Tuesday, December 7, 2010

A year gone by...

It has been a while dear readers. This has been a fine year - with new experiences, and bold/insane challenges, I have enjoyed myself. I am also tired, but finally catching up with it.

I have just finished my first stint as an official clinical nursing instructor (Thank you Tarrah), in addition to my glamorous real job. This has been an excellent experience which is great for my resume, pocketbook, and ego - but my family does not recognize me anymore. My house seems to have a life of it's own; heaving and breathing with dust and piles of laundry - clean and dirty mixed together, in the corners of every room.

At the start of the year I made some resolutions. I wanted to follow up with some of these, and also let you know some other things. First, my friends I want to let you know that I am an overachiever volunteer. You may remember my moral dilemma about whether or not I was exempt from having to volunteer additional time and money for the sake of others, since all I do is nurse the sick, wipe their asses, cry with their families, and fight against administrative sloth and snobbery. Well, the answer the heavens gave to me, was "No, totally not exempt". I am actually not going to be fulfilled unless I dedicate a good portion of my time to enriching the lives of others - I shake my head in disbelief as I write this, as I really would like to just spend free afternoons drinking cocktails and watching movies. But, instead I coached my kid's baseball team for the spring, and volunteered as camp nurse for a week this summer, in addition to choosing not to get drunk at the school auction - and instead I volunteered as a registration/cashier person. The last one actually benefited me - as I saved $700, and was able to laugh at the drunkards, who were actually myself the year before...

Camp nursing is a lot like ICU nursing, only with lots of benadryl and ice. I was able to go for a week to beautiful Orcas Island and I read 3 novels in addition to my rigorous nursing duties. The draw was that my daughter was able to go for free, and I was able to spend an excellent week with one of my best friends as we giggled like girls, while we calmed the crying babes, and appreciated the strapping male 18 year old bodies... as an artist would of course - not like cougars... Also, the week was excellent as I got to give a series of the rabies vaccine to this kid who may or may not, have had a bat fly into his mouth when he was walking in the dark. Don't ask; only know that it was 4 intramuscular shots in a row, and the serum is hot pink - freaky!

I have not gotten more artistic, but I have made some delicious Thai curry.

TFMITW has died. He placed himself on comfort care, shortly after marrying his young Asian bride - truth is stranger than fiction, but I will let your imagination take flight here. He was stoic, and yet a child, and I said goodbye one afternoon, stroking his cheek as he wafted in and out of consciousness, sure in my soul that he couldn't actually die - but he did, three days later.

I have taken a more anonymous route with this blog, as my students are probably nosey, and may be looking for any kind of leverage. I have also been somewhat of a rabble-rouser at work. I am angry about many issues, and you know what? I won't fucking take it! We deserve a voice, and the ability to be progressive, move forward, be able to give the best care possible to our patients, and to be an actual part of the force that makes decisions for our facility. We get all the blame when things go wrong, God be damned if we shouldn't get the ability to self-govern, and have a vote - at least a little... And though I have no fear of being fired, I may try to take someone's job one day, and perhaps I shouldn't lay myself down as a martyr just yet in this forum - I mean really, I obviously still have some work to do, right?

On this note, I will inform you of my newest resolution for this coming year - Grad school. Yes, I am insane and masochistic, not to mention an absent parent, but I am compelled to do more I guess. I can not work in the same setting for 20 years, and I might as well get it over with while I have some of my youthful vitality and clever wit. This will assist me in contributing more to this online diatribe, as you will help me to promote dialogue, give me feedback, and also let me know if that's just the wine talking.

So now I offer you the title of my next entry: Palliative Care - Devil of Defeat, or Humane Patient Treatment?

Happy New Year.

Wednesday, August 18, 2010

Palliative Care - Devil of Defeat or Humane Patient Care?

The word palliative comes from the Latin pallire which means to cloak. It means to alleviate symptoms or to make something less severe. Palliative care has been a quiet movement which surfaced as patients, families, and health care workers grew more and more uncomfortable watching their loved ones suffer for the sake of healing. The idea to cure at any cost has been ingrained into the psyche of our poor doctors. They are expected to figure out what the disease is, and treat it appropriately. If that doesn't work, they try something else. This process continues until all hope is lost, and the family is informed that nothing more can be done. They then, theoretically will kum by ya at the bedside, and kiss their loved one goodbye. This is a nice process on paper, and makes sense as you read it, and yes, you may even be lured into it's simplicity, until you are the one who has to sit in that room. You sit there watching your loved one get worse and worse, lay in pain because fentanyl will cloud their mental status. They also become grossly edematous and their skin starts to weep and tear everywhere. They loose control of their bowels, and are rolled and shoved from side to side as we change their sheets and rub thick paste on their bottoms. This is really the toned down version of what we do. Honestly, I can't begin to describe some of the physical deterioration I witness on a day to day basis. Sometimes I feel like a CIA waterboarder. Patients whimpering as I roll them, begging me with their eyes to stop as I clean away the feces from their macerated skin. This is the worst part of my job - and sometimes I hate myself for it.

(I will say this disclaimer: as some poor patient deteriorates into a wretched, decomposing life form - this is not always the fault of gung ho medicine, but just crazy ass families who refuse to accept the inevitable, despite a ridiculous count of family meetings, or sometimes a blatant refusal to even visit their loved one, who they claim to care too much for to let go. Just keep them alive at any cost. This is a segway that I wanted to avoid - but stay tuned for another blogpost in the future entitled: The Whole Enchilada?)

Palliative care is in essence, the backwater cousin of modern medicine. The herbal healer compared to the Pfizer magician. In short, the roots of modern medicine that were swept under the rug as microscopes and labs replaced thousands of years of oral tradition and observation. Older medicine focused on symptom management and trying to sustain the body as it fought illness, and if the battle was to be lost, the healers provided comfort measures to extend dignity and pain management. As time has marched on, and medicine has become more complex and miraculous, the focus on medicine is now fixated on The Cure. Finding the answer at any cost, despite additional pain and discomfort. Over the past few years, the Palliative movement has been quietly growing. A sprout of revolt from standard care, which also takes into account quality of life and symptom management. It is actually the same medical picture taken from a different angle. Palliative medicine looks through the eyes of the patient and family. The brush is very broad, but covers the bases that traditional modern medicine has missed. Concepts that Palliative care investigates include:

Goals of care - Tell me about your loved one. What are your goals now? What would they be if this or this happened? Has your loved one ever talked about what they would want in this situation? How far should we go? What would you want if you were in the same position?

Symptom management - pain, nausea, vomiting, constant diarrhea, constipation, inability to eat, edema, weight loss, dementia, hallucinations, delirium, depression, anxiety, anger, fear, crazy ass family who doesn't quit, crazy ass resident who doesn't quit - they are extensive, this list could go on - I won't bore you, but you get the picture.

Patient and family support - free psychologist!

Facilitator for family meetings - actually get doctors to talk with one another - Amazing!

Interdisciplinary liaison - actually gets doctors to talk to one another - Amazing!

Spiritual Guru - Gets you to talk to, and listen to the God which has forsaken you! Lord bless a good chaplain.

As you can see Palliative Care takes into account all if those things that people really want, but are afraid to ask for. And frankly, as Palliative Medicine continues with this incredible scope of practice, it is destined for failure in many ways since it encompasses so much. This is really a philosophy that will, over time, be integrated in modern medicine. I don't blame the doctors or other care providers for not being able to cover all these bases, it is now just starting to be routine in MD training, and there are many old school Attendings who are threatened by Palliative Medicine, and sadly, are a very poor example for their young Jedi. The culture is changing however, and soon, I foresee that Palliative measures will be enacted as soon as patients walk in the door.

I was talking to a resident about his patient getting a Palliative Care consult. He asked if nurses were allowed to place the consult, and why we would do it instead of the intern. I told him quite sincerely that sometimes residents and interns are "idiots". Nurses say over and over, "this guy is super sick and going to die here; Palliative Care maybe?". Doctors say: "It is too soon to tell, we are talking to the family, it's not time for Palliative Care." Essentially, they don't want to admit defeat, and really I think they don't want to deal with sticky, emotional situations. I explained that as nurses, we deal with a lot of shit already, and while we are trying to keep a patient alive and get all of our obnoxious charting done, we are not the right people to be an effective emotional support for our families. Taking care of sick people is hard. Nursing school barely trained me to handle a bedpan, much less a grieving soon-to-be widow and her disabled daughter who brings her drunk husband and his biker friends. With all the crying, questions, begging for a miracle, and "can I get a coke, his feet look cold, why are you giving him this medication, by the way he is allergic to pollen, why is he so swollen, I don't think he would want this...." - I am spread super thin. I am awesome, but I can't deal with all that! Give me a little back-up!

Give me a liaison to the emotional realm. The phenomena of human disconnect in the ICU and hospitals in general is very interesting and will be discussed in a later essay - but the point is that in order to function in such a visceral and intense environment, nurses and health care staff must essentially "turn-off" that state of "presence" which is in tune with a family's emotional and spiritual needs. I couldn't function with all of my physical nursing duties, as well as being a genuine soft shoulder to cry on - the RAS section of my brain may literally catch on fire or something from so much overload.

"Sometimes the Palliative Care consult is a cry for help from your nurses" I tell Dr J. (Cute resident who is a boy dressed in man's clothing)

He asked aloud if it was his own ego that was offended by a request for Palliative Care. Maybe he was hesitant to order the consult because he was afraid to admit failure... (Umm, duh) Maybe was because he didn't want to look stupid in front of the other doctors...(Umm, duh).

"OK, then. When is a Palliative Care consult inappropriate?" He asks me. Together we determined a PC consult may not be beneficial when:

- You already have an excellent primary doctor, like an oncologist who knows the family well, and whom the family trusts.

- You have a crazy ass family who doesn't trust anyone, and thinks you are trying to kill their loved one anyway, and then you send in the "death team". This is the family who will believe in a miracle till the bitter end. It sucks.

- You have a very well balanced family who has excellent communication skills and is adaptable to the changing situation. (1 in a million)

Overall, I can feel the current of medicine is changing. I envision true interdisciplinary rounds where Palliative Care, social work, dietitians, pharmacists, and nurses are utilized as resources and equals with the doctors, and a holistic patient picture can be developed. It is easy to imagine, because it is how it should be; it is the only thing that makes sense - and the catch is, it would be so much easier, and would save time, money, and would encompass a real view of our patient's health and wellness.

In the hospital, we are treated only for physical distress, and spiritual crises are passed over quietly. Patients avoid talking about this as our culture does not embrace emotional needs. In the real world, we all are getting Palliative Care in one way or another. We seek out therapeutic friends, who tell us how it is. We self medicate with chocolate. We go to the doctor when we are sick. The difference is, we choose our therapies, and we know what we need when we are outside the hospital. It would be nice if our patients were allowed some alternative and satisfying options that addressed all of their human needs, not just the physical ones.

My good day is someone's really bad day - Confessions of a bored ICU nurse

Since I had too much time on my hands for most of the summer, I took time off from writing apparently. I was uninspired, bored at my job, and desperate for anything to take my mind off how sick I was of my workplace. We were a home for the chronically critically ill, and it almost drove me to insanity - I swear. I became desperate for any exciting event to happen - dreaming of car accidents, trauma hospitals, and even had been contemplating airlift nursing (that is still on my radar by the way). I started out as an ICU nurse - which has been great in many ways, but I sometimes go back to what this older ICU nurse said to me when I was graduating from nursing school: "You don't want to start out as an ICU nurse, because then you will have no where to go". I didn't really understand what she meant, until I have watched four people retire this year who had worked on my unit for like twenty years or something. Jesus Christ! Twenty years??! I know time flies, but please let me spend time away from these same dreary walls and fucked up management (No offense Nurse Manager - who has been fairly decent, and I'm not even just saying that). As I found myself increasingly dissatisfied with my work, and scouring want-ads, those nurses words came back to me, and I looked at my options.

More blood and gore; aka cool new challenges!
I could get my TNCC-Trauma Nurse Core Course, and how cool would that be? I could be in a functional ER with even - get this - a working MRI! (I think I hear angels weeping with joy).
I could also be an ambulance or airlift nurse. Or, I could get some crazy job being the nurse for some foreign dignitary, or even South American drug lords, the options are limitless! I do want my kids to be fluent in Spanish, and who doesn't want to work for the Mexican Mafia? But, my husband has already put his foot down on that one. Usually, it just comes down to the outfit, and I would look really hot in a jumpsuit like this. Admit it people...

This is option one for the bored ICU nurse; more drama and fun. (this sounds good, but I would definitely take a pay cut, and I get five weeks vacation a year - this is hard to give up. Plus, there might be little babies, and that is always hard.

Managing...to take on a whole pile of shit.

I have strong social justice issues. I can see a bigger picture at my workplace, and I see so many areas that we can improve, and it drives me absolutely crazy if I think about it too much. I know that I have strong leadership skills, and I am fortunate to have an ability to encourage groups, and make ideas happen. I am pissed that our nurses (and all other hospital staff) aren't seen for their potential, and that by increasing employee satisfaction and idea ownership, we could improve patient care tenfold. Our nurses are absolutely treated like crap at my work by the upper management. I will say this with not really a twinge of regret, because these people have no idea that I even exist. I got a fucking popsicle for nurses week (from the volunteers), and yet I take all the heat when the Joint Commission comes to town. There is minimal recognition for years of service, basically zero opportunity to participate in greater hospital decisions, and then they wonder why we can't keep staff. Maybe I am ridiculous for even thinking that there can be a better way, that we should just be happy to be working, to know that the man will never listen to the regular working people; but in my heart of hearts, I know that this is bullshit. I know that people who are motivated can accomplish anything, and that by enriching people's perspectives, we can be the best place to work, with the best patient outcomes. I have a passion for excellent patient care, and I want to bring in new research and modernization for our patients and families. I am an optimist, and I fear, dear readers, this will fade in time - especially if I go into management...
Plus, I am still in my youth, and I have energy - I am not ready for the desk job.

Hitting the books

Since I want more, and I don't just want to get stuck in the same place for twenty years, I could go back to school and get my Master's. It would buy me some time, help me make connections, and design the role that I want to have in caring for patients. I have been looking into the Clinical Nurse Leader role, and I think it could be pretty great. But, this is a very new type of position, and there is a lot of controversy about whether or not it will become mainstream. I would still have my degree though, and that never hurts. This would involve me actually reading a book that is not a sci-fi novel or vampire smut, and those are going to be hard to give up, but I might still have the summers to catch up...I have been coddled by my regular day job I suppose.

These are some of the thoughts that have been going through my head this summer. I have not written because I have been tired of being tired. Now, however, my work is indeed exciting again, and I have been able to to give really good care to challenging patients and families who have inspired me to write this and vocalize my ideas.

So, thank you for reading my thoughts, and please give any insights you have. I know that we are nothing without the inspiration of others and I am grateful for that. I am also thankful for the intubated patient who needs lots of blood and pressors, and for the fact we got him better in time for the next one coming in. Amen.

Wednesday, May 19, 2010

The last sense

I have often heard that the last sense to go is hearing. I have also heard the same about smell and touch. I don't know really what is the truth. I have experience with the end of life, and I still really don't instinctively know what people can hear or taste at the end of life. I do know that I am a fanatic about patient oral care, and that I insist on music or the white noise of CNN with my sedated patients. But, I also know that I have no real qualms with taking shop while cleaning up a code brown when a patient is sedated and intubated. There is also a never-ending joke about how in the ICU we are happy to have sedated patients when there has been a large amount of bean dip or cruciferous vegetables consumed the night before - it is easy to blame the man in the bed. I refrain from talking about a patient's condition or prognosis, but am not inhibited when discussing another nurses sex life, or what my weekend plans are. I often take personal calls in sedated person's room, and will chat while drawing blood or giving meds. I like to think the personal commentary breaks up the monotony of unyielding beeps and alarms that are part of the ICU experience.

This is probably crap, and I am a horrible person for dehumanizing my patients, and I do get paid a fair amount of money per hour, so there is really no excuse for not maintaining strict professional standards. Still saying this, I don't really buy that my people are there enough to hear everything that is going on around them. Most will wake up after they are extubated and say that they don't remember anything, and I like to think that maybe I gave them some good dreams talking about my wicked hangover, and the fun love making I (I mean my fellow nurse - of course) had the night before.

Wednesday, May 12, 2010

boyfriend update

A year or so ago I wrote a post about some of my boyfriends at work. I am sad to say that one passed away, and I am just stunned that he could actually be gone. I thought he would be around forever. He deserved a quiet demise like falling asleep after a cigarrette and a burger, and forgetting to put his oxygen back on. I will visualize that that is how he actually went.

You will not be forgotten, and you made me laugh so many times- Thanks. I know that you are going to enjoy the lightness of afterworld.

I wish I had bought him the ham sandwich he asked me for the other day.

Monday, May 3, 2010

A rant

This is going to be a bitchy post.

I normally don't talk smack about people (aside from residents and administrators, who are obviously exempt from this, and just from their job description, need to be heckled occasionally), but I feel the need to express some anger and frustration - and that, I will do now, with you dear reader. I think that most professions generally protect their own. Unless someone is a total jackass; teachers, lawyers, doctors, and nurses will give one another the benefit of the doubt. Publicly broadcasting someones incompetence is a politician's job, and not mine, but, with discretion- I will share this complaint.

OK, yes, I talk about death a lot, and I promised only a few more posts (a lie), and here is another one. Not particularly about death, but more about dying and dignity, and not the political hot potato kind. Dying with dignity to me means: not dying alone, not being a carnival show, having privacy, being comfortable, and having an intuitive person watching over you. Some nurses and doctors get this, and some are fucking oblivious. In the ICU this is a scary/sad thing. I believe that for many nurses, when a patient dies, there is a big difference in care when they are alone, rather than with family present. This goes for physicians/nosey med students too. When there is no family we are more likely to poke and prod, take random blood pressures, talk about how pissed we are at our spouses, and gossip about hospital drama. I know that I am less sensitive when there is only my sedated or stuperous patient - but the key is that I KNOW I am not being delicate at that moment - when under it all, I still am in touch with the current of the room, the patient, and my role as advocate. I can get right back there, where often times I don't know if some other nurses can feel it at all.

I had an event the other day where a new orientee was being trained by and older, very experienced nurse. The patient was placed on comfort care over the phone by their DPOA. The family opted out/was not able to be present for his death, (Granted, he probably had a colorful life, any may not have been the most angelic character, as his ending diagnosis was Hep C and alcoholism) and he was going to die alone. We all knew this, and shortly before I came on shift, his medical care transitioned to comfort rather than cure. I was to assume his care four hours later at 8pm, and in the meantime I was the floating helper nurse. (I will admit that I did remark: "Christ, another trip to the God-damned morgue, fucking great.") (I am not a saint). I went by his room a couple times and noticed that his door was wide open, revealing the bright yellow, bloated form that he had taken. Making sure he had soft music in the background, I shut the door gently each time, only to find it wide open again later. I hear the two nurses in charge of him wondering aloud why is oxygen levels are so high, they thought he would die so much sooner. The new nurse was eagerly watching his monitor for cardiac changes, oohing and gasping when he would have a sinus pause or a bout of arrhythmias. This is pretty cool for a little while, but after a while got annoying, especially when I noticed that his blood pressure cuff kept going off, showing a BP of 30s/20s. I asked why they were taking his blood pressure, and they couldn't give me a good answer. I said "The guy is on comfort care, give him a break!" They said they would stop it, and I let it go - with an eyeroll, and a meaningful look at the nurse next to me. Finally, 8pm comes.

I am the charge nurse and also have this guy. After I make the rounds, I go into his room. I see this man alone, fairly obtunded, with all the bells and whistles attached to him. I call the covering doctor for a morphine drip, which all my comfort patients receive, even for a small dose per hour (which you had better do for me too). I take off all of his extra leads, his BP cuff, his oxygen monitor, and I wash his face. I notice that his oxygen is blaring 6 liters in his nose, and turn him down to 1 liter per minute (No wonder his sats were so high!! (dumbasses)). I hang out with him for a while, swaying to Kid Rock after I change it to the country station, since he is obviously not smooth jazz.

All of this should have been done before me. I notice that after he had been placed on comfort care, his vitals were still written down every fifteen minutes for the next two hours. This irritates me.

Soon his heart rate slows and I go into his room. I stand next to him and sing him a song as he dies.

I took him to the morgue with the goofy escort guy (It was swell. Yeah right, the morgue sucks. I should get paid hundreds of dollars an hour when I have to go there and shove bodies around). Whatever.

I pulled the nurses aside individually the next day and told them that this was not the way to do comfort care and that I was upset about the way that this patient had been treated. They both bristled and made excuses, and I know that we are not on our game all of the time, so I am letting it go now. However, if I am in that bed, please give me a different nurse.

This is a rant really saying that an expected death should be as peaceful as possible, and that the care of the patient shouldn't be lessened if they end up dying without friends or family present. They should have a sensitive hand stroke their hair, and someone there to dream a little of the good person that they were.

So I will leave you with the song I sang, by a lovely woman named Joules who lived on Lopez - I think my guy liked it.

My clothes are ragged and torn,
you know as sure as your born,
that they've been loved and worn for many years.
And from the mud on my toes,
to the way my hair grows,
I see that everyone knows I'm living free.

Cause living free is the only life for me.
Yeah living free is the only way I'm gonna be.

Some see the dirt on my hands
and they just can't understand
how I can live on the land, but that's OK.
I tried my hand at their schools,
but they was acting like fools,
restricting life with dumb rules,
that's not for me.

Cause living free is the only life for me.
Yeah living free is the only way I'm gonna be.

(Jazzy ending)

Friday, April 30, 2010

Puppy Love

Just a few more posts about death, I promise.

When I was 19 and living in a van, with a really great ex, I adopted a little puppy. She was six weeks old, a little black fur ball, and was so small she couldn't go up stairs by herself. She grew up to be this incredible dog, who was always loyal and dependable. I didn't have to use a leash after she was four months old, she learned lots of tricks, and she got along with most dogs and kids, but wouldn't take any crap either. She barked at the door when people came over, and liked to pee in the basement sometimes, but these were her worst flaws. She was always so cool in public, I would take her to festivals and pretty much everywhere I went. She was so mellow, she got left at more than one garage sale; where we all jumped out of the car to check it out. After perusing and buying goods, we would drive away, realizing a mile later that Zu wasn't in the car. I would freak out, flip a u-turn, and there she would be, standing in front of some guys garage, waiting for me. I'd lean over and open the door, and she'd hop in. We'd speed off down the road, as a group of people would chuckle at the scene. Good times.

My dog is now 14 years old. She was diagnosed with heart failure a couple years ago, and her life was graciously extended with dignity by the modern marvels of an ACE inhibitor and a little blue hydrocodone pill. Her symptoms started with this random collapsing when she was exerted. The first time it happened I was walking with friends from the gym, and Zula just fell to the side, laying there, breathing hard. It happened a couple more times, and I thought that perhaps 12 years old was the end for her, and this was just a natural progression. My husband told me to take her to the vet, and she was prescribed some meds that gave us some more good years. (Thank God someone in the family has sense to see the doctor!) Her quality of life has been excellent, despite occasional exertion seizures and accidents, she is always happy and loving. She is the best girl.

Zu-zam has lost a dramatic amount of weight in the past month. She has stopped eating and when she stands up, she wobbles back and forth like a drunken sailor. Her time is near, and I am trying to make her as comfortable as possible. She needs to be carried down the porch stairs to do her thing, and I bring her up again, laying her on a blanket that belonged to my sister. She won't even eat bacon, and we all know this is an ominous portent. I would like her to die at home, in her sleep. But, I don't know how it will all play out.

I tell people at work about her, and they all are sympathetic. One person tells me to use propofol under the skin, another says phenobarbitol, and yet another tells me to bring home an IV kit and some potassium. This is all well meaning, and shit, yes, we all want to save some money, but I'm not going to kill my own dog. I want to be the griever, not the agent. My role is to love and cherish her, not plan for and give her the best death. This is a new arena for me. I have had personal losses, but most have been sudden and devastating. I have not had to watch anyone get weaker and more feeble, except my Grandma, who was comically proactive, planning her own wake from the music and the food, and finally passed away the morning of the event.

It makes me glad that she is not in pain, and still wags her tail when she sees me, but I still lay down on the floor and cry heavy tears thinking that soon she will be gone. I know that she is "just" a dog, but she is part of my family and she has been with me through the most fundamental changes and progressions in my life. As a nurse who deals with death all of the time, It is surreal to have this in my own home. I have been to the morgue twice in three days this week, wrapping the bodies of two people whom I was with when they died. Still, this exposure doesn't prepare me for the loss of my baby and best friend. At home, laying with her, I easily slip out of my day job, and envelope her with inconsolable arms. Thanking the Gods that there is someone else who can lead us through any tough choices we may have to make ahead.