you don't have to go home, but you can't stay here.

The night had been a long one for the outgoing shift, especially Shane. His Patient---soon to be my Patient---had been yelling all night.

"DADDY! KILL ME! WHY WON'T YOU HELP ME? KILL ME! HELP!"

It was incessant. Patient hadn't slept a wink. And he was deaf. One had to shout at him to be heard.

Shane gave me report, head in hands. He refused to look up, to avoid accidental eye contact. Patient had come from an assisted living facility for an altered mental status workup. His family insisted that he only became disoriented whenever he was hospitalized. He was otherwise stable. I was quiet for a moment, and then asked the question that you, Dear Reader, have already thought of: "If hospitalization creates delirium in Patient, how are we supposed to observe him for a return to baseline?" Shane just moaned, kept holding his head, and half-whispered, "I don't know. See if you can get him sent back. This is the wrong place for him. Obviously."

"HELP! HELP! DADDY!" added Patient.

I went to Patient's room to introduce myself. "Hi, there," I shouted, "I'm your nurse today, and I'm going to take care of you until this evening. How are you?"
"I WANNA GO HOME, DADDY! WHY WON'T YOU TAKE ME HOME?"
"Can you tell me your name?"
"DADDY! KILL ME! HEEEEELLLP!"

That was my neurologic assessment. I did the rest of my physical assessment while the patient alternately stripped out of his gown, yelled for help (or to be killed), and swung his scrawny, totally non-functional legs over the railing of the bed. In an effort to be a half-decent nurse, I opened the blinds to let the sun in, and turned on the daily news. If he could be alert and oriented outside the hospital, it was my responsibility to attempt reorienting him---to stop him from being coo-coo for Cocoa Puffs.

I tried to feed him.
"HELP!" Well, okay. It was meatloaf. I could understand that.
I tried to wash him a little bit.
"DADDY! TAKE ME HOME! DADDY!"
I tried to not be extremely angry when he ripped his only IV out of his arm, leaving spatters of blood on his new gown (which he stripped out of) and his fresh sheets (which he also promptly pissed on).
"KILL ME, DADDY! HELP! TAKE ME HOME!"

I gave up, and opted to just turn the bed alarm on, so I would know when he decided to jump ship; hopefully, I thought to myself, I'd hear the bed before I'd hear Patient landing on the floor. It went off every few minutes, like klaxons in a nuclear holocaust.

Sometime in the afternoon, the resident following Patient told me that an ambulance from the home was coming to retrieve him. I went into Patient's room to let him know.

"Hey, Patient...good news! You're going home, just like you've been asking for all day. I've already let your daughter know. She'll be waiting for you there when you arrive, so you won't be alone. Isn't that great?"
Patient shook his head no, and unbuttoned the left shoulder of his gown.
"What do you mean, 'no'? You've been asking all day to go home."
Patient shook his head no, and unbuttoned the right shoulder of his gown.
I had reached a point of dark desperation. "Patient, you have to go home! Your family is there! You know everybody there! And nobody likes it here. I don't like it here."

Patient looked at me thoughtfully, and was blissfully quiet for just a moment. Finally:
"HELP! HELP! HELP!"
His gown hit the floor.

I left the room, closed the door behind me, and put my head down on my desk.

nurse barnum

Not every nurse's report is reliable.

There's this night nurse, the Bulldog, that I respect immensely; he's been a nurse for something like five million years now. Unfortunately, he has a tendency to exaggerate. One time, he told me that a CABG patient's graft leg looked infected, and that it had dark, purulent ooze coming from the incision. I decided I didn't want to antagonize an infected wound by uncovering it, and called the MD in to take a look at it. So the MD made a special trip on a Sunday morning to take at a look at this imperiled leg...and found zip. Zilch. A normal fucking leg with normal, serous leakage. This Patient was black; it was his skin slough that gave it its dark appearance. I felt like a rube. Thanks, Bulldog.

The last time I took one of Bulldog's reports seriously was when I took a Patient with a history of gross pulmonary impairment from him. Report went something like this: "...anyway, we got Patient up to the chair last night. He just hopped right up, and doot-doot-doot doot! got in that chair." (Onomatopoeia was accompanied by a "walking fingers"  motion to further illustrate Patient's able-bodiedness.)
"Really?" I asked. "I had him yesterday, too. He could barely turn himself in bed. How'd you guys do that?"
"He really didn't  have any problems. Swear to God, he just got up like he'd been doing it all along."
"Huh. Okay, we'll try it again today. Maybe if we do it enough, we can wean him off that vent, finally."
"Sounds good to me. But, really...doot-doot-doot-doot!" Walking fingers again.

The day wore on. I did my thing with Patient all day. The more I was around Patient, the more I couldn't believe that he "just hopped up". But why would anyone say that if it wasn't true?

Around 1500, I decided to give Patient a chance.

I helped Patient sit up and dangle on the side of the bed, and...wow. He did really well. I started feeling a bit more optimistic. I explained to Patient how we were going to stand up. "I'm going to count, and we're going to rock forward to stand up on three. Okay?" Patient nodded. Not only could he not talk---he had a trach---but he also had a history of brain injury, so he had a few other impairments, including the inability to operate at an appropriate developmental status. He also suffered permanent short-term memory loss. It was like talking to a five-year old all the time. I was taking it slowly so that he could understand what we were trying to do. I slipped my arms under his arms to help support his weight while he used his scrawny, deconditioned legs to stand.

One.
Two.
Three!

Like a lump, he just sat there. Then he pointed vigorously to his mouth---his signal for a wet swab.
"No, not now, Patient. We're trying to get up, remember? Don't you want to get out of this awful, uncomfortable bed?"
Patient nodded. And kept pointing to his mouth.
Sigh. "Okay. Let's count to three. When you're in the chair, I'll bring you all the swabs you can stand."

One.
Two.
Three!

Lump. A sliding lump. Patient's butt had scooted forward with all the rocking; as a result, he was beginning to slide off the edge of the bed. He wasn't even attempting to use his legs. He was going to hit the floor at any moment.

I had a fleeting image of fractured hip x-rays, panicked, grabbed the patient under the arms, and swung him off the bed and around into the chair.

This was a tactical error.

Twenty minutes later, Patient wanted to go back to bed. Point, point, point. His lines and vent tubing were a horrific plastic tangle. I couldn't figure out how I even got him in the damn chair without ripping a line out, or tripping myself. I stuck my head out of the room, and like a big hairy angel, there stood Hippie. Before I could say a word, he asked, "Do you need help?"
Oh, do I, Hippie. Do I ever.
He came in, looked at Patient, and groaned, "Oh, God. Okay. How well does he stand?"
"Not well. Actually, not at all."
"How'd he get in the chair?"
"I panic-hoisted him. He's a total lift. Sorry, Hippie."

Hippie sighed again. We got on either side of Patient's chair, as Patient furiously kept pointing to his mouth. We locked wrists under and behind him. Then Hippie looked at me from across Patient's lap and posed what would normally have been a reasonable question: "So what's the plan here?"
I looked at the knots and webs of tubing.
"The plan is to get him back in bed any fucking way we can. Really. I don't care how it goes down, as long as we don't drop him."
"Are you kidding?"
"Dammit, just pick him up on three and we'll swing your way. I just want to get him on the bed."

One.
Two.
Three!

What transpired next was the sloppiest, most unprofessional moment of my career. We lifted him, swung his body in Hippie's direction and aimed for the bed. Patient landed with his body cattywhompus across the bed, legs dangling and his head at the foot, still frantically pointing at his mouth. Hippie and I were panting and laughing uncontrollably.
"Oh, Jesus. What if he tells his family?"
"Hippie, he's got a trach. Besided, it's always Groundhog's Day for him. Trust me, in five minutes, he's not even gonna remember this happened."
Patient pointed at his mouth. I handed him a swab. "Better?" I asked him. Patient nodded, sucking contentedly on the swab.

epsilons don't really mind being epsilons

I don't have the talent to be a nurse. I did last week, but I don't now.

I decided recently that I need a change at work. Not because I hate my job (actually, I love it), but because my current hours are putting a cramp in my style and I can't change my schedule, based on the needs of the unit.

So with resume in hand, I started pounding the pavement. I applied to all kinds of jobs that sounded interesting. Some I was qualified for, and some I was not. But, I told myself, I'm a fast learner, and I usually shine during interviews. I could surprise a manager, and possibly myself, by landing something really great and being the right person for the job.

Most of the jobs I applied to were right in my current place of employment. Great---no interruption in insurance and benefits, no dreaded housewide orientation, and if I got really lucky, I'd get to work with people that I've met before and already trust. I might even be able to pick up a few hours in the unit, which would be lovely, like leaving home for college but coming home on the weekends to do laundry. Comfy.

There was only one barrier; I had to undergo a talent assessment.

One to one and a half hours long, a talent assessment is an HR product used to, according to the company that designed the assessment, "[a] proprietary interview technology, which identifies people who have significant potential to be successful in a particular industry or profession and in a particular workplace and/or culture." Well, wait a minute. I've learned a lot since I became a critical care nurse. I've acquired knowledge and skills. I've earned the respect of other nurses, physicians, and allied health professionals. I have a reputation for being a dependable team player. I've kept up with my continuing education. I'm trusted with teaching nursing students and orientees. My evaluations are strong. What about that? According to the same company, "Talent is a natural ability not acquired through effort. It is a person’s capacity to achieve near-perfect performance. Unlike skills and experience, talent is a reliable predictor of performance excellence."

Um. So effort doesn't count. That means all the energy I've poured into becoming a skilled, safe, knowledgeable practioner is worthless because...I don't have the talent to be a nurse. And I'm not near perfect.

What the fuck is a "talented" nurse?
A meringue might be near perfect. People are not meringues.

You know what I know about talent?

As a young child, I was precocious; I was reading and writing at very advanced levels, and placed in independent study in grade school (bad idea to tell a first grader to work on their own). I was told repeatedly that I was brilliant----so young! so smart! I had talent. I blew all the testing out of the water. My response to being told I had brilliance and talent was this: I quit trying. Why? Because I had talent, that's why. I was too cool. Everything was easy, until it wasn't. In junior high, I hit an academic wall. I was asked to work a little harder, met other brilliant kids...and I did not flourish. I was, kindly speaking, fucking lazy. But hey, I was talented.

What a lot of shit that was.

Eventually, I grew up and figured out that a gift is nothing if you don't use it well. I started working harder at everything I was interested in. That's how I became the nurse I am now.

This is what happened: I took the assessment. It was a phone interview peppered generously with stupid questions.
Do you smile a lot?
Do you talk to your patients frequently? Why?
What do you think of people who only come to work for a paycheck?
Are you addicted to a positive attitude?
Do you pay your bills on time?
Do you try to do more than your co-workers?
If you were competing with two other nurses to care for a patient, what would you say to the patient to get them to choose you?

I have not been interviewed by a manager from any of the other departments I applied to, to see if I'd fit in. No one has spoken to me, my cohorts, my supervisors or my (surviving) patients about my strengths and weaknesses. I was informed that I was no longer being considered for at least one of the positions I applied to. I inferred from this news that I'm not eligible for any kind of lateral movement within our institution.

Talent fail.

If I had taken this assessment straight out of nursing school, would I even have a job now?

...and now, dinner and a movie.

Patient had been on the unit for a long time at this point; he had so many comorbidities and wounds, he had a snowball's chance of leaving his room, ever. EVER. He was trach vented. Hadn't spoken in months. Anytime I offered him a communication board, he would only spell out "BUTT HURTS" with the block letter alphabet offered in the left-hand margin. I could put my fist through one of his pressure ulcers. It was heartbreaking. There were other, tough, strong nurses that wouldn't even go in his room anymore.

I liked Patient; he had enough fight in him to get this far, but there were signs that he was giving up. He was glazed full-time; his eyes only grew less glassy when I warned him that I had to change his wound dressings (this was an excruciating process for him). He would still nod "yes" or shake "no" to questions asked of him, but finally he even gave up the "BUTT HURTS" pronouncements. Nothing we were doing for, or to, him was going to fix the pain or the source problem, and he knew it.

On this particular Sunday evening, I really tried to make the dressing change as minimally...horrible, I guess...as possible. I pushed loads of narcs, which were were woefully ineffective. Lots of pillows and propping up to make him more comfortable; whatever, dude. I unpacked the wound, and quietly explained to Patient everything I was doing while I was doing it. It really only took me a few minutes, but it was painfully obvious, as I repositioned him and looked in his eyes, that time had just stretched in unholy ways for him. I was not so much a nurse at this point as this shift's appointed tormentor.

It was nearly the end of the shift, so I was tidying up the room----a habit I picked up after inheriting chaotic rooms and disheveled patients from other nurses. I placed the TV speaker next to Patient, so he could hear it well enough. I glanced at him in a bid to silently say, "I'm not ignoring you even though I haven't looked in your direction in 10 minutes". His eyes were riveted to the TV screen.

The Color Purple was playing.

Two of the characters were getting cozy with each other. They were both women.

I have somehow managed to never see Purple. It was clear that Patient hadn't, either. Neither of us saw this coming. Forgive me, but come on, it was Whoopi Goldberg. She's one of the very last people I associate sex with.

"Hey, Patient...have you seen this before?"
He shook his head no, slowly.
"I haven't either. So you didn't know this happened in the movie? This was a pretty bold move for an '80's flick."
He shushed me, eyes never leaving the scene before him. Shushed me! Then waved me over to his bedside so we could watch the rest of the scene together. Or, at least, so I'd quit distracting him with all the hovering around his room.

And we watched, together. We were united by chicks making out.
And for a brief moment, all was forgiven.

hors d'œuvre

What is it about cancer and chemo patients smoking and pushing an IV pole that pisses me off so much?

don't drive angry!

"Hey, did you know Michael Jackson died?"

Patient had been in this room for about a day and a half so far during this admission. He had left against medical advice (AMA) not that long ago, had a massive cardiac event, and came back with a vent and a sore chest.

"Yeah, I did know that," I replied, setting down the sundry items I'd brought in for him. "As a matter of fact, I gave you the same drug that killed him. It's called propofol. Though, to be clear, I wasn't trying to kill you." He laughed and asked when it had happened. "Michael died...um, about four days ago. You probably don't remember because it's not that unusual for your brain to end up with some minor damage during a big heart attack. Lots of people lose some time along the way." We chatted a bit more, and then he asked for a soda. "Sure, hang on a minute. I'll be right back."

I was right back, soda in hand.

"Hey, did you know that Michael Jackson died?"
"....?...."
"Yeah! They just said so on the news! Wow, I loved his music as a kid."
Uh oh.
"Dude,"---I tend to get familiar with my patients quickly---"he died four days ago. We just talked about this, remember?"
"NO," he laughed, "this just happened. I just found out from the news."
"NO," I didn't laugh back, "we just talked about it. Seriously. Before I got you this soda."
Which I held up.
"Hey, Sierra Mist? I was just thinking I wanted one of those. Thanks."

I mentally facepalmed, told him I'd be back in about an hour, and went to see my other patient.

I was greeted back with:
"Hey, did you know that Michael Jackson died?"
I sighed. "I'd heard. Hey, you haven't said anything about pain today. Are you hurting at all?" He frowned, and rubbed his chest a little. "Well, now that you mention it, I'm sore as hell. Sorta like I got punched really fucking hard, or kicked in the ribs. It's weird."
"You got CPR," I reminded him. "You're gonna be sore for a while. You're lucky it didn't break your ribs."
"CPR?"

I related the events of the last two days---how he almost died at home, that he had a tube put in his throat to help him breathe, the flight from his hometown to our facility. Our many, many conversations about Michael Jackson. He was a tough old redneck; but he welled up with the grief that comes with sudden, irreparable disaster.

I sat with Patient for a while; I patted his hand, and answered his questions about the things that can occur with cardiac events, including brain injury. I was honest with him, and he had a lot of good questions. At home, he was normally the one that watched his small grandson while everyone else in the family was at work. He could see how dangerous this was, not having any short term memory. I left when his wife and one of his kids came up to keep him company, with a promise to come back around dinnertime.

Evening descended.

"Hey, did you hear Michael Jackson died?"

prism

Two transporters, black.
One pregnant white nurse, Serena, and me.
And one enormous Patient. It's going to take all four of us to move him to his new digs.

While we're all waiting to figure out what room Patient's supposed to be transported to, we're watching his TV. A Johnsonville sausage commercial plays; the only black man in the commercial enthusiastically accepts the offer of a sausage fresh from the grill, asking his white host, "Do I look like a chicken man to you?"

Transporter 1: "Why, yes, as a matter of fact, you do."
Transporter 2: [snickers]
Serena: "Mmmmm, chicken...that sounds so good!" [pats belly, leaves to pee]
Me: [looks at Patient, prays silently he's not listening to us]
Patient: [who happens to be black; looks at me, smiles. Fuck.]

Ah, diversity. Don't underestimate its inefficacy.

Is someone recording this?

This is what happens during a code:

Patient has a rhythm change, and one of us figures it out---they see it on the monitor, or they just watch their patient go quiet, and turn the color of faded violets. Unlike TV, there isn't blood everywhere...yet. There will be, but that's not for another four minutes or so. Also, there's generally not a physician present at the onset of arrest. So no, no Dr. Mark Greene calmly stating, "Okay, Code Blue". Nope. When someone's found down, the first, most visceral response is normally "oh SHIT IS THAT REAL?".

If it brings you any comfort, that's critical care speak for "Okay, Code Blue".

Suddenly, we swarm on Patient.
Everyone wants to help.
Everyone wants a piece.

Respiratory therapists, staff nurses, the house supervisor, the shift supervisor, the clerk, a couple of unit attendants, residents nervously gripping algorhythm cards, maybe an anesthesia provider or two, the attending physician all show up. Compressions, ambu bag, back board, pads, drugs, analysis of a rhythm, drugs, broken ribs, followed by attempts at art lines and central lines (this is where it gets bloody; it takes this long for someone to show the resident where the kits are) from the second someone finds Patient pulseless. If Patient is the lucky recipient of quality chest compressions, he's going to end up with at least a couple of broken ribs, which earns him a chest tube for pneumothorax management. Lightning Round: If Patient is having a particularly bad day, there might be a grand opening (cracking the chest right there in the patient's room). Wash, rinse, repeat for 15 minutes if you're following ACLS guidelines, or 30 minutes if your Code MD feels guilty about giving up.

First rule of Fight Club: Almost nobody survives ACLS.

I can't remember the last time anyone wore their safety goggles to one of these shindigs, for the record. Dr. Greene always had them on. No, no, no. 

Soundtrack to a Code: Hippie says he always hears "Sabotage". For me, it's Fear's "Coup D'Etat". Jimmy is too focused; no soundtrack, just a hell of a core workout during compressions. I don't know about the other nurses, though I should probably ask. Fun to compare notes, you know?