Posts Tagged ‘stress’

I was in the bathroom at work yesterday, and this poster is hanging on the door.

Really???? What are these idiot politicians thinking of when they dream up this stuff?
And they constantly cut the pay to the providers and then expect them to try to keep up with all of these ridiculous new regulations and rules.

Do they actually believe that all of this stuff is going to improve healthcare, decrease fraud and decrease the cost of healthcare?  Evidently they do:

Check this link: ICD-10 benefits for healthcare providers

Note that the guy writing it, if you even get half of what he is saying, is an IT guy, NOT a healthcare professional. The talk is about “data-driven” patient care. Huh? My patient care is driven by the patient’s needs, not some IT guy’s addiction to data in his little cyber-world. I don’t think that a coding set is going to alter the fact that a laceration that is bleeding all over the place needs to be sutured. Who gives a crap if the cut is caused by a paring knife versus a steak knife. Time is wasted in asking the difference and looking up the code in a set of 140,000 codes.

“The increased auto adjudication of claims due to increased granularity of ICD-10 code will help in reduced number of claims being investigated or rejected due to insufficient information. ” Right. The fact the patient is cut and bleeding is not enough information to pay for a suture job?

The codes are bordering on the ridiculous. I heard stuff I couldn’t believe. Yet, when looking them up, it turns out to be true. Example: Here in Florida, there is the occasional person who gets injured at the beach. Here are the codes for one type of incident:

2012 ICD-10-CM Diagnosis Codes > External causes of morbidity V00-Y99 > Exposure to animate mechanical forces W50-W64>

Contact with nonvenomous marine animal W56- >

Type 1 Excludes

  • contact with venomous marine animal (T63.-)
W56Contact with nonvenomous marine animal
W56.0Contact with dolphin
W56.01Bitten by dolphin
<span class="identifier">W56.01XA</span> is a billable ICD-10-CM diagnosis codeW56.01XA…… initial encounter
<span class="identifier">W56.01XD</span> is a billable ICD-10-CM diagnosis codeW56.01XD…… subsequent encounter
<span class="identifier">W56.01XS</span> is a billable ICD-10-CM diagnosis codeW56.01XS…… sequela
W56.02Struck by dolphin
<span class="identifier">W56.02XA</span> is a billable ICD-10-CM diagnosis codeW56.02XA…… initial encounter
<span class="identifier">W56.02XD</span> is a billable ICD-10-CM diagnosis codeW56.02XD…… subsequent encounter
<span class="identifier">W56.02XS</span> is a billable ICD-10-CM diagnosis codeW56.02XS…… sequela
W56.09Other contact with dolphin
<span class="identifier">W56.09XA</span> is a billable ICD-10-CM diagnosis codeW56.09XA…… initial encounter
<span class="identifier">W56.09XD</span> is a billable ICD-10-CM diagnosis codeW56.09XD…… subsequent encounter
<span class="identifier">W56.09XS</span> is a billable ICD-10-CM diagnosis codeW56.09XS…… sequela
W56.1Contact with sea lion
W56.11Bitten by sea lion
<span class="identifier">W56.11XA</span> is a billable ICD-10-CM diagnosis codeW56.11XA…… initial encounter
<span class="identifier">W56.11XD</span> is a billable ICD-10-CM diagnosis codeW56.11XD…… subsequent encounter
<span class="identifier">W56.11XS</span> is a billable ICD-10-CM diagnosis codeW56.11XS…… sequela
W56.12Struck by sea lion
<span class="identifier">W56.12XA</span> is a billable ICD-10-CM diagnosis codeW56.12XA…… initial encounter
<span class="identifier">W56.12XD</span> is a billable ICD-10-CM diagnosis codeW56.12XD…… subsequent encounter
<span class="identifier">W56.12XS</span> is a billable ICD-10-CM diagnosis codeW56.12XS…… sequela
W56.19Other contact with sea lion
<span class="identifier">W56.19XA</span> is a billable ICD-10-CM diagnosis codeW56.19XA…… initial encounter
<span class="identifier">W56.19XD</span> is a billable ICD-10-CM diagnosis codeW56.19XD…… subsequent encounter
<span class="identifier">W56.19XS</span> is a billable ICD-10-CM diagnosis codeW56.19XS…… sequela
W56.2Contact with orca
W56.21Bitten by orca
<span class="identifier">W56.21XA</span> is a billable ICD-10-CM diagnosis codeW56.21XA…… initial encounter
<span class="identifier">W56.21XD</span> is a billable ICD-10-CM diagnosis codeW56.21XD…… subsequent encounter
<span class="identifier">W56.21XS</span> is a billable ICD-10-CM diagnosis codeW56.21XS…… sequela
W56.22Struck by orca
<span class="identifier">W56.22XA</span> is a billable ICD-10-CM diagnosis codeW56.22XA…… initial encounter
<span class="identifier">W56.22XD</span> is a billable ICD-10-CM diagnosis codeW56.22XD…… subsequent encounter
<span class="identifier">W56.22XS</span> is a billable ICD-10-CM diagnosis codeW56.22XS…… sequela
W56.29Other contact with orca
<span class="identifier">W56.29XA</span> is a billable ICD-10-CM diagnosis codeW56.29XA…… initial encounter
<span class="identifier">W56.29XD</span> is a billable ICD-10-CM diagnosis codeW56.29XD…… subsequent encounter
<span class="identifier">W56.29XS</span> is a billable ICD-10-CM diagnosis codeW56.29XS…… sequela
W56.3Contact with other marine mammals
W56.31Bitten by other marine mammals
<span class="identifier">W56.31XA</span> is a billable ICD-10-CM diagnosis codeW56.31XA…… initial encounter
<span class="identifier">W56.31XD</span> is a billable ICD-10-CM diagnosis codeW56.31XD…… subsequent encounter
<span class="identifier">W56.31XS</span> is a billable ICD-10-CM diagnosis codeW56.31XS…… sequela
W56.32Struck by other marine mammals
<span class="identifier">W56.32XA</span> is a billable ICD-10-CM diagnosis codeW56.32XA…… initial encounter
<span class="identifier">W56.32XD</span> is a billable ICD-10-CM diagnosis codeW56.32XD…… subsequent encounter
<span class="identifier">W56.32XS</span> is a billable ICD-10-CM diagnosis codeW56.32XS…… sequela
W56.39Other contact with other marine mammals
<span class="identifier">W56.39XA</span> is a billable ICD-10-CM diagnosis codeW56.39XA…… initial encounter
<span class="identifier">W56.39XD</span> is a billable ICD-10-CM diagnosis codeW56.39XD…… subsequent encounter
<span class="identifier">W56.39XS</span> is a billable ICD-10-CM diagnosis codeW56.39XS…… sequela
W56.4Contact with shark
W56.41Bitten by shark
<span class="identifier">W56.41XA</span> is a billable ICD-10-CM diagnosis codeW56.41XA…… initial encounter
<span class="identifier">W56.41XD</span> is a billable ICD-10-CM diagnosis codeW56.41XD…… subsequent encounter
<span class="identifier">W56.41XS</span> is a billable ICD-10-CM diagnosis codeW56.41XS…… sequela
W56.42Struck by shark
<span class="identifier">W56.42XA</span> is a billable ICD-10-CM diagnosis codeW56.42XA…… initial encounter
<span class="identifier">W56.42XD</span> is a billable ICD-10-CM diagnosis codeW56.42XD…… subsequent encounter
<span class="identifier">W56.42XS</span> is a billable ICD-10-CM diagnosis codeW56.42XS…… sequela
W56.49Other contact with shark
<span class="identifier">W56.49XA</span> is a billable ICD-10-CM diagnosis codeW56.49XA…… initial encounter
<span class="identifier">W56.49XD</span> is a billable ICD-10-CM diagnosis codeW56.49XD…… subsequent encounter
<span class="identifier">W56.49XS</span> is a billable ICD-10-CM diagnosis codeW56.49XS…… sequela
W56.5Contact with other fish
W56.51Bitten by other fish
<span class="identifier">W56.51XA</span> is a billable ICD-10-CM diagnosis codeW56.51XA…… initial encounter
<span class="identifier">W56.51XD</span> is a billable ICD-10-CM diagnosis codeW56.51XD…… subsequent encounter
<span class="identifier">W56.51XS</span> is a billable ICD-10-CM diagnosis codeW56.51XS…… sequela
W56.52Struck by other fish
<span class="identifier">W56.52XA</span> is a billable ICD-10-CM diagnosis codeW56.52XA…… initial encounter
<span class="identifier">W56.52XD</span> is a billable ICD-10-CM diagnosis codeW56.52XD…… subsequent encounter
<span class="identifier">W56.52XS</span> is a billable ICD-10-CM diagnosis codeW56.52XS…… sequela
W56.59Other contact with other fish
<span class="identifier">W56.59XA</span> is a billable ICD-10-CM diagnosis codeW56.59XA…… initial encounter
<span class="identifier">W56.59XD</span> is a billable ICD-10-CM diagnosis codeW56.59XD…… subsequent encounter
<span class="identifier">W56.59XS</span> is a billable ICD-10-CM diagnosis codeW56.59XS…… sequela
W56.8Contact with other nonvenomous marine animals
W56.81Bitten by other nonvenomous marine animals
<span class="identifier">W56.81XA</span> is a billable ICD-10-CM diagnosis codeW56.81XA…… initial encounter
<span class="identifier">W56.81XD</span> is a billable ICD-10-CM diagnosis codeW56.81XD…… subsequent encounter
<span class="identifier">W56.81XS</span> is a billable ICD-10-CM diagnosis codeW56.81XS…… sequela
W56.82Struck by other nonvenomous marine animals
<span class="identifier">W56.82XA</span> is a billable ICD-10-CM diagnosis codeW56.82XA…… initial encounter
<span class="identifier">W56.82XD</span> is a billable ICD-10-CM diagnosis codeW56.82XD…… subsequent encounter
<span class="identifier">W56.82XS</span> is a billable ICD-10-CM diagnosis codeW56.82XS…… sequela
W56.89Other contact with other nonvenomous marine animals
<span class="identifier">W56.89XA</span> is a billable ICD-10-CM diagnosis codeW56.89XA…… initial encounter
<span class="identifier">W56.89XD</span> is a billable ICD-10-CM diagnosis codeW56.89XD…… subsequent encounter
<span class="identifier">W56.89XS</span> is a billable ICD-10-CM diagnosis codeW56.89XS…… sequela
Do you get paid more to stitch up an killer whale (orca) bite than a sea lion bite? How does this information improve patient care in the future as stated by the panting IT guy? Will there be required signage on a beach that says “Caution: orcas are 19.75% more likely to bite you than dolphins. Stay clear of orcas.”?
ICD-9 codes numbering at 17000 was bad enough, but 144000 is clearly over-the-top.
This one is also so very necessary here in Florida:  2012 ICD-10-CM Diagnosis Code V91.07XA: Burn due to water-skis on fire, initial encounter.

According to the poster, every form, every procedure, every contract has to be changed to conform to the new rules. Everyone has to be retrained. I love the part where the coding clerks are required to have “a more detailed knowledge of anatomy and medical terminology”. And the nurses have to “revise or recreate every order”. Sure, they have time for that.

Here is a good one, in light of the fact that the government can’t get its shit together with current new guidelines and hasn’t paid our little clinic yet this year for any Medicare or Medicaid bills we turned in,(also note ICD-10 has been delayed due to its cumbersomeness, but when the government says GO! there can be no delay on your part!). The poster states “changes to software, training, new contracts and paperwork have to be paid for.” By whom? The individual provider, of course.  A report by a Nachimson Advisors Study shows that on average, the costs of transitioning to ICD-10 were as follows: Small practice (3-9 physicians) = $83,000, Medium practice (10-99 physicians) = $285,000, Large practice (100+ physicians) = $2.7 million.

There comes a time in each person’s mind when they are just overwhelmed and stop giving a crap.

This will do it.

And all I want to do is take care of patients. I wish the politicians and IT guys would walk a mile in our shoes.


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One of the hardest things to do when starting a new job, is to get a handle on the office politics. The difficulty level is higher when there is a large group of physicians, other mid-levels and a large assortment of assistants and office personnel. Add some new services being set up and the mix gets a bit volatile.

I have never been a real political person, so I would have had a real problem with all of this only a few years ago. After the rigors of post-graduate education, and the “Project”, it seems that I have developed some new skills in dealing with the politics, and a higher level of personal confidence. So far, things are going relatively smoothly, and I am learning who the movers and shakers are, how to keep myself in the loop, who are my allies and which people I need to be careful around.

All in all, considering the amount of people in the practice and the sheer amount of patients seen and procedures done, this three-ring circus operates quite smoothly, and I am feeling more comfortable each day in my new role. We are settling into our new community, making new friends and enjoying the outdoor activities and beautiful surroundings we have here. There is a 43 mile long bicycle trail which runs past lakes, parks, and forest near by which we are enjoying each weekend. Life is good.

I need a new bicycle…

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A classmate who is a term ahead of me, (well actually she has just graduated and passed her certification exam, too) told me that when she first opened the instructions for the scholarly project, she almost threw up. When I first read the instructions, I felt the same way. It is like a thesis in a nutshell. What doctorate students do in acouple of years, we get to do in 15 weeks. Kinda like reading Harrison’s in 15 weeks (2880 pages)…

Our first assignment was to post our understanding of what the project is:

My understanding of this project is that we are to:
1. Identify and research an issue related to family practice which can improve health care in some way, by changing a protocol or creating an educational tool for patients, as examples.
2. Research this topic through an extensive literature review to determine the latest and best information on this topic, and give reasons why the topic is important and appropriate. We will describe in detail how and where we found the information, and analyze the studies using a research matrix to organize and make sense of the findings, and write a report of the research findings.
3. Use the information to develop an intervention such as a protocol change, an educational tool or presentation or evaluation tool, etc., using a theoretical framework appropriate to the topic. We will find established or create new tools for measuring the outcomes of the intervention plan.
4. Implement this plan and evaluate its effectiveness or impact using the measurement tools.
5. Make a comprehensive presentation of the topic by writing a scholarly paper.
6. Present the entire project to the class via a powerpoint presentation
7. Provide feedback to our classmates throughout.

Oookaaaaay…..I know I can, I know I can…just call me Thomas the train.

Well, they say you can eat an elephant if you do it one bite at a time…

So the first bite is deciding on the topic after voluminous research including only primary sources. Primary sources include clinical trials, case controlled studies, etc. Lots of digging through databases including Med Line and CINAHL, reading about correlation, significancy, variants, samples and cohorts, analysis with various esoteric formulae. A little light reading,  hahaha.  All those mad scientists out there love to write up their research in a way to make you crazy yourself trying to figure it all out.

Okay, one bite at a time, what will my project be about? Let’s try diabetic feet.

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So, Christmas is done, the presents opened, Christmas dinner consumed, friends and family visited and partied with. Only New Year is left and then back to clinicals. My dogs have enjoyed the extra treats, opened their presents, removed squeekers from the stuffed ferret, though the hedgehog still has its grunter intact. They still look longingly at the tree, hoping for more goodies.

There is more....isn't there?


I am quietly sitting in my favorite chair, working on an appliqued quilt block. The Fitzgerald study book is laying on the table, causing little rushes of guilt about not studying. I am going to be seeing a whole new type of patient (adults) and am getting the usual feeling of “oh crap, I don’t know anything” again.  After the last rotation in pediatrics, though, it is a little less. It is nice to realize that there is still some room in the old brain to acquire knowledge and experience, and that after an initial period of insecurity, things will look up. I am told that my new preceptor loves to teach, so I am looking forward to a rewarding experience.

There are only eight months left until I graduate. I am hoping to get a couple of trips in after graduation and before I start a new job. My family is in Europe, and one of my best friends, so a trip to Denmark and Holland is planned, and I would also like to see some friends in Pennsylvania and a friend in New England who has a puppy from one of my dogs.

I can actually believe I will be getting a life again. And a career that isn’t a disease (hopefully). Being an RN has been a wonderful thing, but health care going the way it is, the jobs were getting tough to do. Too much paperwork, not enough respect or time to be with patients and actually do nursing. When I graduated nursing school, RNs still made beds, bathed and fed patients. There was an enormous amount of clinical information you could gather from those simple tasks, which I felt were vital to doing a good assessment on your patients. I feel sorry for RNs now, who are responsible to assess their patients with information obtained from “patient care technicians” with a few weeks training, or a quick run in and out of a room to pass meds. That is scary to me. I hope that this trend reverses, for the sake of the patients and the overstressed nurses trying to care for them. I hope that hospitals and nursing homes realize that the heart of their service is nursing, and treat the nurses with the respect they are due and allow them to do their jobs by giving them reasonable workloads and time to do their jobs properly.

Hopefully, being an NP will be different, with some of the same paperwork headaches, but with more responsibility, challenge and patient care focus. I am looking forward to a happy and rewarding career with the opportunity to use my nursing skills to the fullest. I don’t plan to retire until I physically can’t do the job anymore, and hopefully that will be at 99 years old.

Now, I just need to get through the next eight months, and pass my certification exam…

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My shopping trip went well and I actually found some decent clothes at a store where my size was the smallest, but the clothing was cut to actually be comfortable and stylish. Sweet.

So, off I go to the pediatrician’s office in my new duds, only to find out it was casual Friday and everyone was in capris and jeans. Oh, well, better dressier than scruffier. I was introduced to the staff and my preceptor-to-be, everyone was very nice and welcoming. I started feeling better about my future already.

We spent the morning looking at rashes (ptyriasis, saw it in the book. Now, it means something and I will recognize it in the future), lots of cranky babies with sore ears (it turned out to be ear infection day), diaper rash, a strep throat, 3 well baby checks and teens with headaches (2). This office did everything on computer, it was actually pretty user-friendly, and efficient.

Out to lunch with everyone in the office, and three more patients in the afternoon. My preceptor stated it was a slow day.

End result: I actually was remembering things when I saw the patients, got to see tympanometry and insufflation, and learned a lot in just one day. What fun. I think I can actually do this! Yes!

And yes, you do get to see what the presenting complaint is before you go in, and you do get a chance to formulate a plan. Okay, I’m cool with all of this.

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So, this morning I wake up with some weird pressure in my head, I am dizzy and listing to the right, the nausea center in my brain vestibule fully activated. What the heck. Of, course what if’s are running through my head: brain tumor, stroke and numerous other nefarious conditions. I stagger around waiting for the feeling to pass, but it seems to not want to subside so fast. So, of course I resort to surfing on the computer so as to keep my head still.

I find a blog called “1000 Awesome Things”. Okay, I am immediately contrite. What a whiner I have been. Focused on how I don’t feel like studying CHF and PVD and CAD, and definitely don’t feel like taking a test, which is due today. People are writing in to comment on the blog entries in “Awesome Things” telling their stories of cancer and loss and seeing the good stuff in life in the middle of terrible adversities. My problem is just tiredness.

What is an awesome thing I can come up with right now as I sit here in my spinning room? Well, it has to be my husband. He has done the housework and cooking I don’t have time to do, cheered me up when things seemed insurmountable, made do with massively decreased time with his wife in the name of studying, was always there for me and brags about me to everyone he meets. What an awesome husband he is, and an awesome friend. I really couldn’t do this without his support.

This morning he made me coffee and said “It has to be pressure from your sinuses, take your antihistamine”. He’s right of course. Summer has officially hit Florida and you need a snorkle to breathe the pollen-enriched steam we call air. Antihistamines are essential for survival. I just realized I forgot to fill my little vitamin/anti-allergy pill box for the week, and went without for two days. I’m a dummy. So, one antihistamine coming up (second-generation non-drowsy formula, of course) and I will hit the books and take my test. Wish me luck, I heard it was tough.

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In Philadelphia is an area called Manayunk. In Manayunk is a long, steep hill called the Wall. Bicycle races go through Manayunk, and the Wall is the place where many riders quit and pull out.

Foto by Mark Sharon

I have hit my Wall. This does not mean I am quitting, but I am absolutely struggling. There is no more room in my brain, no more facts can be stuffed in. The No Vacancy sign is lit.  This is only a few weeks after “Harrison’s Principles of Internal Medicine” arrived on my doorstep (along with three other books). Harrison’s has 2754 pages, not including a half inch of Bible-thin pages containing all of the appendices. It weighs 9.5 pounds, I weighed it.

 A friend of mine’s husband is a physician. He made a comment about taking three years to get through Harrison’s and we have 15 weeks. Is this realistic? Our teacher glibly stated we weren’t expected to read the whole thing, but our assignment for this week is “Read Section 9”.  214 pages. Quiz by Sunday. Crap. I tend to be a type A when it comes to grades and school work. I want to do it all right, get fantastic grades, be top of the class. Hah, I feel mediocrity slipping in, my motivational level is zero. I had hoped to get out a couple of days and just observe an NP at my first rotation site, but haven’t heard back yet. The idea was to see and remember why exactly I chose to do this.

 I try to remember the excitement I had when my doctor, who is going to be my preceptor for the last term, showed me “my” exam room. Right now, all I want is a nap…maybe a bucket of Starbucks, does that come IV?

Keep pushing, keep pedaling, the Wall will end at some point, I will break through, I will make it. And some people have the nerve to say nursing education is easy.

Wake me up in 20 minutes, maybe some stuff will have fallen out of my brain closet to make room for more.


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