration, grounded on unpopular conviction, changed societies trajectory and history.
As an emergency doctor, I look for patterns. Disease processes in the body tend to have typical presentations. I look for clues or symptoms in order to aid in my diagnosis or exclusion. I’ve noticed that there are patterns in our societies that transcend culture, ethnic or religious barriers. In times of great need or turmoil, there is always someone who emerges to champion the cause. Churchill, an unsuccessful politician with military failures rallied Great Britain to victory against the “unstoppable” Third Reich. Dr. King, An African American pastor, opened the door of racial equality through an unorthodox nonviolent philosophy. Abraham Lincoln, a failed politician who suffered from clinical depression, united a broken country while ending a barbaric social injustice.
Greatness is forged in the trenches of need and injustice. Obstacles become opportunities of change and evolution. The healthcare landscape has recently faced multiple obstacles. Through federal mandates and changes in access to care, we have been asked to do more with less. Increased patient volumes combined with a decreased number of providers have stressed our nation’s healthcare to new limits.
How is the obstacle an opportunity? It’s a wake up call for providers to focus less on the system and more on what matters most. We focus on our patient.
You may say “Jeff, I’m the voice of one……..What can I do to make a difference? I’m an intern, paramedic, or RN in a small ED in Topeka or Toledo…….no one will listen. “ I say do what’s right, focus on the patient centrally and others will soon follow, changing your department, region, then the landscape of healthcare. Remember, David was the smallest of the small and he slew Goliath. Winston Churchill had a lisp, but was able to defeat Germany by the power of his words. Martin Luther King, a minority in a hostile environment was able to champion the fight for equality and change the world. The power is not in the system, but in the cause. Be a champion for your patient and let’s change healthcare.

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My Evolution

11/30/2015

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Modern medical education focuses on disease process, pathology and response to therapy. We spend countless hours focusing on patterns, probability and cause and effect. I can assume that this has been the standard educational practice since Schola Medica Salernitana, the oldest known medical school and has little variation whether training to be a physician, nurse, or APP. The idea is that an intelligent, hardworking individual will spend countless hours in this environment, one day emerging past the curtain to stamp out disease and pestilence.
As an early physician, I rather naively assumed that this would be the pattern of my career as well. Upon graduating, I would put on my blue tights and red cape and proceed to save lives at the speed of lightning. Little did I know that my education had only begun. School laid the foundation, but personal life events have helped me to be the medical provider that I am today.
Empathy can't be taught...........It must be cultivated. Life's journey, no matter how pristine or harsh, provides a framework for our care provided. We can "relate" better once we've been there before. A patient's exuberant joy from the birth of a child or conquering of a diagnosis becomes my own because I've been there before. I understand the helplessness of a parent awaiting a child's prognosis or utter shock when a love one is lost all too soon.
What drives a person to do what we do? For me it is the opportunity to help others in a time of need and provide medical care and life saving therapy along with empathy and compassion when needed most. A patient or family member may forget the titrated IV drip, analgesia or broad-spectrum antibiotic. What they will never forget is your compassion and empathy in a time of need. Sometimes the "little things” have more power than you will ever realize. My education is only beginning.

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The Path

9/20/2015

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Being a goal oriented individual, my days are filled with appointments, deadlines, and to do lists. Unfortunately the path, or time spent between point A and point B tends to go un-noticed as I focus on the goal or end result. I find this type of orientation not uncommon in most western societies, where success or achievement is measured by results and not by how you “played the game.” In parenthood, we teach our children it’s not whether you win or lose, but how you played the game, while emulating a much different set of values.

As healthcare providers we are trained to focus on results. Our main goal, and as it should be is patient outcome, or improved health and longevity. We spend countless hours in the trenches of literal blood sweat and tears, with an end goal of good oxygenation, blood pressure control and pain relief. It’s an honorable profession that provides an enormous sense of accomplishment entwined with echoing emotions and pain that often last forever. Some call it a job or career……..the ones that “get it” prefer the term calling.

Every few months, I’m fortunate enough to have an encounter that gives a glimpse of the bigger picture, understanding that this life is much larger than I realize. I recently treated an individual in a busy emergency department for a minor undisclosed complaint. We had our routine interaction, where I focused on the problem at hand, looking for a solution in the realm of science. Near the end of our interaction, he informed me that I took care of a similar complaint sometime back. The patient stated that something I had said had changed the trajectory of his life. The gentleman thanked me for those words, tearfully expressing the impact. Unfortunately I don’t remember that interaction…….I am sure my focus was on the disease process at hand. What made the difference in his life was not my prescription, but words along the path. Ironically, I’m the doctor, but after the second interaction I was the one treated and transformed.

I don’t believe in chance. I feel that we tend to focus on the finish line or goal, while often neglecting the path or journey. I’m not trying to minimize the value of accomplishment or end results, only to increase the awareness of the power of the journey. Hesse understood this all too well in The Journey To The East, where the league focused on the final destination, later learning that the journey had a priceless reward. Seemingly minuscule moments for you may be life changing events for others, creating lasting impressions that can literally change the world. Whether at the dinner table doing homework with your children, or in the line at Wal-Mart, the path makes a difference. In healthcare, your kind word at bedside or warm blanket in the night may have more healing power than you could ever realize.

4 Comments

Customer Service in Healthcare

6/28/2015

2 Comments

Over the past year I’ve read countless publications concerning the relationship of customer service and patient care. Many have alluded to the fact that customer service in healthcare is not only unfeasible, but also detrimental to patient care. As a huge proponent of customer service it was quite natural to take a defensive stand, posturing against these “absurd accusations.” Over the years I’ve learned, quite often the hard way that natural spontaneous responses, although with honorable intentions, often lead to more confusion and conflict. I elected the mature and enlightening response of stepping back from the situation and actually listening and investigating the topic at hand. What did I learn? That I totally agree with these guys.

I agree that the average consumer whether in healthcare or retail have his or her own set of standards. It’s absurd to cater to all requests when in healthcare in the same fashion as a car dealership or gourmet restaurant. I agree that this could definitely result in detrimental health care. Giving antibiotics and performing invasive tests simply because “its what the patient wants” is ridiculous.

So I’m currently a stanch supporter of the arguments by these credited publications and professionals, agreeing whole-heartedly. But this is where our paths take a monuments different course. It’s in the definition of customer service. It’s so different, that maybe we should use an entirely new term. It’s like comparing an apple and the moon. In retail, customer service is “the consumer is always right,” while in healthcare it should be “I spent ample time with each patient, treating them with respect and courtesy.” Customer service in healthcare hinges on COMMUNICATION with the patient concerning diagnosis, medical concerns, and the risks and benefits of procedures at hand. I would go as far to say that customer service is not giving the un-needed narcotic or antibiotic. Why, that would actually be customer disservice. Good customer service would actually be spending more time with the patient, describing in detail the risk of bacterial resistance when antibiotics are over prescribed or the addictive nature of narcotics when used inappropriately. But……this would take more time with your patients. Its naïve to just assume that a properly informed patient will give a poor rating to an institution or provider because every initial request was not catered to. I actually think that the informed patient would be more complimentary and satisfied with care. It’s quite ridiculous to assume that an informed patient expects Disney World treatment or has the McDonald’s mentality when at the local clinic or emergency department.

What’s the answer to this dilemma? I suggest it’s not posturing by providers but rather embracement followed by better patient communication. As a patient, it’s what I would expect. We don’t have a customer service problem in healthcare, we have a communication problem.

In healthcare, maybe we should use another term besides “customer service” to describe courtesy, respect, and good provider/patient communication. Call it common sense, call it the way medicine should be practiced………..heck call it Bob or Frank. I call it the right thing for patients and the nature of healthcare.

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