When I went into nursing, my first instructor made a very important statement. One I remember to this day. She said that nursing is all about flexibility. You never know where your career or life will take you. Medicine is certainly about flexibility because if you are inflexible or set in your ways, you will never survive in this very demanding field. Take my case, for instance. You would think that with almost 20 years under my belt, my career path would be secure and set. Well, you would be wrong. I am finding myself making some career-altering changes even now. If you stop and think about this for a moment, you will understand why. Your nursing career can span your entire adult life. What you could do when you first started in the field may be something you no longer have the endurance for. You may also find that you are getting burned out in one particular area. Many nurses, as they progress in their careers, go into management or even education. These are by no means your only choices. You can go into the field of litigation, where you are a technical consultant for a legal team. This choice is best for a nurse with critical care experience. You can work as a case manager, a home health nurse, a transport nurse, a dialysis nurse, a perfusionist, or even work for an organ donor agency. Probably the most lucrative duty is as a private duty nurse for wealthy people. I almost fell into a job caring for the parents of one of the wealthiest casino owners in Las Vegas.

But I digress; this chapter is supposed to be about my early years. There is plenty of time to discuss my “golden years” of nursing in later chapters. As you already know, I started my nursing career in Florida. Although I only worked there for a short time, my experience was very eventful. My primary Charge Nurse thought pretty highly of me. She made the statement to my wife, who was the charge nurse on my off nights, that I had not been challenged enough during my orientation time, not only as a new hire but also as a new grad. Yes, I know you should not work on the same floor as your spouse. She, being one of my immediate supervisors, was not able to work on the same nights as I did. So I always got to work with her opposite. Due to our schedule, we only get to have one night off together a week. Some people may say that this was a good thing. We were still a relatively new couple, so it wasn’t ideal for us. But we managed to get through it, and besides, this arrangement, as it turned out, only lasted four months.

It turns out that my nurse “Ratched” had the same name as my first wife, Tammy. While she was not a cruel person, she rode me like the witch in the Wizard of Oz rode her bike. I always got the most challenging assignment, and I was the first to get floated, even though I was a new nurse. I guess, because I never let myself get stressed out. She thought this meant I wasn’t working hard enough. It wasn’t all bad because the unit I was working on was full of very experienced and friendly nurses who were always available with a helping hand. So, needless to say, I was swamped. Our charting was a combination of paper and computer charting. The only part that was on the computer was the medications, labs, test results, and order entries. The actual charting for the doctors and nurses was all handwritten. You may think that this hybrid system was inefficient, and you would be right. Each nurse was responsible for reviewing the paper charting to ensure that all orders written by the doctor were accurately entered into the computer for their 12-hour shift. The charge nurse was responsible for checking that the orders were correct for the whole 24 hours of that day. You may wonder who was responsible for entering this critical information into the computer; that would be the least trained individual on the team, the ward secretary. Makes sense, right? That is why we had to spend so much time checking their work. Life is a lot easier now because doctors in most hospitals can enter their orders directly into the computer. I say most, because nurses still have to enter telephone orders in, as well as any verbal orders given by sneaky doctors who are either too lazy or too busy to do so themselves.

Just before I got hired at this hospital, they had installed what is referred to as a medicine dispensing system. There are two options: the original Meditech system, which we used at this hospital, and the Pixus System, another major brand. Neither one was better than the other. They both had their strengths and weaknesses. Before this, each floor had a narcotic box or cart that the nurses took narcotic medications out of for dispensing. At the end of each shift, a count was done by two nurses. If the count was wrong, nobody was left to go home until the error was corrected. Thank God I dodged that bullet, knowing my luck, there would always be a shortage when I worked.

The reason that I seemed to function well is that I am, by nature, a highly organized and systematic individual. I did my assessments, charted, and passed meds all at the same time. The certified nursing assistants (CNAs) provided for the patients’ personal needs, like bathroom breaks and cleanups. We only had to help when the assistant became overwhelmed. The CNA is one reason why I worked in the medical/telemetry floors for so many years. You don’t have CNAs in critical care, so you have to provide all the care that the patient needs. Our charting was by exception with flow sheets, so it was extremely quick. We only had to write a patient note for anything out of the ordinary. In the medical floors, this usually only involved one organ system, so even that was pretty quick.

One thing that I noticed in Florida was that the doctors in this state were very organized. Many had standing orders that covered all of the patients’ needs, so you did not have to call them for very many additional orders. Some of the surgeon’s standing orders were several pages long. This was a great thing since I always work nights, and it is quite onerous waking up doctors at night for things like Tylenol or a sleeping pill. However, there was that occasional doctor who liked to practice medicine over the phone. This would happen for new admits that came in after the doctor went home. So he would quiz the hell out of you and give you a bunch of orders that would cover their care until the morning. It was a pain in the keister, but I guess it was understandable, and besides, in the surgical units, the admitting doctor has 12 hours to see his newly admitted patient. In contrast, in the ICU, they only have four hours, which is why nurse practitioners and physician assistants are in vogue now.

We had telemetry monitors right on the floor so we could frequently check the cardiac condition of our patients. However, it was the responsibility of specialty-trained individuals in telemetry monitoring that kept a much closer eye on all the patients’ heart rhythms. As part of our tasks, we had to write three notes for telemetry discussing the patient’s cardiac condition. However, not all of our patients required such close cardiac monitoring. Medication passes are usually ordered every 4 hours or, in some cases, as needed, like for pain management and nausea. So, as you can see, even at night we were kept quite busy. So, this is where I digress a little to discuss the unfair treatment nursing gets from the entertainment industry. First of all, we run the hospital, and doctors would be lost without us being present to do all of the close monitoring that the patient requires. Doctors spend only a few minutes with each patient during their daily rounds. They only get a very brief snapshot of their condition. So they rely pretty heavily on us. Besides, who is going to provide the vast majority of the treatments that they prescribe for their patients? While it is true that the doctor has more specialized training, we are also highly trained and hard-working individuals. We do not store mattresses and sleeping bags in the nursing station for breaks during slow periods. Most hospitals require a minimum of rounding every 2 hours, and critical care requires rounding every hour at the bare minimum. We are also not busy in the closets playing grab ass with the doctors and surgeons.

Every hospital has different routines and schedules based on its clientele and the severity of the cases that it treats. In the four hospitals where I have worked, there has been a marked variation in the systems used and even the software utilized for charting and ordering. This is one of the reasons that nurses have to be flexible. However, as the nurse ages, this level of flexibility becomes less attainable. By nature, we become more set in our ways as we age. So, ergo, many nurses chose some of the alternatives enumerated earlier in this chapter.

I am sure by now you realize that I don’t pull any punches, I say it is like it is. Insurance companies, including Medicare and Medicaid, have far too much influence over the operation of hospitals, along with that tyrannical commission known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO. It seems that Medicare and Medicaid take great pleasure in finding reasons not to pay the hospitals for the services they provide. It is bad enough that insurance companies can take an entire year to pay the doctors and hospitals. They also pay less than the rates charged by the hospital. I believe hospitals charge excessively to write off the differences as losses, which helps reduce their taxes at the end of the year. I think that this is the case. JCAHO also seems to take the greatest delight in finding the most minuscule of infractions to justify its existence. Unfortunately, we have to take them very seriously because without their accreditation, we receive no Federal assistance or compensation. I guess they are trying to bankrupt the hospitals? I don’t understand. I have noticed that the largest and, therefore, most essential hospitals get more lenient treatment than do smaller and, hence, less critical facilities. This is an unfair practice, but who am I to say that this is happening for sure? It just appears to be so to me.

Before I wrap up this chapter, I want to discuss a few more niceties about this hospital, things that I have not seen since. Unfortunately, our hospital had a high number of employee injuries related to moving and lifting patients. In response, they developed a zero-lift policy and purchased a significant amount of equipment to assist the nurses. We also had two flex PCTs who assisted the nurses in transporting patients at night for emergency testing, code greys, CPR, and any other activities that required some additional brawn. We also had, considering the small size of the hospital, a 24-hour snack shop that made sandwiches and grilled hamburgers and such at night. We had a wound care book with photos in it that the nurses used to write their wound care orders for. All the doctors had signed off on this, so it made us feel like we were doing something special. Now, nursing has been replaced by physical therapy for the vast majority of wound care. In many hospitals, the department is overseen by specially trained stoma and wound care nurse practitioners. All non-critical care telemetry registered nurses were required to take a three-week telemetry course where we had advanced training in medication administration and care of patients. After we took the class and passed the test, we received a $2.50 raise. Our hospital also required all telemetry nurses to be ACLS certified. In most hospitals, it is only the charge nurses, critical care, and Emergency Room nurses who are required to be ACLS certified. I have also never seen a hospital offer so much additional training and certifications. They offered extra pay for CNAs who had additional skills as well. I guess I took all this for granted, boy, was I shocked when I transferred to my next hospital.