fan mail

"I've been through it all, baby. I'm mother courage."
Elizabeth Taylor

"Full code? Really? Are you fucking kidding me?!?"
Jimmy

Dear Ms. Taylor:

I've been following, with some interest, the news of your recent hospitalization. First and foremost, let me wish you the speediest of recoveries, assuming you survive this admission.

Forgive me for being so blunt---this is my first letter to a celebrity, after all, and I have the social grace of roadkill. However, I think it's time that someone from the unwashed masses shares a fact as sure as tax collection: your CHF is going to kill you. If not now, within the next two years. (That is an optimistic number that I've pulled out of, as you Brits say, my arse.) I hear of your 'second month in hospital', and I picture others of your cohort, struggling to breathe, praying to make it to their granddaughter's wedding in June, or their 53rd anniversary next week, or to Christmas, or to tomorrow.

I think of a BiPAP mask cutting the skin across the bridge of your nose, and your thoughts every moment of ripping it off. I consider the pulmonary congestion, the daily chest x-rays, the barely concealed horror of every nurse that sees your ankles for the first time. I wonder how tired you are of every nurse, every shift, checking your butt for pressure ulcers. I frown at the idea of Cleopatra on a bedside commode with maximum assist back to bed.

I picture your violet eyes crossing when the BiPAP comes off and you get a little hypoxic.

And, since we're being honest here, I'm going to tell you: if you have any personality "quirks", well, it's being shared over report. Repeatedly. Someone who sees you naked daily probably speaks with at least momentary irritation about you and your hatred of oral care/ability to get out restraints/self-extubation/specific odor of your bowel movements/obsession with Pepsi products.

Ms. Taylor---Elizabeth, if I may be so familiar---Elizabeth, let's cut the crap. The ICU is no place to die. My own grandmother is dying of CHF. She was an ICU nurse, she knows she's dying, and yet she still practically told my mother to fuck off when Mom suggested she go to an assisted living facility. Grandma told her that she wanted to die in her home, in front of the TV. Get out of that shiny, decontaminated, tastefully decorated, well-staffed hellhole, Elizabeth. Die surrounded by the things that remind you of your admittedly kick-ass life; your family and friends. Hell, if it's all you have, your cat, sofa and TV. Put on National Velvet, hire some cute boy to rub your feet (tip him well; let's admit, CHF-affected feet are not "dainty"), drunk dial your exes that are still alive, and have a hospice or home health nurse come visit you. He or she will manage your air hunger, your diet, any wounds you might have, and possibly keep you company when you're feeling low. They'll help you make the most of it. Jesus, they don't even let you have a decent drink and cigarette in the ICU. Something about a "fire hazard" and "not good for you".

Go home, Elizabeth. Live in peace, like I wish the rest of my patients would do.

Your adoring admirer,
Kilgore

that book was a hoax anyway

Patient arrived in the mid-afternoon on a stretcher. Not because she couldn't walk, but rather because she was in four-point restraints, and probably would have kicked the still-beating heart out of any staff member in her way if she hadn't been. I looked directly in her eyes, and saw Jodie the Pig Demon from The Amityville Horror.

"YOU FUCKING STUPID-ASSES! WHY THE FUCK AM I FUCKING TIED DOWN, YOU FUCKS??"
Yes, really.
"LET ME THE FUCK GO, I GOT FUCKING FIVE FUCKING KIDS AND YOU HAVE NO FUCKING RIGHT TO DO THIS! FUCKING ASSHOLES!"

And so on. She wasn't even creative about the way she was shrieking at us, but she was persistent. It was old before we ever parked her in her room. She was Mother Superior's patient; I offered to help tuck her in.

Mother Superior is one of the best nurses I know. She is the supervisor for my shift, the leader of our posse. Soft-spoken, thoughtful, reserved and brilliant, she makes The Job look effortless. I have never seen her run, rush, or become flustered. Sometimes, she'll shuffle a little faster, but that's about it. She is the nurse that I endeavor to be. She was the perfect person to take on Satanette. I watched her talk to the patient in that soothing, maternal way that she has, and wondered where someone finds that kind of restraint. I certainly don't have it. That's why I chose to keep my mouth shut that afternoon.

Mother Superior and I worked together to attach Satanette to her EKG leads.
"I'M FUCKING ALLERGIC TO TAPE, FUCKHEADS!"
I asked Mother Superior if she thought she would need any labs.
"YOU BETTER NOT FUCKING TRY, YOU STUPID BITCH! I'LL TAKE THAT FUCKING NEEDLE AND STAB YOU WITH IT, CUNT!"
Mother demurred on the labs.
What about a glucose check?
"LEAVE ME THE FUCK ALONE, THEY ALREADY CHECKED MY GODDAMN SUGAR! DON'T YOU FUCKING PEOPLE TALK TO EACH OTHER?"
She was diabetic as well as apeshit crazy nuts. Mother Superior stuck Satanette's finger for the requisite drop of blood. She was rewarded with a soul-curdling howl and a 352mg/dL.

I pulled back the sheet to assess Satanette and realized, with horror, that the ER staff had left her partially dressed.
That underwear was gonna have to come off.
Both Mother Superior and I sighed.
"Well," Mother said, "I guess we're going to have to just cut them off. I always feel badly about cutting people's clothes off, though. It's all she's got with her."
Satanette's eyes glowed red, but before she could string together a new, ear-wilting string of FUCKs, Mother and I had each whipped out our scissors and sheared up either hip seam.

"YOU STUPID CUUUUUUNTS! IIIIIIIII'M... OOOON... MYYYYY... FUUUUCKING.... PERIOOOOD!"
"I noticed," I muttered, as the offending pad came into view. "See, I'm a nurse. I know stuff. We'll get you a fresh pad."
"FUCKING BITCHES! I CAN'T FUCKING BELIEVE YOU CUT MY FUCKING UNDERWEAR OFF WHILE I'M FUCKING BLEEDING! YOU'RE SO FUCKING STUPID, BITCH!"

Then it happened.
Mother Superior jumped the gun.

She walked up to the head of the bed.
She bent over Satanette.
She took up the edges of the blanket, as if to tuck Satanette in, all snug and comfy. I marveled again at Mother's eternally composed state. I thought of incorruptibles, the scent of lilies.

She wrapped the corner of the blanket around two of her fingers, and started to stuff them in Satanette's mouth.

She whispered. "I...am tired...of your...filthy...mouth."
And kept stuffing.

Satanette was quiet now; not by choice. Her eyes were bulging with fear, and I began to worry. "Uh, Mother? I can't believe I'm saying this, but it might be time to take it down a notch." I gently touched Mother Superior on the arm. No sudden moves here. She was still armed with the blanket.

Mother Superior never broke eye contact with the Pig Demon. She looked over her narrow granny glasses, and slowly withdrew her fingers and the slightly soggy blanket from Satanette's mouth. "You need to be quiet now," she said with deadly calm. Satanette obeyed. The demon had been cast out, for now.

No lillies.

"where there were eyes, there's only space"

Patient was a tough guy and he prided himself on it, to a degree of boneheadedness. He was in a manly profession. He kept his woman in check, and she liked it. He drove the stepdown staff to drink with his tales of great vengeance and furious anger, along with his total inability to follow directions or stay put. In short, he was tiresome. 

He came to the CVU for a CABG, and he'd had a surprisingly rough course. He was intubated for several days (though this was not through a physiologic deficiency. The pulmonologist kept waffling about Patient's ability to breathe, leading me to loosen his restraints so he could "stretch a little"---right up to his own tube. I hope no one billed him for extubation). Once he regained the ability to speak, I found that he wasn't himself just yet.

I walked into Patient's room. He was hunched down in his bed and looking extra bitter. I put on my Customer Service Face and said, "Hey, Patient, I was thinking we'd go for a spin around the unit, but you're looking a bit down. Wanna talk about it?"

He started sobbing.

"Aw, come on"---I fucking hate it when people cry because I don't know what to do---"what's going on? Maybe I can help."

He muttered something unintelligible and continued to sob. What did he say?
He repeated it. "I doh-hnn't ha-a-ave ah fuhmmphmphph." Sniffle.

A frump? A phone? A frog? What the fuck was he saying? I thought for a minute. No one had been to see him but his wife. Friends? A-ha! I grabbed a greeting card signed by all of his co-workers. "No, look. You have all kinds of friends pulling for you. There have to be at least forty names on here. These people all care about you."

"NO! NO! I SAID, I DON'T HAVE A FACE!"

Oh. Oh, dear.

Propofol has a short half-life. It's effective within 30 seconds of initial administration; if only used for short periods of time, it wears off in roughly three minutes. However, if you sedate a pudgy guy for, say, a week, the drug starts collecting in the Pudgy Guy's adipose tissue. Effect: it makes Pudgy Guys koo-koo for Cocoa Puffs.

Patient was a Pudgy Guy that had gotten, oh, a week's worth of propofol.

I tried to convince Patient that his face was still on him. I grabbed a shaving mirror and started to hold it up. "No, dude, no...you still have a face! It's the same one we admitted you with! See?"
He screamed. "DON'T DO THAT!" The sobs were hysterical now.
And unexpectedly, he sat up and clutched me in a a desperate bear hug.

Earlier, after he'd self-extubated but before the Crazy had made its way to the surface, I'd set his bed alarm as a precaution. I didn't trust him to not fall out of bed or walk out of the unit. When he sat up, his bed alarm sounded, loud and proud. Jimmy came running to my room.

There I was, patting Patient on the back while he cried his missing eyes out.

"Uh...are you okay?" Jimmy asked hesitantly.
"Yeah, we're okay. Really. Patient seems to have misplaced his face, but we're gonna find it again, aren't we, Patient? It's probably lost in the sheets, or in your cubby next to your shoes. Could you do me a favor and shut off the bed alarm, Jimmy? It's killing me."
Jimmy's face was scrunched up; he was making his "ew, hugging" face. "Er...sure. Whatever." He flipped up the edge of the bed's console and disarmed the alarm. The only sound left was that of Patient's crying, and it was easing up.

I decided to let Patient take a powder. He'd already yelled, done some deep breathing, and sat up in bed, thereby meeting my goals of pulmonary toilet and exercise. Done, done and done. I got him tucked back in, and turned down the lights so he could try and nap. As I started to slide his door shut, he asked: "You're really nice. If I weren't married...would you marry me?"
I smiled. "You seem like an okay guy, Patient. I'd think about it."
"Even though I don't have a face?"
"Even so."
I shut the door and stepped out into the light of the Unit.

haldol, np: the reason for the season

And finally, a contribution from one of our psychiatric brethren, Haldol NP. I'm especially appreciative of this, because I've been played by some of psych's frequent flyers before. Still a little bitter about that. Thanks, Haldol!

19 year old Patient began her relationship with me by missing her scheduled appointment. She decided to instead drop-in unannounced later in the day to be fit into the schedule. She flopped down at my desk and shoved a piece of paper in front of me.

"Can you sign this?" Patient asked. "This" appeared to be paperwork from the state that proved that she was actively engaged in mental health treatment. I explained to her that I couldn't sign it because this was the first time I'd met her and that treatment had yet to begin. "Whatever," replied the young lady. Emphasis on "lady."

She was actually pretty good at talking and snapping gum loudly, if one considers this a talent.

As the psychiatric evaluation opens, Patient's chief complaint seemed to be anxiety. "I need Valium, I need Klonopin...this is what makes me anxious, talking to you." Patient's cell phone started blaring tacky hip hop; of course, she answered it.
I waited until she was off the phone.
Tacky hip hop again.
I requested that she silence the ringer.
Patient informed me that I was mean.
I insisted I was not mean, but rather straightforward and trying to do my job.
In response, Patient immediately began texting on her cell phone.

She followed up this singular act of respect with knocking on the window of my office to get the attention of a young man in an extemely puffy white coat with dog fur trim. She was trying to guide him to the office. I told her that I consider texting on a phone the same as talking on a phone. The delicate young creature exploded. "I don't understand why you can't just give me Valium. This is why I hate doctors!"

I tried to get across that the point of a psychiatric  evaluation is to collect a history and get to know the patient in order to guide diagnosis and treatment options. I shared with this sweet, sweet girl that I hadn't gotten an opportunity to know anything about her, as she has been otherwise focused.

Patient, the darling turnip blossom that she was, jumped from her chair and stormed out the door. She screamed: "I'LL JUST GO TALK TO MY THERAPIST! AT LEAST SHE HELPS ME, YOU FUCKING BITCH!"
I called back after her: "Happy Holidays."

the virgin mollie: how to get saved!

"I'm a little high on NyQuil and Tramadol as I write, so feel free to edit," the Virgin Mollie starts her submission. We won't hold it against you, Mollie. 

 

You know how we're supposed to have scripted bits we use to talk with patients? I want to know why we haven't received this as a script, because I'm fucking using it. Thanks, VM!

 

This is a story about coming to Jesus.
 

I started my career as a floor nurse. There, on Satan's Li'l Tele Unit, I learned what is probably my most valuable nursing skill: the Come to Jesus Meeting. This is a one-sided conversation, during which I lay out for my patients why we're going to do things my way.  It's a sort of behavioral modification tool, where we---Patient and I---come to an understanding. Usually it is used for those who:

• ride their call lights incessantly with the mistaken idea that their nurse = their bitch
• have unreasonable expectations (only ordering chocolate cake on a diabetic diet, refusing to walk until done watching the Maury Povich rerun marathon)
• have family members who believe, after careful research on Wikipedia, Facebook polls, and Ask.com, that they know MORE about disease/pharmaceuticals/avoiding death than our staff.

Patient was typical of our clientele. He was angry at us for his illness, as if we "gave" him coronary artery disease ("Here's a lollipop for you, and here's coronary artery disease for you"). Since surgery, this patient had been a terror---he'd been on the unit nearly a week. He was the sort of patient that, during global report, was not referred to as "pleasant", "confused", or "cute" (code word for "batshit crazy". Bulldog, the weekend charge nurse, understands "cute" differently than most). I forget the exact terminology Bulldog did use, but it boiled down to "unpleasant".

Usually report and nursing assignments go quickly. "Good" patients are divvied up accordingly and the less intense ones are paired with a sicker patient. There was absolute silence this Saturday morning. No one wanted this guy. Finally, I spoke up: "I'll take him." A collective sigh of relief. 

 

Off I went to get report. I'd been working in the CVU for only three months, so I wasn't trusted with very sick patients at this point. Background on Patient: male, in his late 50s/early 60s; angry; smoker; drinker; had major heart surgery. Secondary complications of renal failure and constipation, and did I mention he was angry? Meanest motherfucker ever, by report. The offgoing RN gave me the rundown. He shared that Patient was a "one-shifter", meaning "after one shift of having him, you will want to kill him and possibly yourself to eliminate every possibility you might end up with him again".

 

Patient hit the call light. Ding, ding, ding, ding, ding. He was also loudly calling out, using a string of obscenities, for his nurse. Night RN finished his report and asked, "Do you want to go look at him (which, in our unit, means 'so I can show you anything abnormal/ interesting/etc' about him)?" He was a recent graduate; he just wanted to go home. 

 

"No, I got this," I said.

 

Patient's call light continued to ding. 

As soon as he saw me, Patient immediately launched into a tirade about his call light going off for more than 30 seconds, which was how soon he expected "the help" (me) to arrive. He then began to curse me at the top of his lungs and tell me everything that was wrong with me. I stepped inside his room, calmly shut the sliding door to his room, and drew the curtain.

 

"I only have to come in here once an hour," I informed him. 

"I am not your maid. I control the pain medications, the nausea medications, the benzodiazepines. Also, the stool softeners. You are at my mercy and I will be directing your care today. I will be polite to you and I expect you to be polite back. You will NOT be hateful to me, or to other nurses."

 

"HOLY SHIT," said his face. And he was saved. Jesus 1, Patient 0.
 

It was mentioned in report for several mornings that someone had done something to him and now he was actually being pleasant. Nah. I'm only an instrument of the Lord.

o-dubs: on the other hand...

I've been really lucky to get such positive feedback from readers, and even luckier to get contributions from some of them. o-dubs wrote this in response to "my empire of dirt". Lightly edited. Thanks, o-dubs!

Patient had already completed round one of chemotherapy, with no discernible progress; she was admitted for respiratory distress. She and her incredibly supportive family were trying to decipher all of the information presented to them by the pulmonary team, the oncology team, the nephrologists, the medical ICU team. She was pleading with me through her tired eyes as I replaced the biPAP mask that she had worn for the last three days; this was the only way for her avoid intubation. I would explain to her again and again why it was necessary for her lungs at this point; she would just politely say, "Do what you need to do, sweetheart. You all know best."

I brought the attending into her room following rounds. He made direct eye contact with each of the expectant faces looking toward him and said this: "Look, here's where we're at. Right now, you are alert, you are aware of what's happening around you, you are able to talk to your family and enjoy the company that they bring. At any moment, all of that may change. Our medical technology will not be able to cure your condition. Yes, we will be able to keep you alive---possibly longer than if we stop aggressive treatment at this point---but your mental status will decline, you will be supported by machines, and some of those machines require sedation that would dull what capacity you have left. If it is more important to maintain the quality that you have right now, to be able to see and speak to your family and enjoy them...get the hell out. Now. Today. Don't stay here one hour longer than you have to. You don't have much time left either way, but right now you have the opportunity to choose to spend that time in a comfortable place, surrounded by these people who love you, not worrying about any more tests, procedures, or results. If that's what you want, now is the time to get out of here. We can help you do that, too."

I don't have any words to describe the relief, the happiness on Patient's face. Her cheeks had color for the first time in the three days I'd taken care of her. She smiled. As her family looked shocked and dismayed at this "failure" of medicine, this woman emanated a peace that was almost palpable. the family discussed this "new development" in the room for quite some time, but the woman's ultimate decision was delivered as a quiet, "Yes, please."

I removed her biPAP mask and traded it for a simple face mask. She was able to speak again. I could finally give her ice chips to moisten her dry, cracked mouth. No more lab draws. No more consults. Later that day, I sent her off to spend the rest of her life in a hospice house surrounded by gardens and art and a family who now had the freedom to focus on enjoying this woman as a mother, a wife, a sister, a grandma. A person.

Not a patient.

my empire of dirt

Patient came to us about a month ago. He suffered from the ICU FunPak of cardiopulmonary diseases----80 pack-years' worth of smoking, emphysema, multivessel disease, and a newly acquired septal defect that took away his heart's "lub-dub" and replaced it with a pathetic "whooooshwhooooshwhoooosh". He was also unable to hear, leaving all of the staff to use his worried family as interpreters. When they weren't available, we wrote short technical manuals for him in Sharpie pen, explaining test results, procedures, and the fact that if he didn't have surgery to correct his defect, he would surely die within weeks. If he did have surgery, he had a great chance of dying on the OR table, but a slim chance of surviving and returning home eventually. The physicians on different (one could say opposing) teams argued with each other, then got passive-aggressive. Send him out to a larger facility? No. Cut him now? No. Recommend palliation and give him a bunch of drugs and an opportunity to live with his family at the end of his life? Oh, hell no.

Precious time passed, and Patient finally went to surgery. After much debate, he decided he was willing to roll the dice on dying because for him, it was worth it to try to survive until his grandchild's first birthday, a short two months from this point.

Patient spent the rest of his life after surgery on an air mattress, stoned to the gills and terminally air hungry. He couldn't be assessed for neural function because he was sedated. He couldn't have sedation lifted because he would fight the vent. He couldn't respond to commands anyway because he couldn't hear us. All he could do was occasionally open his eyes, writhe, and get bolused with more sedative, to keep him manageable.

I use the word "manageable" loosely.

The last time I took care of Patient, I could have sworn I heard more of a whoosh at his apex than I had previously.  I frowned at the find, and chastised myself for not paying more attention during my previous assessments. I couldn't think about that sound being a new development. I talked to his children, his wife; I refused to say "better" or "worse", and just stuck to the facts. I honestly didn't know what to say otherwise. The Surgeon brushed off concerns, and would only say that we needed to give Patient more time. That night, over drinks, I decided to swear Patient off. I couldn't care for him anymore. I was dreaming about him, thinking about what else I might have missed, wondering what I could change, and dreading further arguments with Surgeon. It was time to stop.

A few days later, Patient tanked and died. It was one of those TV Hospital-style deaths, with everyone being heroic, and every measure taken. A horrible, horrible death. He didn't live any longer than he would have without the surgery.

I can't quit thinking. I can't quit thinking.

let me give you the nickel tour.

There have been a few questions about what this blog is.

It is:

• all true, with some story editing for flow and readability. That includes the bit with the "Taco Bell" patient...that one seems popular with you guys.
• complete with all names and some genders changed to protect the employed.
• a way for me to vent, on behalf of all nurses who wish they could share the amazing, dismaying things they see, hear and have to do.
• if you wish, a place for you to vent as well. I don't have the market cornered on the insanity that is nursing. (As a matter of fact, I have a new entry I'm working on editing for "Haldol, NP"---an advanced practice mental health nurse who last year began his work in the private sector).
• A display acknowledging how much we know and give in the course of providing care. I don't care what my mom says, I don't get paid well enough. And neither do you. 
• not intentionally a forum to mock anyone. It just works out that way sometimes. Okay, frequently.
• me trying to wrap my head around why we do what we do; not only within the profession, but within American health care.

sliders

Bulldog:
"I spent years trying to explain to these people that things work a certain way, and I did it until I was blue in the face. But it's not good for my mental well-being, so I stopped. When I'm faced with ridiculous orders and general stupidity, I just smile and make sure all the numbers match, and do whatever I want in between those numbers. The letter of the law, honey...not the spirit."

 

:::::

Resident: That guy that died last weekend? I stayed up the whole night before, keeping him alive. I go home on post-call, he dies.
Kilgore: That'll teach you to go home, ever.
Resident: No, that'll teach me to keep dead people alive.
[pause]
Resident: I never said I was a good doctor or a nice guy.
Kilgore: Touché, sir. Welcome home.

 

:::::

Patient: I got a question. Is Taco Bell bad for you? I eat there a lot.
Jimmy: You're on the CVU. You're almost 500 pounds. Do you think Taco Bell is working for you?
Patient: Jesus. It's just a question.

 :::::

Kilgore: Sir, are you ready to go for a walk?
Patient: Nah. I'm good.
[pause]
Kilgore: I see now how poorly I phrased that. Get up, we're going for a walk.

:::::

Family member: I don't know how you guys work the way you do. How do you do this stuff for 12 hours straight?
Kilgore: I don't know about the others, but I eat like a shrew while I'm here and drink heavily when I get home.

:::::

On a float to the ED:
Kilgore: ...well, sir, since you abraded your scrotum, I need to take a look to make sure it's not extra swollen or already infected.
Patient: What?!?
Kilgore: Yeah, I know. Sorry. If you're uncomfortable with me, I can get a male escort or we can get someone else to look.
Patient: No, it's not that. It's just...you're pretty. I wish this were under better circumstances.

 :::::

During the installation of a rectal tube:
Kilgore: .....aaaannnd...I think I'm past the sphincter...his rectal tone sucks, let's see if we get anything...
[Kilgore watches from the "action side" while Grace and Susie peer over the patient's other side. Diarrhea pours through the tube.]
Kilgore: God, that's a thing of beauty.
Grace: High five!
Kilgore: I guess all I need now is to know when this became normal for us.

:::::

Dr. Obvi: That patient's a dick.

Kilgore: I know. I assessed him.

:::::

The Metatron, overhead: Attention, visitors, it is now time to close the unit for change of shift. The unit will reopen at X o'clock when you may be welcome back onto the unit.

Every nurse, under their breath: Or you may not.

:::::

i'm so glad we've had this time together

RN: Hi. Your nurse is tied up with another patient right now, but since your light is going off, I thought I'd check on you. Is there something I can help you with?

Pt.: I'm in pain. I'm in so much pain I feel like crying. And I feel like I'm lying in bed funny. I need to be fixed. And this alarm over here [jerks thumb over shoulder] won't stop.

R: Okay, let me get you some pain medication, and then I'll get you repositioned, okay? [Stops alarm.]

P: Don't I look funny here? Like I'm really laying in bed wrong? How did this happen?

R: Well, your bed is tilted upright so you can see the tv, but you have to lie flat because of the procedure you had. We'll get you fixed up. I'll be right back. [backs away, silently curses not faking deafness, comes back two minutes later]

R: Okay, I've got your pain medication.

P: What is it?

R: Fentanyl. It's a narcotic.

P: Pssht. That shit never works. How long will it take it to work? Why can't I have more pills?

R: If it never works, how come...[decides, "fuck it" and doesn't ask anything] You can't have more pills because you already took some about 15 minutes ago, remember?

P: Oh. So how long will it take this to work?

R: Since it's IV, about five to 10 minutes. [pushes it, prays it makes P shut up]

P: OW. Jesus. That stings.

R: [tries to care]

P: [tries to sit up, lies back down immediately] OW, shit! That hurt! I'm not supposed to sit up, am I? What is that thing?

R: In your leg? [takes a peek under the sheets] It's an arterial sheath. It's a tube that goes through your femoral artery. There's medicine going through it that keeps you from clotting, so if you antagonize it by sitting up, you could bleed to death. That's why you have to lie flat. I'm sure someone has explained this to you, since you've been here a couple of days now.

P: Whatever. Can you move me? I'm sliding down, I can just feel it. Does this look right to you? I wouldn't slide if you'd let me sit up.


R: Someone is on her way to help me move you.


[RN2 enters.]


R: Thanks for coming, R2. We're just going to scoot this lady up. On 3. Okay, 1, 2, 3.


[RNs scoot Pt. up to top of bed.]

P: God, you could have warned me. I told you I was laying here wrong. Now can I sit up?

R: No.


R2: [rolls eyes, stifles giggle]

P: I could probably move myself if I weren't all tied down. [Waves hands around in the air for emphasis.] Hey, I need cream.


R2: [flees the scene]

R: I'll let your regular nurse help you with that. [Starts to leave]

P: This really itches. [Lifts up gown, right tit; starts scratching vigorously.]


R: I'll tell your nurse.

P: It's a fungus. I really need a cream, it itches so bad. Worst damn rash I've ever had. Jesus, my leg really hurts. Can I have more pain medication?

R: I'll tell your nurse.

P: Tell my nurse. I really need that cream. And my catheter really hurts. I hate that thing. Tell my doctor, too.


R: I'll tell your nurse. Goodbye. [Flees.]

~FIN~

this blog is supposed to have a clear cover.

Attention, staffers:

1. Unless the needle on your patient's Well-O-Meter is closer to "going home" than "needs a morgue pack", do not tell his family that he's doing much better.

2. There are multiple bake sales and events on our campus today. You will not be able to go because your staff is overburdened and only two out of eight of you will be able to sit during your designated lunch periods, as the other six of you opted to walk 20 of your 30 minutes to and from the cafeteria; however, it was felt that staff morale might improve, knowing how diverse life without you is.

3. Overtime will always be approved, even if you don't think you want it. Please speak directly with your manager; otherwise, Staffing will be happy to contact you for opportunities as they arise---frequently.

4. Our administration has decided to abort beta testing of any new technology we plan to implement over the next five years. Customer satisfaction is a must; after careful consideration, it has been decided that regardless of how poorly new systems initially work, that  our clients deserve to have bleeding-edge technology at their nurses' fingertips. "Bugs" can be corrected as the staff integrates barely functional software into their workflow, thereby making it more effective in real time. We will be working closely with our IT department; they will be as prepared as we are, since they are receiving notice of this change upon the release of this memo.

Happy Holidays! Thanks for all that you do, even though you're going to have to do even more next year.

Best,
Administration

chip shot, charlie!

News item found on Philly.com:

"Shortly after Kent Schaible died of bacterial pneumonia at his family's Northeast Philadelphia home in January 2009, a city social worker and a nurse visited to check on the well-being of his five siblings.

During that visit, Kenneth Dixon, of the Department of Human Services, asked Herbert Schaible if he had sought medical treatment for his 2-year-old son, Dixon said.

'He said that him and his wife were faithful to their religion and they believed in God to make their son healthy,' Dixon testified for the prosecution yesterday, the second day of the manslaughter trial of Schaible, 42, and his wife, Catherine, 41.

...The Schaibles are members of the First Century Gospel Church, in Juniata Park, which shuns medicine and doctors in favor of prayer to heal the sick."

I'm sorry for the loss of this child. Also, I've made it a point to not mock religious beliefs that differ from mine, no matter how ridiculous they seem. Lastly, it's not my business to tell anyone how to raise their family or choose their actions. I feel, however, that it's time to point something out.

1. You believe God is the Creator, and responsible for everything.
2. Following this line of thought, he also created bacteria and viruses.
3. But the good news is, Man is what He created in his image, and, if I've got this right, Man is also supposed to be a steward for God's other creations.

4. Maybe hospitals and health care are part of that stewardship.

5. Parenting is definitely part of that stewardship.

6. Unless God was specifically paying attention to your situation and actively rooting for the flora causing your kid's pneumonia, you blew it. God asked you to do one thing, and you actively fucked it up.

 

 

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?