Well, now I am in Las Vegas and working at a hospital that is almost three times the size of my Florida-based hospital. I ended up working there for a little over 8 years before I moved on. As I stated in my previous chapter, each hospital is different. Even sister hospitals are run remarkably different right down to the supplies that they use. You would think that they would use the same supplies to save money but who am I to say. I know one thing, this hospital was certainly an eye opener for me. I won’t mention the name of the hospital nor will I mention the names of the other hospitals I worked at, though I am sure an astute reader could figure out this particular hospital quite easily.

This hospital was certainly a game changer for me. The main tower alone held over 400 patients. I was not used to dealing with so many patients. During the heyday of this hospital all of our beds filled up quickly. We had three cath labs running 24/7. The sheer scale was just mind-boggling to me. The two med/surgical/telemetry floors had 3 units each. One floor was divided up into a rehab unit and an orthopedic floor while an additional floor consisted of two intermediate care units (IMC) and two intensive care units (ICU). Another tower housed 6 more ICU wards along with other specialty units. While I was there a new state-of-the-art children’s tower was added. When I and my wife started working at this hospital, it had already enjoyed 50 years of life. What a metamorphosis it must have experienced in those years. At one time, they even had two suites that were geared towards the more well-to-do residents in Las Vegas. Many people believed that the hospital was haunted by many souls/ghosts of long deceased patients. While I don’t know about that, many people spoke of the interesting occurrences that they experienced. Many are very difficult to explain. Since I was not a partner to any of these paranormal happenings I will not discuss them here.

I spent my first three years on the floor honing my nursing skills. While it is true that I was queried about assuming a charge position on several occasions, I resisted the temptation so that I could gain more experience. Because I believe that a charge nurse should be able to handle anything that the unit can throw at him/her. So I had three years as a time frame to reach the necessary level of skill. It is my experiences of the first three years that I will cover in this chapter. I also worked as a charge nurse for five years on the same floor and unit. I will discuss those experiences in the next chapter.

This hospital was a sister hospital to the one I worked at in Florida, so the same computer software was also utilized, so this reduced the learning curve somewhat. However, the charting was no longer written on paper it was entered in the computer. The Medication Administration Record or MAR as it is known also resided in the computer. So this was quite an advancement. But what I found to be of even greater import was that our Care Plans were now computer-generated and were based on the patient’s diagnosis. You no longer had to do the tedious task of writing your own plans of care and care maps. This is in my mind was the most odious and tedious part of nursing school and frankly, I feel useless part of it. I feel this way because doctors have the final say on what happens to the patient and how they are cared for. The rest of the nonsense we do is just window dressing. I know that these care plans were an integral part of legitimizing the nursing profession they are a necessary but albeit useless part of modern nursing. This is the case because Medical Doctors don’t take nursing as a profession seriously. We simply serve as their assistants, to only be heard from when addressed by our superiors. I know this trend may be changing , it however, is still all too prevalent. Since I like to be complete when I write anything, I will discuss it a little more in depth in the following section.

A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client’s changes in condition and evaluation of goal achievement. Planning and delivering individualized or patient-centered care is the basis for excellence in nursing practice.

The following are the goals and objectives of writing a nursing care plan:

• Promote evidence-based nursing care and to render pleasant and familiar conditions in hospitals or health centers.
• Support holistic care which involves the whole person including physical, psychological, social and spiritual in relation to management and prevention of the disease.
• Establish programs such as care pathways and care bundles. Care pathways involve a team effort in order to come to a consensus with regards to standards of care and expected outcomes while care bundles are related to best practice with regards to care given for a specific disease.
• Identify and distinguish goals and expected outcome.
• Review communication and documentation of the care plan.
• Measure nursing care.

The following are the purposes and importance of writing a nursing care plan:

• Defines nurse’s role. It helps to identify the unique role of nurses in attending the overall health and well-being of clients without having to rely entirely on a physician’s orders or interventions.
• Provides direction for individualized care of the client. It allows the nurse to think critically about each client and to develop interventions that are directly tailored to the individual.
• Continuity of care. Nurses from different shifts or different floors can use the data to render the same quality and type of interventions to care for clients, therefore allowing clients to receive the most benefit from treatment.
• Documentation. It should accurately outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require. If nursing care is not documented correctly in the care plan, there is no evidence the care was provided.
• Serves as guide for assigning a specific staff to a specific client. There are instances when client’s care needs to be assigned to a staff with particular and precise skills.
• Serves as guide for reimbursement. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client.
• Defines client’s goals. It does not only benefit nurses but also the clients by involving them in their own treatment and care.

A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below:

1. Client health assessment, medical results, and diagnostic reports. This is the first measure in order to be able to design a care plan. In particular, client assessment is related to the following areas and abilities: physical, emotional, sexual, psychosocial, cultural, spiritual/transpersonal, cognitive, functional, age-related, economic and environmental. Information in this area can be subjective and objective.
2. Expected client outcomes are outlined. These may be long and short term.
3. Nursing interventions are documented in the care plan.
4. Rationale for interventions in order to be evidence-based care.
5. Evaluation. This documents the outcome of nursing interventions.

The information on care plans was provided by the web page nurseslabs.com. So thank you very much for the valuable information that was provided at this site.

Now that I have made all the clinically-inclined readers happy, I will continue on with my narrative. I was very fortunate in my choices of units to be working in because it was one of the most experienced medical units in the hospital. Several of the nurses had over thirty years of experience. They all seemed to want to take me under their wings. I was just happy that I fit in. I guess, my years as a customer service manager played no small part in this process. So it seems that I just naturally found a way to fit in.

While Licensed Practical Nurses (LPN) were not that common in my previous hospital, they were an integral part of the staff at my new hospital. While they are valuable members of our team, they did have their limits. Initially, LPN’s in Nevada were not even allowed to start IVs eventually this idiotic policy was eliminated. As part of this original plan, they could not give any medications via the vein or intravenously. With this new program, they were now able to administer some basic IV medications like the anti-emetics Zofran and Phenergan and proton pump inhibitors like Protonix and Famotidine. This change certainly helped reduce the workload some. They, of course, were still not able to administer IV narcotics. They also could not do the admission or initial physical of the patient being admitted to the hospital. They could, however, take the patient’s history. Our unit was a 36-bed unit which meant that we routinely had 2 LPN’s and 2 RN’s. So we had to cover all the narcotic pushes for the LPN and help with any admits they might get in the night. So, ultimately we were responsible for 18 patients. Needless to say that we were very busy indeed. In the day time due to the increased work load they only had six patients and also had higher RN to LPN ratio, so that they did not have to cover as many patients.

This hospital is located in the middle of the city, so the clientele were certainly eclectic and disparate. In other words, you were never surprised with what type of patients you got. I cared for transvestites, trauma patients, cancer patients, cardiac patients, prisoners, psychiatric patients, overdose patients, morbidly obese (max 900lbs) patients and, of course, your typical homeless patient. This is just a small sampling of some of the patients I cared for. I even took care of patients who had unique personal relationships and even one case of Oedipus Complex issues. Of course, the cases of neglect and abuse were among the most heart-wrenching cases. It should come as no surprise to the reader that ill health tends to bring out the worse in people. I will do my best to discuss a large number of these cases in following chapters.

Not only were the patients unique, the staff was also unique as well. It turns out that to work over thirty years as a nurse you need to be a very special type of person. Many of the nurses I worked with have never done anything else. So I have to take my hat off to these individuals. I have almost reached the 20-year mark and I am asking myself how I will keep up with the work. One thing that is amazing is the diversity of training that these nurses and support staff have. I worked with phlebotomists who were doctors in other countries as well as several nurses. I had one telemetry tech who was also a doctor and eventually became a software engineer. Considering that the training for a telemetry tech is only a two-week class, this would be considered a bit of over kill, and a phlebotomist requires no previous training at all. It turns out that licensing and accreditation can be a bit of an issue when you had your training overseas. Is this appropriate, I don’t know? But I do know that not all training facilities and colleges are created equal. So my way of thinking is that you should always treat everybody you meet with respect because you never know what their background or experience and skill levels are. I guess, this is also another reason that I fit in so well. I treat everybody like I would want to be treated. I also had the honor of working with individuals from all over the world including places such as Asia, Africa, Europe, Central America, Canada and Mexico and the Pacific Islands. Nursing and the medical field is truly a melting pot of humanity.

There are so many special people I worked with during my eight years at this metropolitan hospital, and I would like to mention all of them, unfortunately, I simply don’t have the room. I will, however, do my best to discuss some of the more unique individuals I worked with. A hospital is made up of many different disciplines. If you take away only one of them, the whole house of cards comes tumbling down. If housekeeping stops working you will soon have no place to put the new patients because all the empty rooms are dirty and trust me, you need clean rooms. You have no way of knowing what type of infection the previous patient might have even if they were not being treated for them. I will get to a story involving the housekeeping staff in the later chapter. I believe in speaking up for those that can’t speak for themselves. Nothing upsets me more than when the weak or helpless or even animals for that matter are abused or neglected. I will also talk about some of these cases a little later as well.

I developed friendships with many of the staff members some as a floor nurse and many more as a charge nurse. But before I get hopelessly bogged down, let’s refocus on the task at hand. I developed close relations with three nurses in particular. Two were LPN’s whose names were Bobbie and Linda and one RN named Mary. Mary was the embodiment of professionalism. She has forgotten more about being a nurse than I will ever know. I once picked out a random term from Taber’s medical dictionary, a term I had never heard of before, not only did she know what it was she gave me working examples as well. She never took notes in report and she never forgot anything even when she did relief charge nurse. Which is truly amazing since you have to keep track of upwards of 36 patients. I had the fortune and honor of being there when she retired. Unfortunately, because of her long history of being a heavy smoker she did not get to enjoy a very long retirement before she succumbed to the ravages of lung cancer. She was a truly amazing individual and a very special nurse who never looked down at any new nurse that came down the pipeline. While I have lost track of both Bobbie and Linda, I am sure that they have since retired. They were truly unique individuals and great nurses in their own rights. They both had the biggest hearts and would literally give the shirt off their backs. Bobbie had a life that came right out of a soap opera and she, however, did have a bit of a gambling problem but I enjoyed the hell out of working with her. She never failed to delight you with the stories of her family. Linda had two major weaknesses…she was way too gullible and she also trusted everybody. She would also come up with some crazy stories about her earlier life.

One particular nurse of note was the infamous Chaz Higgs. He was hired at about the same time as I was. His previous experience had been as a Corpsman in the Navy. After finishing his orientation time, he and another more senior nurse transferred to the ICU. That was the last time I saw him in person, but not the last I was to hear his name. Since his story was probably the most extreme ones that I came across, I will spend a little time covering it here. I am going to pull the story from a Las Vegas Sun article posted on July 30, 2006 entitled “Who is Chaz Higgs?” by Ed Koch and Mary Manning.

State Sen. Sandra Tiffany remembers her reaction when State Controller and good friend Kathy Augustine broke the news: While on vacation in Hawaii, Augustine had married a handsome, younger man she barely knew – a critical care nurse at the hospital unit where her previous husband had died just three weeks earlier.

“When I heard that, I said, ‘What, are you nuts? Are you crazy?’ ” Tiffany recalls telling Augustine of the whirlwind marriage to Chaz Higgs.

Tiffany, a Henderson Republican, says that she met Higgs only once, at a political function: “I don’t think I heard him say two paragraphs.”

And the senator’s first impressions? “He was buff. The guy is self-centered and self-absorbed.”

Tiffany is not the first person to describe Higgs that way.

One of his three previous wives paints a similar portrait of the man whose attempted suicide after the mysterious death of Augustine earlier this month has thrust Higgs from being a bit player as a political spouse onto center stage.

This week Reno Police expect to receive FBI toxicology reports from Augustine’s autopsy. The work is being done at the federal agency’s lab in Quantico, Va., where it is believed Higgs once lived.

Police officials are quick to label their case as merely a death investigation, with the cause being “questionable.” They say that Higgs is neither a suspect nor a person of interest.

But a representative of the Nevada Department of Investigations has asked at least one of Higgs’ ex-wives, who spoke briefly with the Sun, to no longer speak with any media.

Seems lots of people are trying to find out, “Who is Chaz Higgs?”

Extensive research by the Sun – including interviews with two ex-wives and the scouring of scores of public documents – shows a man who:

Little is known of Higgs’ boyhood other than he was born a twin on June 2, 1964. His first wife recalls that he said the boys were raised in Virginia and North Carolina by his Marine father.

Higgs enlisted in the Navy on Dec. 21, 1983, at age 19. There he met his first wife, Dawn Renee Brown, while both attended corpsman school at Camp Lejeune, N.C. They married Sept. 15, 1984, in her hometown of Dillon, S.C.

In a telephone interview, Dawn describes the man she knew as Chuck as a golfer, surfer, weightlifter and bodybuilder. “Always athletic,” she says, “always into himself.”

A few months into their marriage, Dawn says, she caught Higgs in bed with a nursing student in a room behind the garage of his parents’ North Carolina home, where the couple were living.

“He was a little womanizer,” she says, noting that Higgs was such a charmer she put that incident aside and tried fruitlessly to work things out.

He did have positive traits, too. Higgs didn’t smoke, drink or take drugs, Dawn says, and “he was good at patient care.”

In 1985 they transferred to a base hospital in Jacksonville, Fla. There, Higgs met his future second wife, Kirstin Dawn Gonzalez. She, too, was a corpsman. She also was married and had an infant son with her then-husband.

“He (Higgs) was seeing her (Kirstin) while he was married to me,” Dawn says. “He liked to be with other women – he could not be faithful. I was not going to have anything more to do with that.”

The Higgses divorced on Feb. 19, 1988. Dawn went on to a 12-year Navy career, married another sailor and today is a homemaker in New England.

She last heard from her ex-husband in 1993, receiving a letter from Higgs, stationed at the time on a medical ship in Bahrain.

“He wrote that he was young at the time and that he was sorry for what he had done to me,” Dawn says. She threw the letter away.

On Aug. 18, 1989, Higgs filed for bankruptcy in Florida. Four months later, Kirstin Gonzalez’s divorce was granted, ending her four-year marriage. On New Year’s Day 1990, Higgs and Kirstin married.

In all, they probably spent less than six months together, says Kirstin, who left the Navy to care for her baby. According to court documents, Higgs adopted the boy.

In fall 1990 the couple drove across the country. Higgs dropped Kirstin off in Las Vegas, where she became the apartment manager for a complex on Reno Avenue. He went on to San Diego for duty on a medical ship.

The marriage, for all intents and purposes, was seemingly over. In Las Vegas, Kirstin lived the life of a single woman, appearing at one point on “Meet Someone Special,” a Las Vegas-based, cable-television dating show.

She caught the eye of a local law enforcement officer who would later attest to her Nevada residency in Kirstin’s June 4, 1992, divorce from Higgs. According to the terms of that divorce, Higgs was ordered to pay $400-a-month child support until his adopted son was 18. He also was given liberal visitation rights.

Three months after divorcing Higgs, Kirstin and the officer married.

Higgs paid child support for 6 1/2 years until Kirstin and her husband released him from the responsibility, reasoning that Higgs had not seen the boy since he was a baby.

Kirstin, who still lives in Las Vegas, didn’t know that Higgs was living in Nevada until she saw a television news report this month about his suicide attempt. She declined to discuss her marriage to him.

Asked if Higgs had been abusive or unfaithful, she was tearful: “That would be an issue I would rather address to law enforcement.”

Days later, according to her husband, Kirstin was advised by the Nevada Department of Investigations not to talk to the news media.

The state agency referred all inquiries to the Reno Police Department – the lead agency investigating Augustine’s death. Reno Police Lt. Jon Catalano says that his department didn’t ask the state agency, which is assisting Reno Police, to tell anyone not to talk about the case: “They probably did it thinking they were helping us,” Catalano said.

From July 1993 to February 1997 Higgs was stationed in Manama, Bahrain, and that part of his life is somewhat sketchy. Sometime during or after that period, however, he apparently married a third woman – Lorelei Sagmit Gueco.

According to public records, the third Mrs. Higgs did not obtain a Social Security number until 1996 or 1997 in North Carolina, when she was 24 or 25. That could indicate she might not have been born in the United States.

The Sun could find neither marriage nor divorce documents for Higgs and Lorelei in public records. Her name first appears as Higgs’ wife – and joint debtor – in an Oct. 29, 1998, Chapter 7 bankruptcy proceeding in Alexandria, Va.

Those court records also list Higgs as the stepfather of Lorelei’s then-2-year-old daughter. The couple had nearly $30,000 in debt – including $8,600 on one credit card – but only about $15,000 in assets.

Higgs left the Navy on March 1, 1999, according to the Pentagon, which would not give a reason for the discharge. The Navy confirmed that Higgs left at the rank of HM1-E6, a medical corpsman.

In April he and Lorelei moved to Louisville, Tenn . Later that year, they moved to Las Vegas.

When they broke up is not clear.

Lorelei married another man in Las Vegas in 2002 and divorced him the following year. A local attorney who handled the divorce said Lorelei later married another Las Vegas man. The lawyer said he didn’t know when or where the marriage took place, and the Sun could not locate marriage records for them.

Attempts to reach Lorelei – including a note left at her home – were unsuccessful, but her current husband said that neither he nor his wife would comment on Higgs or anything related to her marriage to Higgs.

In 2002 Higgs received an associate’s degree in nursing from Craven Community College in New Bern, N.C. Higgs also has taken Internet courses from the University of Phoenix, receiving both a bachelor of science and a doctoral degree. A University of Phoenix spokesman declined to identify Higgs’ field of study for either degree or when he completed the online classes.

He passed the National Council Licensure Examination test in Nevada in 2002 and received a state nursing license, according to the Nevada State Board of Nursing. The board has no record of complaints or disciplinary actions against Higgs.

In November 2002 public records indicate that Higgs was living in a recreational vehicle park on Boulder Highway.

Kathy Augustine’s life at that time was moving along on a much higher plateau.

The former Delta Air Lines flight attendant and her pilot husband, Charles, had moved to Las Vegas in 1988 and purchased a home in the downtown area in 1990, according to Clark County assessor records.

She was elected to the Assembly in 1992, serving from 1993 to 1995 before winning a term in the Nevada Senate. In 1998 she became the first woman elected state controller.

By late 2002, however, their marriage was shaky, friends say, and on the last day of the year, records show she purchased a small home in Reno in her own name.

Tiffany and other friends say that by the time of Charles Augustine’s July 2003 stroke, the couple had been separated for some time.

He was taken to the Sunrise Medical Center, where Higgs would be one of his critical care nurses. At the time the stroke was described as mild.

On Aug. 19, however, about six weeks after his stroke, Charles died.

No autopsy was conducted on the 63-year-old man. He left Kathy the Las Vegas home and a $1 million insurance policy, according to published reports.

Tiffany says that Kathy had planned earlier in the year to take a trip to Hawaii. After her husband’s death, Augustine invited Higgs to go along. While they were there, Tiffany says, Augustine asked Higgs to marry her.

Of their Sept. 19 wedding in Honolulu, the Sun wrote in its Sept. 26 editions: “Augustine said she met Higgs when he was caring for her second husband, Chuck, before Chuck Augustine’s death. The controller intends to keep Augustine as her last name.”

It would be a major lifestyle change for Higgs. Augustine’s annual salary, according to public records, was $80,000. In the Navy, Higgs’ yearly income averaged in the high $20,000s.

Friends of the couple say that Higgs was quiet, distant and appeared seemingly content in Augustine’s shadow. But all was not rosy, those same friends say – at least once, she had asked him to leave.

And public records indicate Higgs never had any ownership in Augustine’s homes.

In September 2004 Augustine’s once-meteoric political career had hit the skids when she admitted violating state ethics laws during her 2002 re-election campaign.

Augustine became the first Nevada state constitutional officer to be impeached by the Assembly in November 2004. Following a weeklong trial in the Nevada Senate, she was found guilty on one count and censured, but allowed to remain in office.

She was fined a record $15,000 by the state Ethics Commission, and made $500-a-month payments on the fine until November 2005, when she paid off the balance five months after refinancing her Las Vegas home.

Higgs’ name popped up in media reports in March 2005, when he filed a complaint with the Nevada Ethics Commission against Sen. Steven Horsford, D-North Las Vegas, claiming there were irregularities with some of Horsford’s campaign contributions.

Horsford says that the complaint was merely retaliation for his criticisms of Augustine during her impeachment trial, but the senator later filed some amended campaign reports.

Augustine, meanwhile, was retrenching.

Unable to seek a third term as controller because of term limitations, last January she announced her candidacy for state treasurer. She would be running, however, without the support of the Nevada Republican Party, which in May voted to deny help for any impeached or similarly disciplined candidates.

Despite her death, her name will remain on the ballot for the Aug. 15 primary. If she wins, a replacement nominee will be designated – by the same party that disowned her.

On July 8, Chaz Higgs found Kathy Augustine unconscious, without a pulse and not breathing. After he tried to resuscitate her, Higgs told authorities, paramedics were called and took her to Washoe Medical Center. She died three days later.

At a subsequent news conference, Higgs said her cardiac arrest resulted from campaign stress, and that his wife had complained of stomach pain and heartburn in the days prior to her attack.

Preliminary results of an autopsy found there was no evidence that Augustine had long-term heart disease, Reno Police said.

And not everyone subscribes to the death-from-stress theory.

Augustine, 50, thrived on controversy, Tiffany says. “I don’t believe that would have caused a heart attack,” she says, adding that her friend never took drugs, nor drank alcohol. “Even when she was in the roughest times, the toughest times, she was above it.”

Two days after Augustine’s death, Higgs told reporters he had nothing to gain financially from his wife’s death as her estate was left to her daughter, Dallas Augustine.

The following day, Dallas kicked in a bedroom door and found Higgs with his wrists slit and a suicide note, Metro Police said. Higgs, 42, was treated and released from University Medical Center the same day.

Under Nevada law, those who attempt suicide can be held for observation for up to 72 hours without a court hearing. The attending physician, however, may release the patient at any time if the doctor does not believe the patient is a threat to himself or others.

Higgs did not attend Augustine’s funeral, the day after his suicide attempt, and neighbors say he has not been seen recently around the couple’s Las Vegas residence – a huge two-story structure with three pillars, located on a cul-de-sac. The long vertical blinds inside the home are drawn shut, and the driveway and separate garage are void of vehicles.

He also did not attend a memorial service for her last week in Carson City.

Since the controller’s death, Charles Augustine’s relatives have asked authorities to exhume his body for examination if toxicology results from Kathy Augustine’s autopsy are suspicious.

Dallas Augustine and Chaz Higgs did not return Sun phone calls seeking comment, nor has anyone responded to a note left at the Las Vegas home. Calls to the Augustine home in Reno, which also is listed in public records as a Higgs residence, have gone unanswered, and the voice mail says the electronic mailbox is full.

Reno Police have not had contact with Higgs for several days, but are not concerned, says Catalano, because there is no evidence of any crime and he is not a suspect.

And if the toxicology tests come back negative?

“The case,” Catalano says, “will be closed.”

You just never know who you are working with. There are two doctors that I knew who were involved in distinctly unsavory issues of whose stories I will cover, as well as those involving some of my co-workers and colleagues in later chapters.

One thing that I was disappointed in was the opportunities for learning. I thought that this hospital due to its size would have all sorts of classes that you could take, but alas they did not. My lowly little hospital in Florida offered more in the way of learning opportunities.

This hospital due to its location received a lot of transfer patients from the more rural border facilities, mainly due to the fact that there were few specialty services being offered. One omission I found surprising was that they did not have a gastroenterologists, so we would get a lot of gastro-intestinal bleeds (GIB) medivacked to us, what a waste of money. We also received a lot of prisoners from the local jail and prisons as well. These patients never failed to provide interesting cases. It also seemed like many of our homeless clientele used our hospital as a local hostel where they could get three hots and a cot.

Eventually near the end of my tenure at this hospital we became accredited for level three trauma cases. They eventually became accredited to level two in 2005, with University Medical Center (UMC) as being the only level one trauma center in Las Vegas. I won’t delve into what is involved to attain this accreditation but suffice it to say, it isn’t cheap nor easy.