The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Congratulations at new job

It has been some time since I posted a blog. The reason(s): I been busy. (1) Writing about my adventure through Central America—where I ran into some machine gun toting idiots (2) Trying to convince others, at least three organizations, to accept my presentation about “The Customer is NEVER Right”—they all declined, imagine that (3) Getting our van ready for sale (4) A trip to Puerto Rico—where a Marshall’s I was at was robbed twice in less than an hour and the next day our food was stolen from our shopping cart at Walmart and (5) Trying to land an emergency department job here in Phoenix—the focus of this latest blog.

I would like to thank everyone who sent me congratulations when I updated the book’s LinkedIn account after landing my current locums job. Although I appreciate their kind words, I would have chosen, “Good Luck!” rather than, “Congratulations!” knowing my baggage. Having said that, I hope I do not disappoint them if I am asked to resign. Not being a pessimistic but a realist. Especially after told by an administrator, “Patients here do not complain.” A comment I found thought-provoking, as I had not asked if patients complained. Or was the administrator making the comment because my baggage had arrived ahead of my arrival and the administrator wanted to set the tone. On top of that, the same administrator pointed out I would be supported if a drug seeker complains. All of which sounds so familiar, especially support from irrational complainers, like drug seeker, I guess. That would be great, except drug seeker are not the only irrational complainers and I wish healthcare administrators would recognize that. Not to mention, bad stuff happens to bad people and because of that drug seeker should not be dismissed.

On top of that, my experience has been that drug seekers do not complain. They may kick, figuratively, although sometimes literally as well, and scream at the moment but that is more about them being unhappy than dissatisfied. If anything, the behavior of drug seeker is more manipulative then expressing dissatisfaction. I have said that, too, over and over and over…and again, redundant, yet others do not catch on.

Not surprisingly, once I began working in the emergency department I was told by the grapevine to lay low, as others have been asked to resign after patient complaints, despite I was just told that patients do not complain here. Interestingly, one of the healthcare providers at this new job is leaving to go work at an emergency department I worked at where the hospital policy was that healthcare workers who received a patient complain had to write a letter of apology, on hospital letterhead, to the complaining patient.

Interestingly, the healthcare provider leaving did not see that hospital policy an issue. I would think, even if you never got a complaint, although I find that hard to believe, the hospital policy alone is offensive. However, I get offended when I learn that someone has eaten else’s food, not mine, or that something was taken that does not belong to me either. However, that is The Knitted Brow.

Now, I could be wrong but I believe every healthcare worker gets at least one complaint in their career. In the book I described an occupational health medical assistant who I thought was the epitome of customer service, and maybe the ONLY healthcare worker Fred Lee would say was PERFECT! Yet, although the medical assistant possessed the superpowers of customer service, Fred Lee talks about, she too encountered a patient who complained about her. 

Granted, it was a single complaint but it was obvious that single complain bothered her to the point she believed she had let her employer down. When the medical assistant mentioned to me that someone had complained about her I told her to save the details, as there was no reason anyone should complain about her. The fact someone complained about her was upsetting to me and I said to her, not to comfort her but as a fact, “I can understand patients getting upset with me but there is no reason they should get upset with you.”

Because the medical assistant was the epitome of customer service I entertained the idea of hiring her to be a patient advocate who would follow me after I saw a patient knowing her superpowers would defuse any animosity I left behind. However, when I pitched the idea to an Emergency Department Director, the Director shot it down claiming patient advocates had not move the needle when related to customer satisfaction. And he was right but neither had anything else healthcare organizations had implemented in the past decades, as Fred Lee divulged in his Ted Talk video. I would add that includes “bending over” which, if anything, has left a significant trail of collateral damage behind of which healthcare administrators have ignored, yet, somehow they are okay with that.

Nonetheless, thank you to everyone as the job is in Phoenix and I get to be home after every shift. And, and, and! Not to mention I get to put gel in my hairagain. Maybe there is a rainbow* at the end of this tunnel, after all.

*Because a light at the end of the tunnel just isn’t enough and although a pot of gold at the end of a rainbow would be nice, this job is not a rainbow, even if the staff are a great group of healthcare workers.

On that note, here are the new emergency department dissatisfactions, although not formally complained, at least not that I been told, after the first month:

~A female in her 40’s comes in saying her Primary Care Provider (PCP) referred her to the emergency department (ED) due to a possible dislocation of her left (non-dominant) elbow. History of present injury/illness (HPI): A ground level fall (GLF) from her wheelchair onto the ground two days prior to seeking medical attention, however, the patient was unable to recall how her left elbow was injured. There were no other injuries. The physical exam (PE) revealed some bony tenderness to palpation of the left elbow and some decreased active range of motion (AROM) due to increased discomfort with flexion, extension, pronation and supination. Otherwise the elbow was unremarkable; the skin was intact without ecchymosis or swelling, there was no obvious deformity, and when distracted the patient moved her left elbow without limited AROM. Did I mention the patient was wheelchair bound and she had gotten herself into the room under her own power, wheeling herself into the room? The x-ray of her left elbow showed some degenerative changes but was otherwise unremarkable, without fractures or dislocations.

When I went to discharge the patient, informing her she had arthritis in her left elbow but not dislocation or fracture, the patient lit up into me saying, “No one ever told me I had arthritis of my elbow. My shoulder yes but my elbow never.” To which I replied, “Has anyone ever taken an x-ray of your elbow before tonight?”

Yes, tonight. Because something I failed to mention here, but intentionally did not address with the patient, was she came to the ED at 11pm. Now what PCP has their office open so late they would refer the patient to the ED for a dislocated elbow at that hour. Nonetheless, the patient stated she had never had an x-ray of her left elbow.

Of course, after all that the patient asked for “something stronger” than the ibuprofen I suggested. Again, I know, I know, it’s repetitive, but I have no idea what “something stronger” is. Not patronizing, it’s just that my profession, and my practice for that matter, is based on objectivity not subjectivity. It’s no different when a patient says, “I am burning ‘down there’.” What does that mean? That they have a bad case of athlete’s foot? In the same manner I do not make assumptions of what “something stronger” is.

Then the exacerbation of melodrama exploded. “How do you expect me to get around? If you have not noticed I am in a wheelchair,” the patient explained. Not that I mentioned it but “something stronger” was not going to facilitate her getting around any better. Actually, it would impair her from getting around as “something stronger” is not supposed to be taken when operating machinery, and I think that includes a wheelchair.

More drama, “I want to see someone else!” the patient said in a loud and discontented tone. “Well, you can. Follow up with your PCP,” I replied. Not what the patient expected. Then the nurse got involved trying to save the visit and involving the attending physician who asked me to order a Computed Tomography (CT) scan of the patient’s elbow. The physician was no more than appeasing the patient and by no means undermining my decision-making. Nonetheless, after X dollars and another hour waiting for the CT report, the findings were degenerative changes of the left elbow, wait that was what I said with an x-ray. Not to mention, at a whole lot less cost and in significantly less time. Later, I thought the patient would have appreciated the $500, or so, cost of the CT more than the unnecessary radiation exposure and not only been satisfied but would have even nominated me for Healthcare Worker of the Year, not to mention, she would have completely forgotten about not getting “something stronger”.

Unfortunately the patient continued upset, although not likely due to the CT findings, but because the prescribing treatment had not changed. Of course, the patient commented on how uncaring I was for sending out without “something for my pain” then she wheeled herself out of the ED, without any difficulty and as if nothing had happened.

~Days later, and unrelated, I saw another female in her 40’s, who I had to wake up from her sleep in the ED. After asking her, “What brings you in?” The patient uttered a long and convoluted story that covered nine months and three orthopedic appointments without finding out what was wrong with her left knee before I interrupted her, “Ma’am, you still have not told me why you are here tonight.”

“My knee hurts!” she fired back.

“Why does your knee hurt?” I asked.

“I do not know. That is what I was telling you,” she replied.

And before she nodded off again I asked, “Have you had any trauma or injury?”

“No! It just hurts!” she woke up answering.

“Have you taken anything for it?”


I found myself having to reply quickly and shorten my words otherwise she would nod off. “Does it work?”

As if upset that I asked she replied, “If it worked I wouldn’t be here!”

The patient was wearing tight jeans and I did not think she would be able to get them above her knee so I asked the nurse to have the patient change into a gown. At the same time the patient had pulled her pant leg just above her knee. When I looked over I was not impressed, the skin was intact and there was no redness or swelling. When I touch the medial and lateral knee joint line, while the patient was distracted pulling her pant leg up, there was no tenderness to palpation. And I push pretty hard. I then noticed the patient wearing two-inch heels so I asked the patient to step out of them and walk. While distracted with my conversation she was able to walk with an unremarkable gait.

I then told the patient her knee x-ray, which was ordered prior to me seeing her, was unremarkable. However, the x-ray had actually caught my attention. When I first looked at it I was impressed with how smooth the joint looked and that it belonged to a 40+ year old, as the x-ray looked a lot younger than the documented age. Unfortunately, that is something I do not share with patients as a number of them have not appreciated the compliment and instead taken as if I was downplaying their symptoms.

Nonetheless, I suggested to the patient she wear a knee brace when weight bearing, alternate cold and heat, home physical therapy exercises, ibuprofen or naproxen, use flat shoes and follow up with her orthopedic surgeon. Well, she had done all that and it had not gotten better. Although I wanted to point out she was not wearing a knee brace or flat shoes I remained mute, as I knew it was a losing point.

Surprisingly, she said she would take ibuprofen, yes the over-the-counter kind, after I declined her request for “something stronger”. However, when I returned to dispense her a bottle of ibuprofen she had left so I gave the bottle back to the nurse to return to the Pyxis (automated medication management system) and I moved on to the next patient. Moments later, the charge nurse (CN) approaches me asking about the patient. I explained, of course, that I went looking for the patient but the patient was nowhere to be found.

The CN returned the patient to the patient’s room and after getting the ibuprofen back out of the Pyxis I head back to the patient’s room. However, it was not the ibuprofen or the discharge instructions the patient was waiting for, it was a work absence note which I declined as I could not justify why the patient could not go to work the next day. Except, I was wrong, again, imagine that. The note the patient sought was not for the following day but for missing work for the past week. It did not get better when the patient said to me, “I am going to lose my job if you do not give me a note for work.”

The patient abruptly storming out of the ED when I said, “No. I cannot justify you missing work tomorrow and much less for you missing work last week.” As the patient walked out of the ED, in her two-inch heels, her gait was non-antalgic to say the least.

~Days later I saw a 4-year-old brought in by his parent due to the patient had a non-productive cough for four days without treatment or seeking medical attention prior to me seeing him at 4am on a Wednesday morning. Other than a runny nose and a non-productive cough the child looked great, active, non-ill appearing and definitely non-toxic. His vital signs stable to include a SpO2 (Pulse oximetry—non-invasive oxygen saturation monitoring) of 100% on room air. All over stated in documentation in order to justify skipping the chest x-ray, and more important the radiation. After an extensive discussion with the parent, she agreed to defer the x-ray, but was willing to take an antibiotic and a prescription for Zytec, the latter to be picked up later as we do not have it in the Pyxis. Although surprised, the parent declined the guaifenesin with codeine, which I was glad, as I only offered it because to many complain that I did nothing for them. This job has been a rebirth I have had in order to keep this job, however, this time it looked like the parent did not appreciate my intent to prescribe a narcotic for cough. I can never win and why I have not given up on banging my head against the wall, hoping, someday, I will get it right. 4:30am DONE!

Of course not! If so I would not have been writing about it. After discharging the patient home to the parent’s care. Again, wording for the chart. The parent returns, I am told by the nurse. “Yes, ma’am?” I asked. “Can I get a work note excuse for his dad?” the mother asked.

“Where is his dad?”

“At home. Taking care of his [the patient’s] sister.”

“The discharge instructions have the time he [the patient] was seen and discharged. His dad should be able to use that for work,” I naïvely suggested.

“He needs one to be off for the whole day,” she replied.

I thought, “It’s 4:30am why can’t he just go to work a little late today.” However, I did not share my thought with her. Instead, I coward and, in order to avoid a complaint, I said to her, “How many days would you like it for?”

“Just today,” she said. But only because I think I caught her off guard.

In the month I been working here, I believe I have written the most work absences than ever before for the same number of days. Again, a rebirth, or maybe just not caring, in order to keep this job. But I will continue to not include days before I see patients, even if it cost me my job because even a coward should have a thread of integrity in their spine.

~A few days later, it was a 28-year-old male with progressive vague abdominal pain times three weeks for which he had not sought medical attention. However, in the last two days the pain had concentrated in the right lower quadrant and his appetite had decreased. With a leukocytosis of 15.8k it was hard not to do a CT of the abdomen and pelvis. It just happens that night, the CT was down and we had to transfer patients to other EDs for their care. After discussing this with the patient I returned to inform him that an ED near his home, a request of the patient, would accept his transfer.

Then came the questions of how much it was going to cost, to which my rehearsed answer is, “I do patient care not finances.” However, the patient insisted on finding out the cost he would acquire related to the transfer rather than going on his own. With that came a long and convoluted story that he did not want to leave his car behind. That the person he was with did not know how to drive. Yada…yada…yada.

It was the hospital’s policy, not mine, that patients are to be transferred via ambulance and not privately own vehicles (POV). I am sure the reason is litigation on the hospital’s part, as it did not matter to me. There is a box to check on the hospital’s transfer form, which informs the patient that their condition may worsen during transportation as a risk related to the transfer. And I agree, a worsening condition is never a good thing when one is driving themselves to another facility.

Anyway, at first the patient was willing to be transferred by ambulance. Later he said no and signed a form stating he was leaving against medical advice (AMA). Then he said he wanted to go by ambulance. But then I was told he changed his mind again and when I went to talk to him a third time over his decision he was on the cellphone and he asked me to wait. So I did and I went to see another patient. When I came back the patient had eloped.

I have no idea if he showed up at the other ED and much less what his outcome was. However, I am sure if the patient had a bad outcome somehow I would be mentioned during litigation. Not that I practiced defensive medicine but I can see why others do.

~The most recent was an 18-year-old female who came complaining she had acid reflux. After listening to her HPI I was not convinced it was reflux and shared why and my concerns with the patient. However, I was not able to convince her otherwise despite my attempts. After the PE I was even more convinced it was not reflux and shared my concerns, again, with the patient who told me that she knew her body better than I and all she needed was a GI cocktail. As a compromise, because it makes sense in medicine, especially in the ED, NOT! I offered the patient that would be fine BUT I also wanted to do some blood and urine test. The patient refused. Insisting it was her reflux and nothing more. Ok. One GI cocktail coming up.

Thirty-minutes later I checked up on the patient. Not better. Now the parent was in the room, not that I have a problem with that, except I could feel the tension in the room as the mother rattled off a list of home remedies the patient had tried for her reflux; aloe vera juice, lemon juice, baking soda, apple cider vinegar, chewing gum, had eaten slippery elm and licorice, drank milk, laid on her left side, and Zantac, and none of it had worked. Interesting, when I entered the room on the initial visit the reflux expert patient was laying on her right side, something I did not mention to the mother. However, I did mention to the mother that the patient had denied taking Zantac prior to arrival (PTA) when I asked the patient prior to giving her a dose with the GI cocktail. Interestingly, the parent and the patient went back and forth on whether or not the patient had taken Zantac or not. Then, as if that discussion had not taken place I was told by the patient that the only thing that worked was a “medicine that numbed the throat”, which the nurse had asked me about prior to giving the patient the GI cocktail. However, as I told the nurse, I told the patient, “I am not a fan of viscous lidocaine but if that is what works I will ask the nurse to bring you some.

It had not been five-minutes after taking the viscous lidocaine when I heard the patient vomiting. When I returned to the room the family, and the tension, was still present. The emesis was bilious and I said to the patient, with the family present, “This is not reflux. Would you be okay if I did some test of your blood and urine?” The patient, receptive to my input, agreed.

After getting the urine and blood result I went to the room and although the patient was more amenable I could still feel the family’s tension. I then asked the patient if she mind that the family wait outside and she agreed. As they stepped out of the room I closed the door behind them and informed the patient, “You have a urinary tract infection and you are pregnant.” The last diagnosis shocking the 18-year-old. After reexamining her abdomen I told the patient I was going to order an ultrasound of her abdomen as well. She nodded her head yes but seemed to be shocked by the fact I told her she was pregnant. Prior to leaving the room I asked her if she wanted others to know she was pregnant and she said, “No.” I asked her because now it was the change of shift and I wanted to let others know the patient’s wishes. I opened the room door, let the family back in and walked down the hallway, letting the nurse know the findings, the plan for an ultrasound, and to pass on to the oncoming shift the patient’s wishes. I then reported off to the day physician about the patient, to include the patient’s wishes with regard to being pregnant.

When I returned for the night shift that night, the day physician shared with me the 18-year-old was 14wks pregnant and was taken to surgery to have her gallbladder taken out due to she had cholecystitis as well.

I have nothing to gain by doing right for patients, it is simply the expectation of the work I do. Of course I could have just placated the last two patients and done whatever they wanted in order to avoid upsetting them, and their families, thus keeping them happy and not complaining about me regardless that the care would have been inappropriate. However, my job is not to make patients, or their families, happy. My job is to help others and that includes being truthful, even if patients cannot handle the truth. Having said that, patients have to want to be helped. Because, if they have another agenda that is neither I nor the work I provide. Interestingly, patients complain that I am uncaring when in fact I do care. That is my job—to care. It’s just that complaining patients are not interested in the truth.

To top things off, since I began working at this ED the administration has installed The Yacker Tracker, an electronic device used to monitor and control noise in the area. The device is quite the attention getter and when noise at the nurse’s station raises above a set level it sounds an alarm, and may even command, “Quiet please.” The device will take some time to get used to; some have unplugged it from the wall not knowing it has a backup battery. But the most common response has been healthcare workers wide-eyed covering their mouths when the alarm goes off, like a child who suddenly realizes they said something wrong. I know The Yacker Tracker was not installed with me in mind, however, I find it interesting that administrators continue to implement idiotic ideas chasing after the customer experience. Although the device may have only cost $100, or so, that is money that would be better spent elsewhere.

My two sense [sic] for this first month of work, again, not a rainbow but a job near home and where I get to wear hair gel again. One thing is for sure, at this new ED, by far, I have heard the most "Thank you" from patients than any other ED I have worked at, and I have worked at many. Hopefully that is a good sign.

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