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.

Saturday, April 10, 2010

the power of now

0700
Me:'I hope I get someone super sick today...God, is that wrong?'
Husband:'No. But it's weird.'

Anyone who really knows me understands that myself and my family have been having a rough year or so. Tragic events, coupled with strained relationships, have made me very close to the self-help section at Barnes and Noble. It is a startling event when you realize that whenever you go to the library (after your therapy session), you are consistently drawn toward books about spiritual enlightenment, comfort food, and hot, teenage vampires. Anyway, my point is, that yes, I have had some Lifetime Channel moments, and I am pulling myself through, one trip to the bookstore, and one blog entry, at a time.

Along my journey of self reflection, I found the pinnacle of modern spiritual growth, Eckhart Tolle's The Power of Now. The point to this book is pretty simple and is not rocket science (Monica), but easily missed in our daily rat race. He says people in American society don't focus on the present, and instead, dwell on the past, or think about the future. He writes that the mind evolved as a helpful mechanism for humans to develop strategy, and assisted us in ultimate survival; but has since taken over. We think of our minds as our self, when really, many of the thoughts are crap repetitive tapes cycling through our head. This rang true for me in some ways, and I started to make an effort to sweep away nonessential thoughts, and to think of my mind as a tool, not as my true self. (My mind likes to talk a bunch of bullshit, and so do I in daily conversation)(ask anyone)

Being in the now takes the effort to quiet the mind, and just be aware of where you are. A section of the book mentioned that in emergencies, you have to be completely present, and that your mind is useful to get you through the event, but it doesn't throw out a lot of it's regular rambling. This struck me as I read. I realized that one of the reasons I like working in the ICU, is that I have to be present and in the now most of the time. I do well in that now. I like to call ahead to get challenging patients, and I want to fill my day running to catch up. Sometimes it can be overwhelming, and I don't need the action everyday, but I love that feeling. I am strong and useful, and am becoming expert at anticipation and reaction. I feel empowered when my movements are instinctual and correct: drugs, ACLS stuff, airway patency, arrhythmia's, knowing how to look calm in front of families. I feel at home with this self. When I was at the bookstore looking for meditational insight, I did not realize that I had already carved a niche at work where I did have some sense of self and inner peace. (You just have to ignore the blood, shit, and festering wounds - then, voila! - Nirvana)

In real life, I am still working on trying to swim through the constant chatter of shoulds, needs, wants, and all of the baggage that goes on in family life. Finding those quiet moments with kids as enthralling as my day job. Loving my kitchen again, really smelling and seeing the soil as I turn it over in the garden. Finding joy in the little things that don't involve gore and vasopressors. These are things I am working on.

Wednesday, April 7, 2010

TFMITW - The Foulest Man In The World

Disclaimer - This entry may contain profanity. I have censored some of my recent posts as I have been publishing some of my stuff on nursing blog forums, which tend to be more scholarly, and try to be serious/conservative in nature. This is despite the fact that a lot of real life nursing deals with crap and bureaucratic bullshit. I for one, love swearing and crass commentary, and have felt, well, almost suffocated by these fucking boundaries of professionalism.

TFMITW lives in my unit. He won't die, but he also won't get better. He teeters on the edge of life and death all the time, and when he is doing ok, he is rude, is always on his fucking call light, and is always, hideously incontinent. His stench is unbearable and it permeates to your very core when you take care of him for the day. He also refuses to turn, refuses to cough and deep breath for pulmonary hygiene, always is screaming for pain medication, and worst of all, if he doesn't have his speaking valve or call light handy - clicks incessantly with his mouth like a horny Spaniard. He is now basically paralyzed, has an ever oozing trach, and needs everything done for him. Wiping his nose, feeding him, flossing his teeth, "milking" his rectal tube, changing the channels, and moving him repeatedly one inch at a time - "No! Too much, back toward you! Get the wrinkles out, Oh God I hate the wrinkles. Oh my rectum hurts, it burns! I need more dilaudid! Oh Christ, I just crapped again." This is your day with TFMITW. Oh God it burns.

He is the bane of the unit and we trade him off like canned spinach. I have to assign him to people, and will trace it back to the last time someone had him. Sometimes I have to go back over a month in order to make it fair. This whole junior high bullshit pisses me off. People will sigh heavily, whine uncontrollably, and beg to pass him off. I mean he isn't pleasant, but seriously, groveling?

The sad thing now is that he doesn't really bug me anymore. I actually feel bad for him, and have found out over time, that we actually get along pretty well. He calls me Nurse Ratchet. I set limits, tell him no, and say "Jesus Christ TFMITW, give me a fucking break!" He likes this. I am the one who got him out of bed for the first time in two months and took him outside - for a cigarette, of course. The light shone in his eyes as his son held the smoke to his crusty lips, and he winked at me as the sun played on his face. He was so grateful for that moment, and I felt pretty good about it. Then later, we had to go upstairs and replace the large rectal tube that he is always shitting out as he has no more rectal tone. sweet.

He always asks when I am coming back. He has a couple nurses who don't treat him like crap, and he wants to know who is coming on after my shift. He doesn't understand why he always gets a different nurse, and gets depressed and angry that no one listens to him. He doesn't mean to be TFMITW, but alas, it is his fate. He is an asshole, and if he was more proactive and nice, he probably would have gotten better care from everyone. People look at me in horror when I say that I don't mind him. "Well, why don't you just take him all the time then?" they ask smugly with sarcastic smiles. Well, for one thing, bitches, he is a patient and deserves care despite his physical and personal flaws. We all need to do our share and deal with backtalk and crap. So you too, can get off your ass, deal with his needs and find a way to communicate and help him so that he doesn't call you every five minutes. Plus, I am getting tired of coming home and taking a thirty minute shower which includes a complete nasal flush.

TFMITW is looking like crap again by the way. It is nice when he is stuperous and can't get his shit together enough to call for help. But it is sad listening to his confused and rambling hallucinations. He is half the asshole he was, and this is an ominous sign. He is on pressors and is dependent on the vent all the time now. I think that many people on our unit might be happy if he was listening to "smooth jazz", but I would miss him. (Well, I'd miss him as a person, not necessarily taking up a bed for god damned ever)

Good luck TFMITW.

Sunday, March 28, 2010

The ugly cry

The other day we let a patient die. He had been dependent on the ventilator for a couple months, and no matter what we tried, he still needed tons of extra oxygen and pressure (peep) to keep up his oxygen sats. He was always anxious and frequently requested anxiety medication. He had a trach but couldn't talk, didn't have the ability to write, and was literally trapped in his body. He was miserable, his family was torn apart, and his girlfriend was by his side all of the time with a look of heartbreak in her eyes.

He kept pulling out tubes, and over time it became clear that he did not want artificial nutrition or invasive lines. All the medical disciplines came to see him and he made it known that he wanted to be removed from the ventilator and for us to let him go. He had been fighting this for over two months, and it was clear that he would never leave his room. His family understood and accepted this, and his girlfriend was more hesitant, but ultimately, she accepted his decision, and a date was decided upon. I was charge nurse that day, and I was assisting in the comfort care process with a new-ish nurse. It is a trick to balance sedation and comfort with dying patients. You want to give them enough to sedate and comfort them, but you can't suppress breathing and actually be the death mechanism itself. (tricky). He had about eight family members and friends in the room when we started. He was given a bolus of versed and fentanyl and when he was comfortable, we disconnected him from the ventilator. We covered his trach site with some humidified oxygen, and watched him for signs of discomfort or fear. His family gathered around him, anxiously watching his face, waiting for the moment he would escape from his body. We gave him some extra sedation a couple times, but really it was a lovely passing. For his final and greatest journey, he was able to know when his time had come, all of his closest people were showering him unconditional love and support, and he was comfortable the entire time. What a blessing.

His oxygen sats slowly lowered over the next hour, his cardiac rhythm widened, and shortly after, he was in PEA. Soon had no cardiac activity. His family was told that he had passed, and it was an emotional time for them all. I was in and out of the room through the day, helping out and answering questions when I could. It was also taco day for the nurses, and I spent some time in the back getting the fiesta together while I oversaw the unit. Later, his nurse went for lunch and I stayed in the patent's room to act as family support and explain the process of what happens to his body after they leave. I stood close to his girlfriend on the side of the bed who was still holding his hand. Her eyes were red rimmed and moist, but she was calm. They had been high school sweethearts who reconnected fifteen years ago. They never married, but lived together and loved each other as life partners. She was the one who would go home to an empty house, clean out his belongings, and figure out how to carry on. His daughter began to gather up her family and say goodbyes to friends who came to be with them. I stood by the girlfriend and took in this scene of goodbye. I got weepy as they all took turns kissing the patient and waving in parting to his ladyfriend. She still sat by him holding his hand as they drifted out, the daughter was the last to leave, signaling to the partner that she would call her, her hand as the telephone to her ear, and she walked out the door into the hall. This moment was profound. This ritual of death, mourning, and goodbye. I was so there; I was both observer and participant. I found myself in the partners chair, holding his hand watching all of the others leave, and being left dreadfully alone. A flood of emotion welled up with me. My little tears turned to rivers, I began to literally heave and sob. This moment, that had been replayed over generations, centuries, since the beginning of humanity, was unfolding before my very eyes. I was hit with the full force of these very human emotions and experiences, and in that instant, I rolled in this emotional tsunami.

What a blessing.

I looked out the window and tried to pull myself together. I grabbed some tissue and dried my eyes, squeezed the girlfriend's other hand meaningfully, and walked out of the room, trying to keep these emotions in check. Then with red rimmed eyes, I went to the break room and ate a taco. My coworkers asked me if I was OK. I nodded and sat down. We all ate in silence for a while. The moment passed, I ate my tacos (delicious), dealt with the unit, wrapped up his body, and had the room cleaned. The day was done, I went home and had a beer or three. I kissed my family, read the kids books before bed, snuggled with my husband, and felt incredibly grateful. I slept without dreams.

I told my friend Jaime about this emotional experience I had, and my uncontrollable visceral reaction. She matter of factly said "Ahhh, that was the ugly cry". The spontaneous, overwhelming emotional response that possesses both body and mind. A labor pain of sentiment that strips away all personal discretion and composure, revealing the raw, pure soul within you. I was able to explain how real that moment was for me; how it symbolized humanity, mortality, unhindered love and loyalty, the true complexity and beauty of relationships. I tied it together with one encompassing word: Lovely.

It was amazing to witness such a power, such a time of incomprehensible sadness, mixed with love and hope, and to see this dance of human relationships. I was truly present for that striking moment, and it will stay with me forever.

What a blessing.

Saturday, March 13, 2010

Jinx

You really never know who is going to do well in the hospital and who won't. You can guess fairly easily based on vital signs and labs, previous experiences, a person's feeling of well being, and your own instinct, but really all of those things have failed me more than a couple times. People can have massive MI's suddenly, and they are just - gone. Despite your best efforts to stabilize them and get a cardiac rhythm back, you fail, and they are lost to you and their loved ones in an instant. Some people you can expect this of; they have been having chest pain, they have horrible cardiac disease, they look like crap, their mentation changes. But some people give you no warning at all. They come in for shortness of breath which clears quickly with a little lasix, and you send them to the floor with a cardiology consult, never guessing that they will code that night.

In a small hospital with limited ICU beds, we are constantly trying to shuffle patients in and out. There is a lot of pressure to move patients to the floor when we think that they may be (possibly/probably) stable. Many times this is a crap shoot - the truth is, when you only have two patients, you can detect subtle changes that are missed by the floor nurse who has 10 patients. You can see when their respiratory rate goes from 20 to 35, you are there to assist them cough out huge amounts of thick, sticky sputum, you run in when they are starting to throw up and begin to aspirate bile. The floor is a different animal; where questionable patients are left to fend for themselves unless they are aware enough to use the call light, or if someone happens to come into their room at the right instant. It is a toss up, and you just pray that nothing goes wrong with them when it is your call to push them out of the ICU. When I say push, I really mean push by the way. We use gentle pressure on the residents, saying: "We have no ICU beds in the hospital. If there is a code, we have no where to put them. Who can move out? Now." We look at the patients, determine who is the least sick, and send them out, sometimes crossing our fingers. This is the nature of the beast, (and inadequate staffing) and we just hope that everything works out ok.

Through these patient transfer experiences and my own personal adventures, I have found out an amazing thing. I have a gift/curse from God. I have a horrible talent for hexing people via words of reassurance and encouragement. Oh, you good people may scoff at this, but I swear to the higher power that it is true. I incite the fates by trying to tame patient/friends fears, and I have learned that to improve the odds of survival, I must be as noncommittal and vague as I possibly can, for the sake of others. I think doctors and tattoo artists have also learned this lesson, as they will never tell you what you should actually do as a patient/client. They give you scenarios, tell you the odds, but never, ever will come out and tell you what operation you should have, or what colors would work best for the Chinese dragon you want to place on your torso. Always the same damn thing - "These are your options, I can't decide for you, this is what has worked for some other people in your situation, but I can't say it is the right choice for you". They must be jinxes too, and are taught in their schooling the nuances of ambiguity.

So, since I have learned these lessons about myself and the nature of my job, I know a few things that I will never say again in order to protect the safety of others:

"That baby will slide out like a little seal" - Translation: That baby will be born breech and you will be in heavy labor for many hours.

"It's not like you are circling the drain or anything" - Translation: Actually, this is your last night to be alive, you should call your mother.

"God, you look great, you'll probably leave in the morning" - Translation: You look good now, but wait for a couple hours after I leave - not so much.

In the hospital, we are sometimes forced into difficult choices where we have to push the patient out of the nest, to see if they fly or not. Usually this goes off fairly well, other times they come back to us in a day or two. These "repeat offenders" usually will have a hard time ever leaving the hospital, and ultimately may be treated in a palliative fashion, keeping them comfortable, and out of the ICU because we can't actually make them "better". I will not worsen their chances however, by making a generalized, overly positive statement about their condition, which, as we have learned, would mean their demise. Instead, I will take a measured, cautious approach which is noncommittal, but warm - "Hey, I hope you get to leave, but if not, I have lots of jokes and obnoxious commentary to keep you occupied for a few days while we work on it, ok with you?".

Is that better?

Wednesday, March 3, 2010

patient advocacy - not as easy as you'd think

I received my first, rather horrible, critique of my nursing practice the other day from a comment on this blog. As a person who is used to praise and commendation, I was first dismissive and cold when this person presumed to judge my nursing skills, my patient devotion, and overall ability to be a fabulous nurse. When I first read this comment, I was pissed. My unedited mind said: "Fuck you. You wish you could have a nurse like me. You don't know me. How dare you put me in this little box, focusing on out of context words, and trying to chop me at the knees. Get some fucking counseling and kiss my ass." This IS a rather extreme reaction, and I held myself from responding that evening, and instead, drank some wine and slept on it. Many days later, I take a deep breath and brood on patient advocacy. Could I have done more? Should I have done more? What prevents me from acting more, on what I believe are my patient's best interests?

There are many factors involved in being completely present for your patient, and I am not perfect people! I try to be the best patient advocate that I can be, but there are a few issues in my practice that fluster these intentions. First, I am the NURSE - I take orders, not give them. Second, people say "no" all the time - this doesn't mean that they "mean" it. Third, I am fucking busy, and do not have the resources it takes to research deep issues and have many heart-to-heart discussions. These three concepts will be further explored in this essay. Angry commenter, please accept this as a rebuttal and understand that I am not an evil sadist, but a person just like you - trying to get by, and do the best that I can with my time on this Earth. Peace.

I am a nurse. Not a doctor, soothsayer, or magician. I get orders and pretty much follow them unless they are totally stupid, totally wrong, or cause more pain than they are worth. The third reason is fairly subjective and frequently, if I suggest that this might be the wrong choice during rounds, I automatically seem to sprout two heads and am stared at without comment, and the interns return to their patient plan quickly so as not to embarrass me further. Nurses during rounds are really only worth anything when the Attendings are trying to look PC, or when all other ideas have failed. So yeah, I do say what is on my mind - "This person is sick and probably going to die, have we had a family meeting recently?", "Has Palliative Care been consulted?", "Is this invasive procedure necessary, and is it going to change our plan of care?". I say this stuff, and I hope for a meaningful response - but really am only effective if I take issues up with a resident in private, and they then present the idea as their own. They proceed to get a pat on the back, and then wink at me meaningfully when they are done rounding on my patient. nice.

People shout out "No!" many times during my day. They come into the unit with a GI bleed and are tachycardic and hypotensive. I explain what I am going to do beforehand, but they are of course upset and kicking away as I push a tube into their nose to go to the stomach in order to lavage the blood out. They say "No!" when I start IVs, restrain them from pulling out tubes, or putting in a foley because they are pissing all over themselves. These same confused/sick people tend to clear up within a couple days, and are sent off waving goodbye as they leave with a thank you, and I hope to never see you again. Coming into the ICU sucks, it is not a trip to the spa. It is hell to get better sometimes, and I walk the fine line of trying to figure out if the discomfort is worth it. Sometimes no means "I hate this, I hate you, but I don't want to die like this". During these times, my patient advocacy means putting the patient's long-term interest before what they may want at that particular time.

My third reason for not being a super patient champion is because I am stretched to the max sometimes. With two patients who should actually be one-to-one, I am running my ass off all day, and can't even sit down to review their chart. Maybe this is my fault for working in a hospital that doesn't provide adequate staffing. Maybe it would be different somewhere else where I wouldn't have days where I feel like a kicked dog when I leave. Is it different anywhere else though? I don't know. My work has great benefits, awesome staff, usually a good working relationship with the doctors, and I have good potential for the future. The patients are great; very colorful, rich histories, amazing families, and usually I feel very satisfied at the end of the day. Sometimes though, I know that if I had an ICU physical therapist, respiratory therapists who actually cared about vent weaning, or even a competent nursing aide, I would be much more effective at my job.

This is a depressing post.

As a nurse in a small hospital without much nursing support, I do the best that I can with the time I can afford. There needs to be a fundamental change in the way we view patient care at the ICU level, with a holistic focus and commitment to improving patient outcomes, and accepting when we are beyond our means of making some of them better. Probably, my best way to be a better leader in patient care is to move into administration and really push for greater resources and training. But, then I would be away from where I really shine - at the bedside, with the patients whom I really do appreciate, and try to either get them better, or help them leave this world peacefully with dignity, surrounded by someone who really does care.

Monday, February 8, 2010

Nursing: It's not just a job, it's a lifestyle

Being a nurse, doctor, RT, or any bedside clinician means that you never really leave your job at the workplace. I am always asked random health questions from friends and neighbors, as well as doing the occasional dressing change for the diabetic old man across the street. I am the on-call assessor of allergic reactions, bug bites, and power tool wounds for the neighborhood. I also am approached for advice on hemorrhoids, vaginal elasticity, tooth abscesses, and the benefits of fish oil by strangers when they discover I am a nurse. This just comes with the territory, and usually I just try to lay low when in line at the grocery store.

My nurseyness is also displayed at the gym and the airport as I spot the AED placement around the facility. My ears perk up when the 88 year old grandma says she is dizzy during her AOA workout. I also travel with a resuscitation mask and many pairs of barrier gloves in my trunk. My first aid kit is ready for a mass shooting event, and I have many N95 masks in multiple sizes, in case of widespread swine flu outbreaks. I brought my kids home PAPR masks in case they wanted to be bee keepers for Halloween. These are some examples of how my work travels around with me.

My "nurse as a lifestyle" reality was further demonstrated last night when I was at a Super Bowl party, and the kids had a sign-up for a talent show. While the other adults put down: headstand, "olive trick", and yodel, I put down "CPR demo". This is in fact, a worthy talent that all people should know. And while I was thinking about rate and depth of chest compressions, I had many male volunteers who wanted to be the dummy, and not for the chest compressions. I had to explain that now the AHA recommends Hands Only CPR for the layman, and that Rescue Breaths are not indicated for the community - sorry guys. Granted, I had a couple beers in me and perhaps had poor judgement on appropriate "talents", I could really only think of this skill I could put down. We left before the talent show commenced, thank God, because I didn't really think of the whole up and down motion of chest pumping with a the mixture of drunk people and kids in this particular setting. Alas, I need to find another, more appropriate talent to come up with, maybe burping the alphabet?

So you can take the nurse out of the hospital, but you can't take the hospital out of the nurse; in fact most of the hospital is actually under my bathroom sink (I hope my manager doesn't come over).

Thursday, January 21, 2010

Hey world, I just wiped your grandpa's ass, are we cool now?

I have many moral dilemmas. I am constantly trying to find the balance between good and good enough. I feel obligated to do many unselfish social deeds, but then I think to myself; "Christ, don't I do enough?". You all know dear readers, that I usually give 100% of myself at my job. I serve mankind everyday. I understand that most jobs are serviceish and that they indeed benefit society as a whole. Teachers, doctors, garbage collectors, waiting tables for rich jerks, and countless other areas of employment, are all jobs that require you to put aside personal distastes and get the work done. Many times these employees will require deep breaths and personal time outs, in order to keep the patience one needs to be nurturing and understanding with the people you are supposed to be caring for. Being a nurse who really tries to be present and deliver the best care means I have to get downright intimate with my fellow man. I put on a smile and clean crap, listen to someone scream for Jesus all day, wash genitals, rinse festering, stinking wounds, work to fight for the best plan of care for my patient, and seriously - save lives. I ask you world: Is this enough? Should I feel obligated to volunteer and put forth community service during my days off?

This is totally a selfish question. I know in the pit of my gut that, yes Lisa, you dumbass, you get paid to do your job and since you are even having this moral questioning, you know that you should be giving more. But, I also know that most people don't even have this question on their radar, and they don't give to their fellow man the way I do! What makes some people give so much, and others don't even think about it? When I was younger, I had two goals: To be able to go anywhere and "make it"; meaning survive, find a niche, succeed anywhere in the world. The second, inspired by John Irving: "To be of use". I really believe(d) that to contribute things to this world for a greater good, is the most profound thing a person can do with their life. When I made these goals when I was 19, I had no idea that I would get into nursing. Years later, after I had been working as a nurse for a couple years, I revisited my long forgotten goals, and realized that I had made both of them a reality. What an epiphany! "How clever I am." I thought. But, as I patted myself on the back, I also had a deeper question, is this enough?

There are two sides to my thinking about this query. The selfish reaction: "Why should I donate to the leukemia foundation? I'm already the kidney failure/liver failure/cancer care/putrid leg ulcer turned septic foundation! No one donates to me!" Then the rational, compassionate side says that of course I am obligated to help others every day, using my time on this earth to really count for something is the most important thing.

Now, I don't want to give anyone the idea that I am actually an actual volunteer or anything, I show up for an hour at my kids school a few times a year, and donate to the Salvation Army a buck or two during the holidays. I am really saying that I would like to like to volunteer, just like I would like to like to be more artistic. So really this back and forth is that indeed I do want to do more, despite my knowledge that indeed I do serve people in a great way during my work week but obviously it isn't enough for me. I guess that by putting these words into written form, I will begin to make this a reality, no matter how much I may scream and kick on the way. Consider it a resolution, along with: cooking more Indian food, not screaming at my kids so much, going to the gym more than once a month, and yes, being more artistic.

I will do a volunteer update at the end of the year - (no commitments though...I might change my mind).