teachable moments

hello, i'm your friendly trauma nurse and i would like to take this opportunity to teach the general public how to not be so stupid.  please pull up a chair and make yourself comfortable.

may i start out with the cardinal rule: never tell your nurse you want to kill yourself.  don't even imply it.  and when you do start making foolish comments about throwing yourself out of the window (um, ground floor, try again), don't be surprised that you get a sitter and a psych consult faster than you can say 'suicide risk'.

another rule of thumb: please avoid attempting to punch hospital security in the face.  though it's entertaining to watch you being tackled to the ground, i'm guessing that your fractures don't feel any better with 200 pounds of the law sitting on your back.  for the record, assaulting hospital staff is the fastest way to get tied to your bed, or in this case handcuffed until the sheriff can come and arrest you.

this next tip might be common sense to some, but recent events prove that it deserves mentioning.  if your mother is a morbidly obese diabetic on dialysis who lives in a group home, YOU SHOULD NOT BE GETTING HER DRUNK.  seriously.  day passes are for cute mother/son dinners and trips to church, not for slamming back 40s until mama's so plastered that she falls and breaks her face.  three times the legal limit people...no lie.

it never ceases to amaze me how people are bound and determined to find new ways to totally screw themselves and the ones they love.

  

try again.

so when you've been missing from the floor for five hours, i'm really not going to believe you when you tell me you were "just chillin in the parking structure".  as we have had security and management looking for you for the past two hours, i think that we can all agree that you are lying to my face.  so where were you?  oh, that's right, YOU WENT HOME.  with your dad and your aunt.  and it was very unfortunate for you when the car broke down in the middle of the monsoon thunderstorm apocalypse outside and you were stranded out in the rain.  because, you know, you're sick.  and, newsflash:  when you're sick enough to be in the hospital, you need to stay there.  like, until you're discharged.  what part of that is difficult?  did we really have to tell you that you can't just have your homeboys load you and your wheelchair up into the back of the truck and drive you around for awhile?  you still have a foley.  your neck is broken.  i'm not sure you're to be trusted with your IV out in the 'hood.   and the whole parking structure facade?  seriously?  LIE BETTER next time, or at least close your door when you tell your girlfriend about your fun joyride.  because I CAN HEAR YOU.  

thank you and goodnight. 

dreams

i get asked all the time if i'm a floor 'lifer'.  i guess it's because i've been on my unit for just shy of four years, which is an eternity in the land of trauma.  in four years, i have the most seniority on the PM shift.  when our veteran day RN retires in august, i'm up first for day shift.  but here's where it gets tricky.

i don't want it.

i hate days, always have.  when my eyes open before 8 am my first thought is 'kill me now, i just want to die'.  i hate driving when everyone is on the roads and the commute back and forth to work is an hour instead of 30 minutes.  i hate the thought of being a day vampire in the winter, where you go to work in the dark and come home in the dark.  i hate everything about day shift, and while i'm young, single, and childless i don't have to feel guilty about living the PM life...sleeping in, staying up late, going out for drinks after work at midnight if i feel like it.  days is out for me.

and don't even get me started on grad school.  if there's one thing i do know for sure, it's that i belong at the bedside.  i have lots of respect for NPs, i just am not meant to be one.  we'll leave it at that.

but i'm starting to feel stagnant.  i've watched nurses leave the floor for ED or ICU or float pool for years. i know i could never do float pool...changing floors everyday would make me crazy.  and ED is not a place for someone who is (yeah i'll say it) kind of high strung.  but the ICU...now that calls to me.

well, it calls quietly.

truth is, i'm terrified of leaving the floor.  i still don't feel like i've got it all together there.  i learn new things all the time.  codes still make my heart beat practically out of my chest.  i don't know how i could possibly be ready for the ICU.  and when i start thinking about having to start all over?  forget it.  if i knew four years ago how hard this job would be, i don't think i would have done it.  i would have found a library and started shelving books, living out my librarian dreams.  and the thought of changing jobs just when i'm finally almost comfortable?  sickening.  

i'm so jealous of people who can make the ICU transition without even flinching.  who don't think twice about all new coworkers, or being faced with vents and pressors and half-dead patients, or starting out paying their dues on the night shift.

i hate change, HATE it.  passionately.  but i also hate feeling like i'm settling.  i hate feeling like i've plateaued, like i'm doomed to live a dreamless life of quite complacency.

i am a damn good floor nurse, let me tell you.  floor nurses don't get any credit, usually.  people think that we're not smart, and doctors often don't take us seriously.  the floors are the trenches, people.  i have 5 patients to take care of, no big glass rooms so i can see them all the time and no continuous monitoring.  i hang heparin drips to treat PEs and take care of VACed open abdomens and give blood and have patients with four chest tubes and three broken extremities and my patients are busy.  if this were ten years ago, these patients would be in the ICU.  heck, if i didn't work at a level 1 trauma center, these patients would be in the ICU.  but how i would love to collaborate with a physician about patient care instead of being treated like an annoyance.  and how i would love to do some of the things i hear about from the ICU nurses...mass transfusion protocols and codes with cracked chests at the bedside and hypothermia...wow.

now i'm not one for cheesy quotes (ok so i am.  don't judge.), but lately i've been thinking of one.  if your dreams don't scare you, they're not big enough.  i haven't been scared for awhile.

but maybe it's time.

so back to the question: am i a trauma floor 'lifer'?  four years ago i would have said yes.  four years ago this was my dream and i was scared.  every day.  but now i'm not so sure.  and that, for now, is as close to an answer as i have.

FAIL

1.  we get this admit from ED.  now i know that the ED is crazy, and i'm not one of those nurses who needs every little detail that i can find for myself in the computer in report, but i do expect the basics.  like the diagnosis.  so this kid is apparently a fall off a balcony.  the report was as follows: "mmm ahh,  2 IVs in...i think 2 IVs...chest tube on the left (not correct).  i think he fell.  (yells to coworker in background) DID HE FALL??  ok, yeah. and mmmmmm, yeah we're sending him up".  the patient arrives with a chest tube that's supposed to be to suction but is not.  he apparently has a C-spine fracture, which was not mentioned at all in report.  he's for some reason still attached to the ED's TRAM monitor, but not the actual monitoring screen, just a brick with some outlets.  and the first words out of his mouth when i asked him what happened?  "I jumped, because IT WAS THE WILL OF GOD!!!".  um, yeah...you are clearly a suicide risk and therefore a sitter patient.  upon further investigation, the patient was not supposed to be transferred to the floor until his sitter arrived.  when we called the team and asked where the patient's orders were, we learned that the team wasn't aware he was coming to the floor either.  they told the ED to hold him.  once again, i know the ED is crazy, but if you're going to dump a patient on us, would it be too much to ask that you actually tell us what's wrong with him?  you know, before we leave him alone and God tells him he needs to strangle himself with his oxygen tubing.  transfer FAIL, ED.

2.  we get this transfer out of the ICU.  little old man with rib fractures.  i'm headed across the hall to my patient's room when i hear a noise.  like a train.  puff puff puff puff puff puff puff.  so i follow the sound, and find the little old man in his bed breathing at 50 a minute.  that noise?  is the sound of Jesus coming for the little old man who is (naturally) a full code.  oh, but not to worry!!  upon transfer, the ICU nurse said that the patient had "been like this".  well this?  is not ok.  ever.  because little old man can't breathe at 50 a minute forever.  and soon he will stop.  breathing, that is.  and then he will be dead.  so after a rapid response, some nebs, a little IV lasix, and some prayers that he wouldn't code, we 'return to sender'-ed him to the ICU, only 3 hours after he came out.  shame on you, ICU nurse, for allowing him to be transferred to the floor in the first place.  and for that, you get a FAIL.

3.  a patient was brought to us after hitting a tree with her face.  clearly after such a trauma, the patient was knocked unconscious.  in an attempt to help, a bystander began to administer CPR.  unfortunately the patient was still breathing with a pulse, and the attempts to resuscitate her only stopped when she opened her eyes and croaked "i'm alive".  so now it addition to her facial trauma, she has rib fractures and a cracked sternum.  note: if when giving CPR, your victim is watching you and trying to talk, STOP COMPRESSIONS.  kudos for having good intentions and trying to help, but ultimately that's a CPR FAIL.

a little math/physics/common sense

in a drag race between two motorcycles, who wins?

the semi that crosses their path.  because semis win EVERY TIME.

and open fractures were had by all!!  except the semi, of course.  it just had a dent in the back from one of the motorcyclist's (helmet-less) head.

i've said it before and i'll say it again.  make good choices, people.

on being an evil crazy monster nurse.

so i had a bad day yesterday.  couldn't get anything done, everything kept going wrong, people constantly calling me, behind all day and couldn't catch up.  and as i drove home, i was pretty sure that i should never go back to work because i suck so bad.  then i woke up this morning, and i still feel like i suck so bad.  

do you know what's sad?  when i'm drowning at work and trying to keep 5 people alive and well (one of them being myself), i get real bitchy real fast.  i distantly remember the days when i had infinite sympathy and patience.  i don't know where it went.  it wears me out, doing and saying the exact same things 12 times a day, always having to convince people that i do know what i'm doing and may be able to help them feel better.  i'm exhausted by it.  

i feel like i have had one patient my entire nursing career.  i keep telling them they need to get out of bed and they don't want to.  i have to try to convince them that the oral pain meds really will last longer than the IV stuff.  you need to do your IS, no you REALLY DO NEED TO DO IT, because you will get pneumonia with all those rib fractures.  but it's not just one person, it's dozens.  the same thing every day, the same discussions, the same arguments, and the same moment of realization that they come to when they discover that doing all the things i'm telling them to is making them better after all!!  shock!!  and then they get discharged and we're back where we started, with another version of the same patient that thinks that it's a good idea to lay flat on their back with all the lights off and their head under a blanket and feel really really sorry for themselves instead of doing the things that they need to to get better and get home.  

i hate myself for thinking about people this way.  i feel like i'm a monster.  i used to be a REALLY nice person, and this job beat that out of me.  in the beginning, i had so much empathy that i almost couldn't function.  i really felt bad for people, and i cried all the time because it was all so sad.  i could not do my job like that.  i came to the point where it was quit or suck it up, and i sucked it up.  

but i'm mean now, sometimes.  and i feel heartless.  and i have a low tolerance for a lot of things.

yesterday my patient came in with multiple rib fractures after a car accident.  she moaned in pain at everything, despite frequent IV meds.  everything hurt, whether i was flushing the IV, washing the blood off her hands, or doing something that really did hurt like helping her turn.  she insisted that the head of the bed be completely flat and would not even attempt to sit up.  she nibbled at crackers, but would not actually eat because she was nauseated, but then said that she couldn't take pills because she had an empty stomach.  she complained of 10/10 pain, but would promptly fall asleep after meds.  then she would wake up and start shaking and writhing in bed and her family would come to hunt me down.  the IV morphine wasn't giving her good pain control (and made her sick, like everything else), so i wanted to change her to orals.  of course the order that i had was for oxys, which was one of a list of 3-4 meds that she couldn't take because "they make her sick".  so i went to talk to the resident.  i was fed up, and said something sarcastic like "i want you to give her something to put her out".  and the doctor just stared at me and was all "i'm not putting her out".  that's when i started to feel like a horrible person, because a good nurse would never even kid about something like that.  and that resident probably still thinks that i wanted to snow that patient.  which i didn't.  i wanted her to have something that worked, that would make her feel better.  I wanted to feel better, by helping her.  

but no, instead i had to get all mouthy with the resident and say stupid crap like that, and of course then she thought i was crazy angel of death nurse and didn't want to give me anything i asked for, including the ativan that i really thought would help with the patient's anxiety issues.  and first i hated the resident and glared at her and wanted to strangle her neck.  and then, instead, i kind of hated myself a little for being an awful person and saying mean, hateful things and putting myself in the position of having doctors think that i am evil and crazy.

and then, this morning, i read this amazing post by one of my favorite nursing bloggers, and i started to feel a little better, just a little.  but that's a start.

maybe today i can go and be kind and loving and sympathetic towards people.  maybe i can be more patient.  maybe i can cut other people a little slack, and maybe i can cut myself a little slack too.    

syncope

there must be something about me that says 'come by me, then have a syncopal episode'.

when i had been out of nursing school for about a year, i was out at a bar with a few friends.  i noticed some commotion by the bathrooms, and went over there to find a guy laying on the floor.  leaning over him was one of the ortho residents that i knew from work.  to this day, i am humiliated by the fact that i practically yelled "DO YOU WANT A BLOOD SUGAR?" and then whipped out my glucometer and took a fingerstick.  also by the fact that the guy eventually got up off of the floor and went into the men's room, where i followed him to make sure he was steady and not going to collapse again.  overzealous much?  ok.  

maybe a year later i took my first vacation day EVER up until that point.  my friend and i were about to leave her apartment to go to an art show, when we noticed a group of housekeepers gathered outside of her neighbor's door.  apparently she had passed out and fallen several days before, then couldn't get up.  they could hear the elderly lady inside, but couldn't get in because her door was double locked and they only had one key.  while my friend called the fire department, i took a brief history while yelling under her door.  i'm sure the firemen appreciated my helpful "she's A+Ox2.  and diabetic."  they axed in the door, and took her to the hospital.  only two words come to mind here, people: life alert.  get your favorite senior citizen one.  

then there was the time last summer that i was having dinner with a fellow nursing friend at Applebees, when a woman ran into the restaurant screaming "call 911".  we ran to the parking lot to find a little old man on the ground between two cars.  i made myself very helpful by taking just about forever to find a pulse because i was shaking so bad.  he came to, the ambulance arrived, and he refused to go to the hospital.  unfortunately, i had pretty much lost my appetite for the santa fe chicken salad after that.

and today, i was at church listening to a detailed description of leprosy, looking around to see if anyone was going to barf from all the graphic talk of skin boils and open wounds.  i watched a woman get up and walk out of the service.  i heard a crash, and ran out to find her on the floor.  by the time i got there (approximately 30 seconds), we had 2 EMTs, a retired fire chief, and 2 other nurses.  so this lady was unresponsive, pale, and clammy.  breathing.  pulse weak but there.  we had equipment, so while someone got some oxygen and someone else took a blood pressure, i ran for my trusty glucometer (yes, i am a freak) and tried to get a blood sugar.  which took me 2 tries because i was shaking so hard.

*i would like to break here and say this: adrenaline is not my friend.  no matter how competent you are, it is very difficult to look cool and collected while shaking like a crackhead who needs a fix.  as inconvenient as that is for me, it's just how i respond to trauma.  but this is your job, you say.  you should be used to this by now.  yeah, maybe i should.  but when i'm at work, i'm in the zone.  i have my eye on the people i think might get sick, so i can be ready.  and when something catastrophic and unexpected (like an out-of-the-blue code) happens, i get all my people there and usually do the thing that requires the least coordination...like the compressions.*

so anyway, blood sugar is fine, pulse is fine, pressure is fine.  ambulance arrives and loads her up.  i make myself useful by helping her with the earring she's trying to get off her ear, as my fine motor skills chose this moment to finally return.  and off she went {for the record, i'm thinking orthostatic hypotension secondary to over-aggressive BP meds caused this, and not the gory leprosy sermon}

so there you have it: my unfortunate history of syncope and good samaritanism.  or something like that.
 

the truth about nursing.

so it's nurses week and i'm bombarded with all the flowery, happy words and sentimental thoughts about healing and it makes me want to throw up a little.  then you dig a little deeper, and you reach all the jokey ecards about sponge baths and stealing narcs.  can nobody come up with something honest?  because i can tell you exactly what nursing is, as illustrated by my night saturday:

so while everybody else in the world got to go out this weekend and wear fancy party hats and watch the kentucky derby and/or drink margaritas and celebrate cinco de mayo, i spent all of saturday getting screwed over, as usual.

we had eleven admits.  ELEVEN.

everyone was in pain.  or just dramatic.  anxious.  crying.  generally needy.

i get the morbidly obese man with the enormous leg tumor...we're talking toddler-sized here, people.  NOTHING would go right with him.  his PICC from the outside hospital wouldn't draw, and it took me 15 minutes of pulling to get a syringe of blood.  then lab called to say that everything was clotted and needed to be redrawn.  kill myself.   his large tumor smells and is leaking all over everything.  i had to roll him like 6 times to adjust his sheets and put him on the bedpan and so the doctors could see the back of his giant tumor.  and before i even had his admission done, the next one had arrived.

who was in uncontrolled pain.  who broke both arms.  who arrived to the floor 30 minutes before night shift starts and therefore i was expected to do all admission paperwork and charting and then go buy a FREAKING BOW AND PUT IT ON TOP OF HER HEAD.

and then there was my drama king patient with the rib fractures.  seriously?  i rubbed his back and listened to him discuss all his fee fees and murmured soothing words and put up with his histrionic crap all night.  pity=gone.  if you don't want to be in pain, maybe you should stop refusing everything i offer you because "that will make me throw up and i can't throw up with these riiiiiiiiibs".  sir, you do not have stomach problems, YOU HAVE MENTAL PROBLEMS.  now take your damn vicodin and leave me alone.

and while we're at it, i'm sorry that your 0.5 mg of xanax isn't as good as the 3 mg that you take at home.  i know you are anxious and angry that none of your friends came to visit you.  perhaps you should make your way down to the other end of the hall and sit with my other patient with borderline personality disorder.  he, too, would like someone to sit in his room and "just talk".  while you're at it, he would like someone to rub his back.  so get on that.

and, for the record, we got not as much as a cheap pen set/gross cake for nurses day yesterday.  as always, the appreciation from management is awe-inspiring.  but not to worry because, as always, my love of bending over backwards for people and running my butt off night after night (with little gratitude and no thanks whatsoever) keeps me warm at night.


THIS is what nursing is:

it's doing 3 things at once while knowing that you're so far behind you'll probably be sitting for an hour after your shift catching up on charting.

it's driving home at night kicking yourself because you forgot to chart that PO intake, or forget to double check your I&Os, or didn't look at the 2000 vitals.

it's simultaneously doing a huge dressing change and fielding phone calls about staffing and placing new admits.

it's your phone ringing 4 times when you're in a patient's room with people calling about beeping pumps and patients who need pain meds.

it's calling a doctor, waiting 15 minutes for them to return a page, and then having them call back the second you go to the bathroom.

it's sitting at the nurses station trying to chart and not being able to because the call light goes off every 30 seconds and family members are continuously coming up to the desk for refills on water and to get more blankets.

it's like being a mother of 4 toddlers, all who depend on your for their every need.  it is a job where people will bleed you dry then demand more.  and there is ALWAYS something more you can do: another committee to join, another responsibility to pick up on the unit.  and instead of recognizing that this is an impossible job and congratulating you on being able to do remotely what you need to, management will take all possible opportunities to tell you what you're NOT doing.

nursing is HARD, but people have no idea why.   most days, it's not that i have to do gross things.  or that my patient's stories make me really sad.  it's that the system is broken.  people take no responsibility for their own health.  patients are often rude and entitled.  and it's just so FRUSTRATING.  i have spent the better part of the last four years completely frustrated.  

so hallmark, why don't you make me a card about THAT.

in which i pretend i am an ICU nurse, AGAIN

yeah yeah yeah, my patients are sick and there are lots of them and only one of me and i get people who really should be in the ICU for closer monitoring.  i know i'm a big whiner.    

but SERIOUSLY.  where do you draw the line?

when you have 4 different oxygen delivery devices at bedside and have to keep switching back and forth 234234 times during the shift?  ok, 93% means we can go to the high flow nasal cannula, yay!  then 79% after turning...boo...back to the simple mask.  still only 85% on 10 liters?  guess it's back to the nonrebreather again.  91% on 15 liters...what a nice stable floor patient.  

i'm talking q 15 minute checks on this patient for 10 hours.

continuous pulse ox...yeah know i'm not supposed to do that but it's my "ICU" and i can do what i want to.

constant cheerleading to "take nice deep breaths" and "cough that out" and "iiiiiiiiiin through your nose".

and 3 other patients with needs.  you know, like to see my face every once in awhile.

i'll tell you right now, i love this stuff.  i like the critical thinking and the stat labs and scans and i like it when the doctors actually get concerned about something and prove that they are not indeed robots, as i sometimes believe.  

but i would like to do all that without neglecting the other 75% of my patient assignment.  and i would like the doctors to respect my opinion, like in the ICU.  and i'd take more money for my trouble.  

just saying.