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?

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.

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).

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).

Sunday Paper

I have never asked if other nurses are addicted to the obituaries like I am. Every day I go to the local news section and peruse the death notices. I look for people who I have taken care of, and usually find one or two a week. I like to spot them and read about their lives, and think about them before I knew them or their families. I like to hear about their careers, loved ones, and accomplishments. I like to see smiling faces, and think about the lives they have touched.

Most of my patients don't get obituary mentions. Some come from out of city or state, but mostly I think it is because obituaries are EXPENSIVE. It cost about $600 for a Sunday listing with a picture. I know this from personal experience, and it upsets me that people can't share the life of their loved one because of financial reasons. The obituary and burial/cremation expenses can run in the thousands or ten thousands if you can swing it. Death sucks enough without adding up a numeric value to the life of someone you can't imagine living without. So, it short, I do not fault my families for not sharing more details with me in the print notice - I just appreciate it when I can.

If I do not see any of my people, I still read about dear Aunt Mabel, and 23 year old Brandon. I take in the stories and sadness and bring it all close to my heart. As common as death is for me, I still am at times overwhelmed by it. The last memories put to paper are a poignant part of the grieving process, and allow me to connect with people in a way that I have to restrain at work. While I am always comforting and understanding when I am with a patient and family when death is near, I always hold myself apart, still ready to react and intervene if crisis arrives.

Drinking my coffee, laying in bed, and locking the kids out of my room; the Sunday paper lets me relax with death, and more importantly, appreciate the wonderful living people have done.

Incompetence is a four letter word

Recently a nurse from another unit and I were talking. He is a good work friend to me. We get lunch sometimes; hang out in the hall and chit-chat. We talk about relationships, bad managers, and gripe about the political bull that we have to endure at our lovely hospital. ‘I’m going to go to the yellow team room and ask out one of the residents.’ He announces. ‘Which one?’ I ask. ‘The R2, I think her name is (blank)’. He replies with a glint in his eye. I flashback to my previous week with her and cringe. In the ICU you get to know your residents very well. ‘Oh God, not her’ I say rolling my eyes. He gets a worried look on his face and asks ‘What’s wrong with her?’ I go over some of my recent experiences with her and the team she is supposed to be overseeing, ‘Frankly my friend, she is incompetent’. He lets out a sigh and looks down. This is the worst insult of all.

I feel bad as I write this. If someone called me incompetent, I would be horrified. This is a label that cuts to your very foundation if you have a Type A personality like I do. Most professions are important enough that to be incompetent would be unacceptable. You want your mechanic to be qualified, childcare to be safe, a bartender who takes care of you, and an accountant who will keep the IRS away. Some professions only require adequacy, where there isn’t much to loose. Depending on how well the job is done, you may or may not get called on again. Healthcare is different. You don’t get to choose your doctor or nurse in a hospital. You are at the mercy of people you hope to God won’t forget about you. People you pray will optimize care for you, working tirelessly to get you better faster, and let you go on with your life in the real world.

Not all healthcare workers have the same philosophies. Some strive for excellence, some adequacy, and the others just try to stay under the grid, not really caring, hoping no one notices. It seems that many nurses and doctors are satisfied if their patient is alive at the end of the day. I guess that this would be adequate performance by some standards, but for me is not quite enough. The far side of the spectrum is the resident (or nurse for that matter), who looks good from the outside in the morning during rounds, saying the right things, nodding emphatically and writing down the plan for the day, and then walks away as if all patient care has been completed. They don’t check on the patient, respond assertively when a nurse calls with issues and questions, nor do they make measurable goals with solid outcomes, change care plans, call for back-up when the patient is circling the drain, and then they are surprised when they get reprimanded the next day. They are children who have no sense of obligation or duty it seems. Maybe they are intimidated by critically ill patients and use denial and rose-colored glasses to camouflage the true nature of the patient’s condition. Whatever the reasoning, there is no excuse for letting your patient crumple in front of you and then failing to respond. That is when I call the fellow. Too late, unfortunately in this case. But, of course the doctor still fails to take any responsibility the next morning, instead blames nursing for not putting in IVs, or relaying patient condition information, when really, they were on call all that night, and failed to make plans for your patient before midnight and it was too late for such and such procedure. So my friends, I did what any assertive ICU nurse would do, I got even with her for trying to make me look bad. Yes, vindictive I know, but it felt really good.
The attending who has known me for over three years became very informed of all the team’s shortcomings, and how the inability to have any accountability was an affront to the nursing staff which has shown repeatedly to have excellent patient care skills and intuition. He nodded in agreement with me, and with his jaw set, said he would have a talk with her/them.

The best residents and nurses who can see a holistic vision of their patient. They see beyond the hospital stay. They see the patient before he came, and what it might be like when they leave. They work for the benefit of the patient everyday, not just keeping them alive, but making their lives better. Getting them stronger physically and emotionally, giving dignity and understanding throughout the patient’s stay.

Incompetence for me is a four letter word, and I hope that I never have to be a patient of someone who doesn’t understand this. However, you can try to date and screw one who is apparently. As my friend so succinctly put: ‘Well whatever, she’s hot’.

Fun at the morgue

Going to the morgue is one of the most nasty parts of my job. I pawn it off on new orientees and escort services when I can. The morgue is not a place like they show in TV shows. Our morgue is this weird, cramped space with stainless steel tables set up with overhead shower sprayers. It has fluorescent lighting, sloped tile floors with a central drain to wash away bodily fluids. Walls are lined with shelves of glass containers that contain various organs, labeled with names of people I have taken care of. There are tables with cutting devices, pliers, hammers, and saws. It is straight out of a Frankenstein movie, and it really freaks me out.

Of course the times that I do go, it is at night when there is no other staff to force into it. I walk down with the escort, pushing the draped and wrapped body. We don shoe covers and go into the dark morgue past all the jars and dissecting equipment, to the body refrigerator. We open it, and look for an open shelf to place the body. The floor has a small pile of various wrapped limbs. Legs and arms wrapped in hospital sheets. The worst part of this experience is transferring the body to our archaic, rickety lift that deposits the body on our chosen shelf. We must slide the body onto this metal tray and use a manual lever to lift the body up to the proper elevation. This lift was designed for a 175 pound person, not the 300 pounders that frequent our establishment. The tray wobbles back and forth, barely making it to the needed height, and yes, it has almost tipped someone out. We reach up with gloved hands and shove the tray in place. Our friend is deposited with the other six for either autopsy or delivery to the funeral home. I wash my hands twice as I leave. I shudder at the thought of going there.

Despite the distaste I have for the morgue, one of my favorite lunch breaks is spent on Fridays at the weekly autopsy review. This is usually the haunt for doctors and eager medical students. Nurses don't much come to these briefings, but I always feel welcome, and some doctor who knows me will pat the stained cloth seat for me to sit next to them. The debriefing that follows consists of a medical history, circumstances during hospital stay, and a run down of the death events. The radiologist pulls up CT's and x-rays, and then the fun begins. The resident step up eagerly and a large metal tray is pulled out of the fridge across the room. The organs of importance are unveiled and I see the patient I took care of in smaller pieces. The forensic doctor, or whatever he is, stands by and talks about the cool findings during the autopsy. He is a pudgy short man wearing a plastic apron and boy, does he love his job. He picks up each organ and carefully plys away at the intricate dissection. he shows blocked arteries, enlarged livers, and even the surprise necrotic brain tumor they never expected. He encourages the residents to put on gloves and feel the rubbery nature of the spleen, inviting them into his magical world. The last time I came however, he stood by without touching, and let the forensic medical students do the displaying. He was instead holding his miniature terrier dog lovingly against his white apron. The dog was well behaved, as this is commonplace apparently, and did not once try to take a nibble.

I don't really know how to end this after that visual, but I will say that I will try to attend next week.