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Just Plain Ruff

ok, so my son is in cubscouts. He wants the scholarship but the only way to meet his goal which the scholarship is 2500.00 in popcorn sales, is to hit up everyone of our friends, neighbors, relatives and whoever else he want's to sell to.

I find that a pain in the butt because people seem to feel like they can't say no. I've said no enough but only because money is so tight.

I put this here because I'm offereing online popcorn ordering but only if you agree to have an email sent to you with the popcorn sale link.

If you want a popcorn item or want to purchase popcorn to support my son and his cub scout pack, please email me at ruffems@gmail.com

I will send you a link to my son's popcorn ordering page and you can order online and have it shipped directly to you.

No pressure. Just voluntary if you want to get some pretty dang good popcorn if I do say so myself.

if you would consider purchasing popcorn to send to the troops overseas, you can choose the two Military popcorn options, 50.00 and 35.00 Both of these items gets popcorn in that amount sent to the military serving overseas as well as domestically.

Thanks for listening and reading.

Just Plain Ruff

Ok, this is a rant. Left Tallahassee florida today with what I thought was at least 400 dollars in the account.

Drive to Ocala florida and stop to get something to eat and a bit of cash out of the ATM. The ATM kept disconnecting and I did get my food.

I then made it about 50 miles down the road and found a small convenience story, Love's if anyone knows them.

Tried to take out cash, said insufficient funds. Turns out the bank was 800+ overdrawn.

Called the wife to have her check the account and it turns out Avis had put a hold on my account for my rental I was driving for 432.00 and they charged me again the same amount 3 minutes later. So I'm now having over 800 dollars being held by AVis.

I was able to make it to Orlando with the gas I had, I then filled up (yes I was able to do that) and I got some food.

I try to check into the hotel now in Orlando and they say the card was declined so I had to go set up a rewards stay to be able to stay here in the hotel.

I called Avis, they said that they only charged me once. I said differently. They say nope they charged it only once.

I now have to argue with Avis tomorrow morning to get the hold reversed.

I'm tired, frustrated and mainly pissed.

That is all.

On a positive note, the night manager gave me a beer.

Just Plain Ruff

ok, I love barbeque. I love it. Can never have too much barbeque if it's done right.

I went to Sonny's bbq today during lunch. All was superb except the mild sauce, not my taste preference. The sauce just didn't tickle my taste buds.

What happened after lunch is what pissed me off.

I put 10.00 for a 7.82 meal. I tip good if the service is good.

I walk out, get in my car and the waiter runs out to my car saying I hadn't paid.

I told him I had and that I left a 10.00 bill on the tray with the receipt.

He said I didn't and asked me to come back inside.

I did. I showed him where I put the money and the tray was empty.

I argued the point that I had paid. The manager disputed it.

I said I'm not going to put any more money down. I said that either the waiter wasn't honest which I believe him to be honest or one of the scum sucking patrons that sat in the next booth took the money.

I said this loud enough for those aholes to hear me and none of them spoke up. I used that as evidence that one of them had taken it plus they were laughing.

I told the manager to call the cops as the 10 dollar bill had a specific marking on it.

The police arrive, the management would not allow any of the patrons near the table I sat at leave the restaurant.

Well needless to say, one of those dumbtards fessed up that his friend took the money. The officer did a frisk of the offending dumbtard and guess what - he got arrested for theft.

Now I have a court date in 6 weeks or whatever to be a witness. There's no guarantee that I will still be in this city or will be in another city at a different client.

The restaurant did give me the meal for free. I got my money back. I did give the waiter 3 in a tip.

for it wasn't his fault this happened.

Kudos for the local police to take this seriously, kudos for the restaurant manager for being a standup guy.

Screw you to the shithead who tried to make off with an extra 10 bucks.

Even though I don't like the sauce, I'm returning to that restaurant and using a credit card next time.

Just Plain Ruff

I have been doing some reflecting and thinking and if bathroom talk offends you then stop reading.

There is this one bathroom near the office that I work in in Lakeland Florida

It's a relatively busy office and hallway.

It's the only bathroom in the entire hallway and nearby area.

Why can I go to the bathroom and go pee every single time and nobody will come into the bathroom while I'm peeing. But when I'm trying to take a crap in private because nobody likes to hear someone in a public bathroom farting or making disgusting noises when the poop comes out. Why when I'm taking a crap does this bathroom suddenly become grand central station?

Take yesterday for example, Being a diabetic I go pee a lot what with the medications I take and then the amount of fluids (soda and water) I take in makes me go pee a lot. I pee'd over 10 times yesterday and not once did anyone come in the bathroom.

Well Metformin makes my stools quite loose sometimes and yesterday was just one of those days. Each time I went to go poop the freaking bathroom became a area of multiple arrivals. At one time there were 3 others waiting for the urinal and who knows who was waiting for the toilet. I don't understand it.

Does this mean anything in the grand scheme of things, nope but I can't help but wonder if there isn't a segment of society that has to go to the bathroom when they see me walk in the bathroom?

Just Plain Ruff

Blessed Redeemer by Casting Crowns

Up Calvary’s mountain one dreadful morn

Walked Christ my Savior, weary and worn

Facing for sinners death on the cross

That He might save them from endless loss

Blessed Redeemer, precious Redeemer

Seems now I see Him on Calvary’s tree

Wounded and bleeding, for sinners pleading

Blind and unheeding, dying for me

“Father, forgive them,” my Savior prayed

Even while His lifeblood flowed fast away

Praying for sinners while in such woe

No one but Jesus ever loved so

Dying for me

Oh how I love Him, Savior and friend

How can my praises ever find end

Through years unnumbered on Heaven’s shore

My songs shall praise Him forevermore

This song says it all. I can't imagine what Christ went through during his trek to Calvary's Tree but it had to be more than anyone that I know of or anyone out there at all could bear.

To be more like Christ, I try to be but this just humbles me.

Just Plain Ruff

Throughput and bogdowns in the Emergency department Part 1 Recently I spent some time with a good friend Kourtney Govro of SphereOne out of

Kansas City, Kansas and some members of her company discussing Emergency departments and what their biggest challenges are relating to throughput. What causes the most headache causing bogdowns and system halts? This by no means was an easy task nor did we decide we had all the answers. What we did decide is that whoever can leverage the knowledge of how to reverse or fix the bogdowns seems to have the market to themselves. We decided to focus on the top 5 throughput areas and what can be done to fix the slowdowns. Today I will focus on one of those areas and give some concrete ideas on how to begin to address the fixes. Like any ED in the country, understanding the slowdowns is one thing, putting the fixes into place, is definately another. I will focus on the area of triage as one of the biggest slowdowns in the Emergency department. First a definition of triage is in order. Triage: sorting and allocating aid on the basis of need for or likely benefit from medical treatment or food (wordnetweb.princeton.edu/perl/webwn)

The military which is the originator of the triage system as we know it today puts triage down as this: evaluation and classification of wounded for purposes of treatment and evacuation; immediate sorting of patients according to type and seriousness of injury, and likelihood of survival, establishment of priority for treatment and evacuation.

www.army.mil.nz/footer-links/about/glossary.htm

For the typical emergency department, triage is the way that patients are classified according to severity to facilitate the flow of those said patients through the emergency department with the least possible interruption of said care. Wordy definition which one can boil down to these simple words - allowing the sickest to be seen first. Slowdowns revolving around triage seem to fit this mold. One triage nurse for many ill patients. The bogdown occurs as follows. Patient A arrives to the ER with a complaint of an illness. That triage nurse will bring patient A into the triage area (usually a private room reserved for triage purposes) and will begin to ask all the pertinent questions. Depending upon which triage system you use the patient will be triaged to either ESI level 1 through 5 or the 5 categories of triage (Emergent, Urgent, Non-urgent, Catastrophic or None - these seem to be military based for the last two) but for sake of argument they could be classified as Emergent, Urgent and non-urgent. Assume that some departments will add a category or two such as Critical or Semi-urgent. Whatever triage system you use, you expect it to work the same way. The bogdown occurs when multiple patients come in at the same time or within a short period of time and your single triage nurse cannot keep up. So what do you do? The simple answer would be to add another triage person to lighten the load. Sounds simple but is it truly the right thing to do? Do you staff that 2nd person 24 hours a day. There may just be a few times during the day that require a second person.

What are some of the other alternatives?

Here is what some of my discussions with others in the field have told me.

1. Provide alternative patient registration models. Do you require a number of questions that have to be asked of every patient or can you streamline the questions to a certain few. Do you really need to capture in triage the last time they had a flu shot or pneumonia shot? Do you really need to capture the last time they were seen by a physician? Can these questions be better asked elsewhere in the patient treatment process. What questions are the minimum types of questions on the triage form. The minimum number of questions that should be asked on the triage evaluation will be the number that makes sense to your organization. Taking out even 1 or 2 questions could decrease the time spent on triaging each patient. By all means, do not remove questions just to remove them. The removal has to make sense.

2. Do you open a secondary department for the clinic style patients? The ones who meet ESI level 4 and 5. Can they safely be moved to a off site clinic that can better meet their needs. If your department is overwhelmed with ESI level 4 and 5 patients at certain times of the day, what is the option of opening a fast track and or minute type clinic. These patients would still have to be triaged but once the nurse determines that there are no life-threats and no injuries that would require the full focus of the emergency department then those patients could safely be moved to another style clinic or treatment area that would be better suited to take care of them. This all depends upon cost and space constraints but one suggestion put out there is to take one of your ER non-urgent rooms and make it a fast-track room. Staff with a PA or a NP and a nurse and you effectively have added a possible decrease of triage bog-downs.

3. Are there triage protocols in place? Can the patients who meet certain criteria be triaged out to their physicians office. A patient who presents with a cough or cold like symptoms having been going on for a week more than likely meets the criteria to be seen in their personal physician’s office. The caveat here is what does their personal physician say about this thought process. In the emergency departments that I’ve worked in, the patients that fit this criteria are at the emergency room because their physician cannot get them in on that day.

4. Who do you allow to perform the triage exam? Do you require a nurse only or can other staff members such as LPN’s or Paramedics. This goes directly against what some of the professional nursing groups say is a national standard but can you train your LPN’s or Paramedics to ask the same questions every time, go down the same criteria list each time and can those ancillary staff members do as good a job as nurses can. If your organization is comfortable enough to allow those types of staff members to perform triage you can effectively staff two lower level staff members for the price of one nurse. Not a popular idea in many areas but take if from the author here, it can be done, it can be done well and it can be done with minimal if no adverse effects on patients. Our facility has been using paramedics and LPN’s and even EMT’s to triage patients for years and it truly does work well.

5. Immediate Bedding. For the times that your ER is not busy, do you rely on the triage nurse to triage everyone or can that triage nurse immediately bed a patient and have the staff nurses in the ER begin the treatment. Consistently the immediate bedding has shown in patient surveys that this is a good thing. The triage nurse can quickly do the triage and initial registration or quick-reg and then return to her duties in the triage area awaiting a new patient. If the triage nurse is on break or in the bathroom or getting a drink, do your nurses in the ER go get the patient and bring them back to a bed if one is available or do they tell the patient to “Fill out the form and someone will be with you in a few minutes”? Immediate bedding of all patients is a easy way to increase patient satisfaction(the patient believes they are being seen right away), a decrease in the triage area and a decrease in the length of time that they have to wait to be seen or treated. This is a win-win situation for all.

There are many more variables which affect patient throughput throughout the emergency department.

On a future blog I will continue this discussion on the triage process and how can we improve the speed in which patients get triaged and put in a room. What are the minimal number of questions that should be asked on a triage questionnaire? What triage system should be used? Future blogs will also focus on how to help physicians increase their throughput and how to increase satisfaction of the patients by implementing certain technological advances or gadgets.

Thank you for

Reading.

The author, Michael N. Ruff EMT-P, MPM has over 17 years of emergency department experience with direct patient care in the emergency department for 8 of those years. Michael has also implemented the Cerner emergency department system in multiple hospitals across the country. Direct observation of these departments as well as discussions with nursing staff at those departments have allowed me to gain a insight as to what nurses and staff members want over a broad geographic area. What is remarkable is that any staff member in emergency departments across the country wants the same basic things. Nurses from Colorado Springs are not that different from nurses in Jacksonville florida nor are their needs different from nurses in New York City.

Just Plain Ruff

Tonight I spent some time in a Church in Lakeland Florida meeting one of my new favorite authors. He wrote a short book called “A Knights Quest” which has messages in it that are timely and forever. That’s not what I’m writing about though. I spent time in their bible study and this changed my outlook on things. This study tonight was the 2nd to last study in a series by John Maxwell, called “How to Empower Potential Leaders”.

Tonight was on empowering people and principals that Mr. Maxwell has developed over the years in his times being a pastor and inspirational speaker. Here is what I learned.

The leadership lesson learned tonight that focused me was this, Those close to me determine the level of my success. What you see in a person is what you get from the person. There are three essentials to lead people that are close to you. Evaluating people, equipping people and empowering people. Evaluate the person, find their abilities and then determine whether they match the needs of the organization, Equipping people is to provide the person with education and teaching along with the tools they need to help the organization and finally EMPOWER them by giving your influence over to them for the purpose of their personal growth as well as the growth of the organization.

So how do you empower someone? Maxwell gives 7 steps to empower others. Each step is denoted by the letters in EMPOWER.

1. Evaluate them. Do not empower people recklessly. Do it with purpose I in mind.

2. Model for them – people respond better to one who models the behaviour that you wish to instill in them.

3. Pray over them. If one who you are trying to empower says something to you that you feel deserves or needs a prayer, pray for them/with them right then. It’s amazing what a 30 second prayer can do to empower someone.

4. Open you life to them

5. Walk alongside them, walk their journey with them

6. Express your belief in them – tell them every day that you believe in them.

7. Release them – let them loose and run on their own.

A quote Maxwell gives is this “The person who knows how will always have a job… but The person who knows why will always be the leader.”

An empowered leader is a effective leader. Does your leader pass these tests? In Acts Chapter 6 verse 1-7 we find these 7 tests that Paul give us.

1. The influence test – Select from among you

2. I was unable to get this one written down

3. The Credibility Test – Are they men/woman of good character

4. The spiritual test – are they full of the Spirit

5. The administrative test – do they have the wisdom

6. The servanthood test – “whom may we put in charge of this task”

7. The attitude test – are they full of faith?

The three questions which must be asked in an empowering relationship. Do they have the knowledge to do what the is required and in addition, do they know why it should be done. Do they know how to accomplish what is required and are they accomplishing it? Do they have the motivation to get it done? If you cannot say yes to the above then is empowering being done?

Evaluate yourself as a empowering leader: Maxwell gives 10 questions to ask yourself as that empowering leader. These were put together on napkins and legal pads by Maxwell over the years. Rank yourself from 1 to 10. 1=never 10=always

1. Do I believe in people and feel that they are an organizations most appreciable asset.

2. Do I feel team leadership can accomplish more than individual leadership?

3. Do I pray for potential leaders and quickly assimilate them into the organization? I need to add something here – Maxwell said something that sticks with me. He said that God will send you the caliber of person based upon the size of your need. If your need is small (let’s say a level 2 need) God will send you someone of level 2 caliber. If your need is leadership in a Men’s ministry and your need is GREAT – then with prayer and God’s guidance – he will eventually send you what kind of leader you need. God does not waste his resources.

4. Do I desire to raise others above my own level of leadership?

5. Do I invest time developing people who have leadership potential?

6. Do I enjoy watching others get credit for what I taught them?

7. Do I allow others the freedoms of personality and process or do I have to be in control?

8. Do I give my influence publicly to potential leaders as much as possible?

9. Do I plan to have other take my present position? Am I willing to turn over the reign to another person?

10. Do I hand-off the leadership baton to a teammate and truly cheer for them?

What are the barriers to empowerment?

1. Job security – “What am I going to do next?”

2. Love for Position “I enjoy my role, perks, etc.”

3. Resistance to change – “I like it the way it is”

4. Lack of Confidence – “Who else can do the job like me”

5. Loss of Investment – “I’ve put too much into this organization to let it go”

6. Fear of Retirement – “Me, retire?”

7. Self Worth – “This role is my whole life”

So how do we empower people. We model empowerment to them.

“People do what people see”

“Empowerment is transferral and this first step in the process is visual. Empowerment is more visual than most things. Not what you say, but what you do. How you walk, how you carry yourself. People who empower have a sense of confidence.

What attributes do others see in an empowering person or leader?

1. Provide security – they feel safe with empowerers.

2. They are charismatic

3. They have passion

4. They are anointing

5. They have a sense of success

6. They have tremendous humility

What can we do to empower others. Number 1 thing is to Pray over them. You pray for the people you are working with and who you are empowering. Charles Spurgeon was asked about his success – he replied “My people pray for me”

Every empowerment program will begin with motives. Good empowerment programs begin with the right motives. Poor programs begin with the wrong motives.

Of course there was more to this message and study but this is what I gleaned from the 35 minute video tonight.

Just Plain Ruff

So I'm on the blog page looking at the trackbacks. On each of my blog entries there are a minimum of 400 or more trackbacks.

I go to look at the trackbacks and all of them are from some dirtbag companies that have to do with online pharmacies and narcotics. What the hell!!!!!!!!!!!

Can't we turn off those trackbacks. They make our system look like a narcotics anonymous site.

but just a vent from me.

Just Plain Ruff

Hello all, well here I am writing about pregnancy again.

Just to update all the mrs. was discharged from the hospital this past monday and she was told modified bedrest meaning not on her feet more than 5 mins and only on the couch and the bed. nothing more.

Well we thought we were doing the right things but that was not to be

She felt some tightness in her lower back and pelvis and went to have an ultrasound at the hospital. They determined her cervical thickness was equal to or less than 1 cm. That is not a good number.

So back to the big level 1 trauma center and level 3 nicu and ob department and on strict "on your back ma'am" and she can't even get up to go to the bathroom, she gets to use a bedpan. I can tell you she really does not want to go #2 at all.

So the high risk perinatologist came in and told her that it would be day by day but he wouldn't be surprised if we have a baby girl Ruffems in the nicu in less than a week.

Now my dilemma is how do I get the nursery ready, keep the house clean, feed the dog, get carpeting done for the baby's room, mow the yard and keep in tow a 6 year old who wants to play all the time and then work 4 out of every 7 days.

I'm at the end of my endurance. I will go home this morning, take a 4 hour nap from 8a-noon and then get up and get to work on cleaning out the baby's room, then will go mow the lawn and then after all that is said and done I'll have to play with a 6 year old when all his daddy wants to do is to sit on the sofa and relax and then I get to go teach sunday school sunday morning and then go to work that night.

To top all of it off, my car blew a tire and i had to change the flat on 71 highway with assholes driving in the outside lane within 5 feet of me changing the tire. If you are one of those a-holes who don't move from the outside lane to the inside lane to keep someone like me changing the tire safe, then you are lower than low. I used the bird a couple of times.

I'm logging off for the night, I'm working and i need to get some work done.

Later all. More to come.

Just Plain Ruff

Ok, for those of you who don't know this, my wife's pregnant. This for many people would not be one of those WOW WOW WOW things but if you knew our history you would know that this is truly a miracle. We just don't get pregnant like other people do.

My wife was pregnant about a year ago and she carried to 16 weeks and then the baby died.

Well now we are 23 weeks 5 days along. During the previous pregnancy we found that the Mrs. has factor 5 lytem which has necessitated heparin injections 2 times a day every day till 34 weeks. My wifes stomach is quite bruised.

This past monday we had an ultrasound to determine cervical thickness and it was 1.1cm when it should have been 3.4 or thicker. This prompted no small amount of activity by the OB doc's office. They immediately put her on her back, called the local Fire department to come get her to take her to the big guns with the perinatologist.

We had a fire truck and an ambulance to take care of someone in the doctor's office which I think is overkill but hey, I don't do the budget in that city. If I did things would be done differently but hey I digress.

She arrived at the hospital and placed in a room and she was seen by the perinatologist pretty quickly.

A sidebar to this day was that Jennifer (my wife) had to deliver a meal to a family who had just attended a funeral. My wife put together this dinner with the help of our sunday school class. I ended up delivering the meal while my wife was being transported to the hospital.

Her doctor said that she was going to get a cerclage done on tuesday and for those of you who don't know what a cerclage is, well let's just say, stitches to close the cervix. But remarkably, this went really really well.

So she is on modified bedrest for the next week and may be on bedrest for the rest of the pregnancy.

My week was busy this week but it's going to get much busier.

Just Plain Ruff

Tonight I had the transfer of a lifetime. We transferred a 654 pound patient to a specialty center 120 miles away. He was intubated, paralyzed, Diprovanned and all that.

We had the basic stretcher but it's capacity was 700 pounds so even though the cot protested the cot was able to go up and down.

Midway thru the transfer he became more agitated throughout and we ended up giving him more Vec.

I have not worked (physically) on a call like I have on this one.

My back is sore, my butt hurts, my feet hurt.

But in the end, he made it to the receiving hospital and they took him from there.

Just Plain Ruff

Apologies -

Tonight I had to swallow my pride and make an apology. Had a woman in our ER complaining of a multiplicity of complaints and we had done everything that we could do for her and we discharged her to home. She got a free cab ride out of it to home, she tried to get out of the cab and she was "too weak" to get out so she came back to the ER.

She came back in and gave the same complaint that she left with and I went out to tell her that we had done all we could for her and we weren't going to do anything else for her.

She got all pissed off and called her friend the housekeeper and he came down. They then called the nursing supervisor and she listened to this woman complain yet again about her treatment in the ER.

She also insisted on an apology from me so I go out, swallow my pride and tell her that I apologize for being rude to her and she proceeded to yell at me and say she would not accept my apology. I told her that I did apologize and all that but she wouldn't hear it. She also said she was calling the administration about my behaviour.

I told her that she could do that and I even wrote out the number and the person she needed to talk to.

I told her I apologized and that was all I could do and if she did or didn't choose to accept the apology was her issue not mine.

You know, no matter what she said to me it was ok, an apology (even when you don't mean it) costs nothing and sometimes it makes all the difference in the world. Tonight, NAH!!!!!!!! she was not going to be satisfied. So she had to find her own damn ride home, she got the cab for free already tonight.

Apologies - priceless

Just Plain Ruff

My New Endeavor

I have finished the website. It's still in the process of daily updating on what I find that is wrong or missing but for the most part the website is finished.

http://mokanfcp.webs.com

I'll be updating the website often but now it's up to me to promote the chapter. God has led me to do this and I intend to complete the task set before me.

I hope to havemany members but I'm not getting my hopes up for the first year. Word of mouth needs to be set out there and see if I can get at least 10 members.

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