the abyss

"He who fights with monsters should look to it that he himself does not become a monster. And when you gaze long into an abyss the abyss also gazes into you." -Friedrich Nietzsche

last week wore me down. 

there is this dynamic in my patients' lives that i just can't understand.  so much of my nursing practice involves working with this population, and it completely baffles me.  we take care of this core group of 18-21 year old men who are trauma patients (usually shot or stabbed) with no jobs, criminal records, multiple children by multiple different women, and seemingly no desire to do anything worthwhile with their lives. 

i just can't figure it out.  it's not a race thing (although it's way more prevalent in certain groups), it's not a class thing it's a LIFESTYLE, and this lifestyle is being glorified all around us.  somehow these guys have gotten the idea that certain things in life are the most important: money (the biggest problem, in my opinion), power, reputation, being desired by multiple women, having a lot of kids as a symbol of being "a man", certain clothes/shoes, a "hard" attitude, etc.  i see the same signs of people trying to live this life all the time.  it's in the tattoos covering my patients' bodies that say things like "money power respect" and "get rich or die tryna".  it's the fact that these boys have the mentality and impulse control of children but the anger and ability to destroy things of adults.  it's the way that these patients cry like little boys when they're in pain, and then an hour later are on the phone ranting about "doing their business" and how they're "grown".  there is such a disconnect here that i have trouble putting it into adequate words for myself, much less explaining it to other people.  

essentially, i often feel like my patients are doomed, and their children who are being born into this lifestyle are doomed, and that society in this city is destroying itself and there is nothing we can do about it.

working with this population has changed me, and probably not for the better.  

i want to grab these boys and shake them.  i want to talk some sense into them, to make them realize that this life they are aspiring to is beneath them, and that the things that they are living (or more accurately, dying) for are not as important as they think.

but i also realize that i have no idea how life is for these guys.  i haven't grown up in their neighborhoods, i haven't been indoctrinated with the idea that selling drugs is normal, going to jail is no big deal, that getting shot is some bizarre rite of passage.  i've had opportunities, and a safety net, and a chance.

so instead, i find myself without sympathy.  i am SO SICK of this.  i'm tired of watching people perpetuate the behaviors that are hurting them.  it's like watching someone smoke 2 packs a day for 30 years and then get lung cancer.  do they deserve it?  no one deserves that.  did they earn it?  probably.  

i sent a patient to jail last week for violating his parole by accidentally shooting himself with a weapon he wasn't supposed to have.  he had no idea he was being discharged, and no idea the police were waiting for him.  when they walked into his room to arrest him, he didn't bat an eye.  

it was like he didn't even care.  

it's things like this that have worn away at my optimism, made me doubt that i can ever make a dent in the problems in this world, made me so jaded and cynical that even i am shocked at the things that come out of my mouth sometimes.

i have looked into the abyss, and it has looked back into me.  and now i need to figure out how not to become a monster because of it.

wearing out our welcome

mark my words, we are going to get kicked off of our new floor.

it all started after our 'big move' d/t construction on the old unit.  suddenly for the first time since i've been a nurse, we have neighbors!!  this is nice in the way that it conveniences me when i need a green top or a vial of metoprolol, but strange in that i can't tell which patients belong to us and which are just passing through.  and then there's the whole matter of our unit showing its true colors...

we are hood.  and now everyone knows it.

it started innocently enough, in a baby momma fight that involved weave getting ripped out in the middle of our shared hallway and the screaming of the phrase "stupid ho" loud enough to make the nurses on the other unit come running.  the sheriff showed up and hauled people off to jail, and that was that.

then a week later security showed up looking for some visitors.  when trying to find teenagers who steal food from the cafeteria, apparently our unit is first on the list of places to look.  and sure enough, there they were.  after getting lectured by security and having someone pay for the food, the kids were of course very apologetic and saw the error of their ways.  just kidding.  they actually went back to the cafeteria and threatened the workers who turned them in, leading the sheriff to pay our unit another visit.

a few days later, we had a gentleman who thought it was acceptable to grope at the nursing assistants and call them "baby".  a manager tried to talk to the patient and explain that this was inappropriate behavior, which didn't go over too well.  things ended with the patient chasing our manager down the hallway in his wheelchair and calling him a homosexual.  cue the sheriff.

and a few days after that, one of my coworkers was asked to put his patient's coat away.  he opened the closet in the room only to find a samurai sword.  yes, a samurai sword.  when the sheriff showed up (for the fourth time in two weeks, but who's counting?), the patient was also found to have a hoard of oxycodone and his urine came back positive for cocaine.

these things happen in the land of trauma drama, but not usually so frequently and never so publicly.  but now here we are, on display for the rest of the hospital to see.  i'm half glad that other nurses can see what we're dealing with while they're taking care of normal looking people, and half embarrassed to be "that floor".

thankfully it will only be a few months until we move back to our own unit, tucked away in a corner by ourselves for reasons that i now see very clearly.  and it's my hope that these few weeks of lawlessness will reinforce to 'the man' that we really do need the locked unit we've been begging for.

but until then, new neighbors, my apologies.

presence

nursing is usually just a series of tasks.  pass the meds, walk people, do some dressing changes, call the doctor to clarify orders, whatever.  we run from patient to patient usually desperately behind and looking to spend as little time as possible in each place so we can catch back up.  the whole idea of patient care, the actual caring about and spending time with people often gets lost in the shuffle.  it's just the way things usually go.

last week i found myself in a unique situation.  we were shuffling all of our patients from one unit to another because of construction.  my job was to wait for my patients on the new unit and to settle them as they arrived.  because of the hugeness of picking up and moving a whole unit in several hours, we were blissfully staffed with the never before (and never again, i'm sure) ratio that essentially left all of us with only 1 or 2 patients to move.  my first "patient" to arrive was actually just her husband pushing a wheelchair of her belongings, as she was in the OR.  the patient had advanced cancer and was getting a washout for an infection from a previous procedure.  as i started to put her things away, the surgeon came to the room to let her husband know her surgery was over.  i was on my hands and knees wiping up the entire bottle of the saline i'd just dropped on the floor when i heard him tell the husband that there was a tear in the bowel.  this was followed by a very matter of fact "if she gets a fistula, i think it's time to pursue palliative care.  if it were my wife i'd start thinking about how long you want to fight this thing".  and then the surgeon left, and it was just me and my patient's husband whom i had met less than 5 minutes before.  

what do you say in a moment like that?  i've been there?  i'm sorry?  i'll do whatever i can to make this even the tiniest bit easier for you?  all of the above?  are there really any words that can blunt the pain of that kind of conversation?  

no, there aren't. 

in nursing school we aren't taught how to be helpful when someone's world is falling apart, probably because that's not something that can be learned.  so i offered the husband what i had, what i NEVER have but for some reason on this day in this situation, i did.  my time.  no other patients to worry about, no other tasks to run to, no ringing phone to interrupt the moment.  

i sat with him.  i gave him the comforting words that came to mind, and when those sounded like not enough to my ears i was just there.  it didn't change things, or make the truth any less difficult, but it was something.

i think that it's easy to lose sight of the fact that just being present when people are hurting is helpful.  sitting with someone whose heart is breaking is sad and sometimes uncomfortable, and for me brought up memories that i'd rather not remember.  but it was what the moment called for, and because of that i was happy to be there.  

this is the thing that i so easily forget: taking care of people means actually caring.  it's so easy for me to view the day as a giant checklist of meds and tasks that i put a line through when i finally finish.  i power through 10 or 12 hours with a death-grip on 'my plan for the day', trying to be productive and efficient.  but sometimes the day just calls for sitting in a chair and shedding a few tears for someone else's pain; for offering up my presence when i have nothing else to give.

2014

2013, i don't know what to say about you.  it wasn't a bad year, but it certainly had it's moments.  it was a year of growing pains, and i'm not quite sure why.  i feel like this was the year that i became officially branded as 'trouble' and i resent that.  i feel that the hospital's need to make money, cut costs, please patients to unrealistic levels, and essentially eat the lower half of the state reached an all time high.  i feel that i'm being asked to do more things in less time taking care of higher acuity patients and all with a smile on my face.

but that, i suppose, is just healthcare now.

in 2013 i finally learned to stay in my own backyard; that i need to leave people to care for their patients in their own way and that i get to do the same.  i don't find myself having as many run-ins with the residents, mostly because i don't really think that i have anything to prove anymore.  i know that i'm good enough, and i think i'm figuring out more and more which battles to fight for my patients and which to just let lie.  the longer i work at this job, the more that i see the shades of grey: the policies that don't apply in every situation, the rules that can be bent, the nontraditional ways to provide good care...just a more intuitive way of practicing.

i'm not a perfect nurse, not by a long shot.  but i care about my patients, i want to give them my best and that is something.

so without further ado, in 2014 i would like to:

• be less judgemental; of the doctors, of my patients, of my coworkers.  we are all only human and doing the best we can.  i need and expect grace when i fall short and i need to give it in return as well.
• try to be manageable.  i have a rebel's heart, and i don't like being told what to do/how to do it.  as a result, i have a big problem with authority.  i realize that i'm to the point where i've got an axe to grind over just about everything that comes out of 'the man's' mouth.  i need to be open to trying things a different way, and i need to give change a chance.  
• not let 'comfortable' become 'stuck'.  my job is like a little security blanket that i haul with me wherever i go.  i know it,  i'm good at it, and i'm more than a little afraid that i'll turn around one day and realize that i'm about to retire and i never left the floor because it was easier that way.  i simultaneously want to be challenged and am terrified of the unknown.  i need to keep my eye on the prize, which right now seems to be moving to the ICU.
• never be too busy to be compassionate.  i easily turn selfish and focused on my own stuff, and it freaks me out how i forget to be grateful that i'm not the person in the bed.  cardiac nurse bff once told me about a patient satisfaction survey where someone complained 'no one said sorry i'm sick'.  entitled as that might be, it stuck with me, and now i try to remember to tell my patients that i'm sorry this happened to them.  

i like the new year because i like definition and order and the belief that one particular day turning into the next somehow means that i have a clean slate.  i guess that's what i want more than anything in 2014.  i need a fresh start, and the chance to prove that i can be better than i am now.  first i was a good person, then i was a good nurse, and now i want to be both.  

here we go.  

christmas cray

...because it's not christmas until we're wrestling with a hallucinating amputee who's trying to run from the guy who's trying to kill him in his room.

restraints and haldol to all and to all a good night.

these are a few of my favorite things

lately i've been trying to find joy and satisfaction in whatever i can at work.  typically this comes in the form of things patient say and gross medical procedures.  so without further ado...

• patient diagnosis overheard in report "got shanked at the library".  dangerous places, those libraries

• awesome coworker's patient was vomiting non-stop and needed an NG.  i was her second set of hands and watched her put in a beautiful NG that pulled 2,125 ccs of bile out of the patient's stomach.  picture a 2 liter bottle of soda...yeah, that much.  it was a magical experience.  

•  new terminology: "chronic GSW".  you know, for when we take care of you after you get shot on more than one occasion.  you'd be surprised by how many repeat customers we get...they are the ones that i like to target with my "make good choices" speeches.  

• the patient satisfaction surveys... full of gems such as "you don't have MSNBC on the tv" and "the vending machine took my money".  my personal favorite were the responses from two different patients, one of which said "don't bring me water unless i ask for it" and the other "i shouldn't have to ask for water to be brought to me".  yes, these are the things that our patient scores depend on.  

• our developmentally delayed pt who wanted to go "take a tour" of some newly constructed rooms so he could request one for his next surgery, all while decked out in christmas gear with stuffed elves hanging from his IV pole.  cute.  

• we have had such good residents lately!!  attentive, smart, wanting to collaborate...a holiday miracle, for sure.  

• my wonderful coworkers.  they get me, and they remind me who i really am and the kind of nurse i want to be.  

the last few months have been hard for me, that's for sure.  but i DO have things that i love about my job and i DO have so much to be thankful for. 

on criticism

i had a painful meeting this week with management on the topic of "expectations and opportunities".  this is apparently a euphemism for 'everything that is wrong with you'.  it did not go well.

they were quick to tell me that i'm a great nurse and that i provide excellent patient care.  which, if i'm not mistaken, is my job.  take care of patients.  be nice to them.  work well with others.  follow policies.

did someone forget to tell me the part where i agreed to think only happy thoughts all day despite bleak morale, impossible expectations, and understaffing?  or the part where i said i would be only rainbows and smiles 24/7, on all the time with no trace of frustration or feeling overwhelmed?

THAT IS NOT MY JOB.

i have apparently become some sort of "leader on the floor", which is another management euphemism for "fall in line before others mutiny".  keep in mind this is not something i asked for, nor something i have been payed for.  no, this honor has been give to me because i'm one of the only people who has been able to survive 5.5 years on the floor, through 5 different managers, 3 directors, countless threats of physical violence, verbal abuse by patient and doctors, unsafe staffing/patient assignments, and little to no credit or thanks most of the time.

so you're probably wondering what i did that's so awful, right?  did i have a screaming fit at the nurse's station?  did i rant to a patient?  did i tell off my manager?

no.

i said that staffing was "not ideal" (which it wasn't).  and i said it to my coworkers (who are my friends and should get to know why their assignments suck).  while making up the day's assignments (which i am not payed extra to do).  which i actually have to do before i punch in for the shift, so i am doing them on my own time for free.

i for one thought that i was being pretty tactful, given what i would have liked to say, but i guess i should be ashamed of myself.

so anyways, something silly like daring to voice an unapproved thought led to almost an hour meeting about how i am in charge of my shift's morale.  i must be positive.  i must not say negative things about staffing to my coworkers.  if i must say these things, i should find my manager, go to her office and close the door (this was emphasized) and then i am allowed to speak with "candor".  otherwise, i must take time to "collect myself" before returning to work...apparently with a 100 watt smile and my pom poms, cheering the team on.

as i have previously mentioned, i'm at the end of my rope with this job.  i'm giving everything i have left to my patients, which doesn't leave a whole lot of energy to be fake around my coworkers.  i'm tired, and i'm sure it shows.  but i am TRYING.  and i don't understand why i'm being held to a different standard than anyone else.  i don't want more responsibility, or more pressure.  i basically want to be anonymous and to be left alone.

so to recap: i'm expected to take on additional responsibilities like being the charge nurse, precepting, and being a resource, which can be inconvenient, annoying, and stressful.  and this somehow makes me a "leader".  but instead of getting more of a say on the unit, or getting the right to voice an opinion and bring about change, i'm being stifled.

so which is it, management?  do you want me to lead or not?  do you want me to advocate for my people, to be their voice?  or do you just want me to do all the work, toe the party line, and shut up?

i think the answer is obvious.

at the end of the day, i need to answer to myself.  can i be proud of myself?  did i stand up for what i believe?  am i saying things that need to be said, or just whining?  there's a fine line between advocating for myself and my coworkers and being divisive.  but there's also a fine line between being a "leader" and being a drone.