Of NARH and NARS

The title will make sense later. Trust me.

As I’ve mentioned before, I split most of my residency training time between two hospitals: a large tertiary care center that has all the bells and whistles, and an understaffed county hospital that on occasion struggles to perform basic functions of a healthcare facility, such as checking routine vital signs or (spoiler alert) admitting patients.

I refer to this latter hospital as NARH, in honor of a favorite ICU attending who screamed on the phone, “THIS IS NOT A REAL HOSPITAL” at 2 am during one of my now-famous thirty-hour call nights.

(Seriously, I have the bad kind of fame for these calls. Nurses and medicine residents I have never met are afraid of my name.)

Contrasting the two sites is a favorite pastime for our residents. For example, my tertiary site has an entire ICU devoted to liver transplant recipients. An entire ICU! My county site sometimes has the ability to dialyze patients in renal failure, but sometimes it does not. My tertiary site’s cafeteria has six different food stations, an impressive salad bar, rotating healthy meal options, and a real Starbucks. My county site has a guy named Alfredo who makes breakfast burritos.

PS: lest you think I am exaggerating, not a single word of the preceding paragraph is even a slight embellishment. And to be fair, they are excellent burritos.

Last year, our nurses’ union at my tertiary academic site elected to go on strike. It was a bit of a weird strike in that it was announced far in advance and had both a start and an end date: the strike was to last three days, and the union leaders published quite clear guidelines for who exactly was not expected to show up to work.

The hospital system had weeks to prepare. In addition to continuing negotiations, the administration hired traveler nurses to fill gaps in coverage, kept us updated throughout, and generally tried their best to continue to provide patient care.

When the strike happened, life was a little more challenging and we had to make do with less. In general, though, we continued to function as a real hospital and provided real medical care.  Everything went back to normal in a couple of days.

This year was a very different story.  A few weeks ago, we heard from our medical director at NARH that the nurses were going to go on strike. In response, the powers-that-be at NARH elected to not hire replacement nurses; instead, they chose to try and discharge the entire hospital in anticipation of not having any nurses for a while.

Yes. You read that correctly. Instead of even pretending to be a functioning hospital, we essentially said “welp, guess everyone has to go home.”

This created interesting problems for the emergency department. As frequent readers of this site know (hi Grandma), the ER serves as the clearinghouse for all admissions. Unfortunately, we were essentially prohibited from admitting all but the sickest, most unstable patients. At NARH, the average acuity in the ER is pretty low, so we discharged basically everyone. If someone absolutely had to be admitted, we transferred them to area hospitals.

Suboptimal, but doable… right?

Well, not quite. NARH signed mini-contracts with all these area hospitals where we would pay for the patient’s stay, allowing us to transfer them out. They forgot, however, to include physician’s fees in these memoranda. So while the hospitals were happy to take our patients, we had a challenging time finding accepting doctors, since they weren’t going to get paid for the admission.

This is why I continually refer to this place as NARH.

For the week leading up to the strike, we essentially functioned as an urgent care with a CT scanner. Anyone who was well enough to go home went home, and those who were not… got sent to other emergency rooms.

Anyone we tried to admit had to go through an extra-stringent version of an existing process called “Utilization Review,” or UR.  At NARH, UR is a group of nurses that review all requests for admission from ER doctors (i.e. me) and then call us to tell us that the patient is not allowed to be admitted because they are not sick enough. This kicks off a negotiation between myself and the UR nurse that goes like this:

UR Nurse: Doctor, your patient does not meet Interqual [our word for admission criteria, because saying ‘admission criteria’ is probably not 100% legal].
Me: This patient coded in the lobby.
UR nurse: The system is telling me that “coded in the lobby” is not on our checklist.
Me: She had no pulse, we did CPR and we brought her back to life. I can’t discharge her. What if I write in my note “patient needs admission for IV antibiotics?”
UR nurse: That might work.

This is, astoundingly, normal for us at NARH. We learn over the years what catchphrases trigger the magic green box that says “MET” on our trackboard.

The pushback from UR got much worse during the pre-strike.  All of my usual strategies for meeting Interqual became moot. The normal tactics of “patient needs IV antibiotics” or “multiple rounds of intravenous pain medication have failed to control the patient’s pain” failed. These sentences in my note no longer met Interqual.

As House of God says, we had collectively turned into a WALL, blocking all new admissions. We probably should have put up this sign I found on the internet but it’s an EMTALA violation.

(i.e. not NARH)

We also received a message from our medical director telling us we residents would be expected to perform some duties normally done by a nurse, such as starting IV’s, administering medications, and pushing patients ourselves to radiology for imaging studies.

This seemed to me great fun. For starters, I do not know where radiology is. I imagined myself freewheeling a patient’s bed around the hospital at 3AM, aimlessly in search of the alternate CT scanner (the main one is usually down for maintenance. It’s NARH).

Also: there are fifty-plus residents in the program at present. I can think of maybe five or six off the top of my head that I would trust to start an IV on me without the help of an ultrasound.  This was going to be terrific!

The strike was scheduled to begin on a Tuesday evening at midnight. By Sunday afternoon, I spotted the medicine teams wandering aimlessly around the hospital, taking three-hour lunch breaks and going home at 2PM. One of them admitted to playing hide-and-seek.

Whole floors of NARH were empty. The only unit functioning normally was the ICU. And if you recall, “functioning normally” and “NARH ICU” are oxymorons to begin with.

I was scheduled to work that Tuesday morning. Honestly, I was kind of interested to see what would happen to an emergency room with no nurses, residents starting all the lines, and everyone running around like the place was on fire.

Checking my email on awakening, the first thing I saw was the title: “STRIKE IS OFF!” Apparently the union reached a deal at the last second the night before.

Not a real hospital, not a real strike. Now it all makes sense.

3 thoughts on “Of NARH and NARS

  1. dear nathan, i cannot stop laughing at your blog! yes, im glad we both read HOUSE OF GOD because he shows how important humor is -especially in a hospital.

    this book you are writing should be published so all can enjoy . it could be compulsory reading for future medical students.

    look for a box arriving soon. will someone take it in ,in case its comes after you leave town?

    cant wait to see you . love,grandma >

  2. Pingback: Not My Hill | crashing resident

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