kibbles

so i just had the kind of shift where i got completely slaughtered.  people were having seizures, new admits came with terrible pain issues, ICU patients transferred out that had only been off the vent for a few hours...that kind of thing.  completely.  slaughtered.

i had already accepted the fact that the night couldn't be salvaged, so my orientee and i just had to hold it together for an hour until the night nurses took over.  we walked into our total cares trached/PEGed patient's room and what did i spy upon the floor but a bowl of kibbles and a water dish.

sadly i didn't blink an eye.

so i asked the patient's daughter the first question that came to mind.  "...is that cat food?"
and she nonchalantly replied, "no, it's dog food".

i suddenly noticed the zipped shut black duffle on the chair that was squirming suspiciously.

"ok", i said.

and then i finished my cares and left.

things i don't have time to deal with:
1. dogs in duffle bags.

and that, friends, is a prime example of choosing your battles.

six years

yes, it's true: i've been a nurse for SIX years now.

thoughts on this include:

1. i've survived (!!!)
2. i am old
3. it took this long to feel like i've kind of got it together

something magical has happened in the past year, something i can't really explain as i don't understand it myself.  one day i just realized that all i have to give people is my best.  i came to terms with the fact that people will do well or people will do poorly and that i don't get to control that.  all i can do is be vigilant and competent and the best nurse i can be, but people will still get sick and code and even die and that is NOT MY FAULT.

so long i lived with the fear of feeling the terrible guilt and depression that i felt after my first code and death, and it crippled me.  the weight of that has lifted this year and i finally have some perspective.

i'm only human.  i give everything i have and some days that's enough for people, some days it's not.  but that's all i have to offer.  i care about my patients, i fight for them daily, and i try to be encouraging and kind and sympathetic.  but my other patients have needs, and my coworkers require my help, and i've finally learned that giving everything thing i have until i'm empty and emotionally drained isn't good for me and ultimately doesn't help anyone.

some days patients aren't going to like me.  doctors are going to think that i'm making a big deal out of nothing.  management isn't going to want to hear my opinions on a new policy.  my coworkers are going to think that i'm overreacting to something.

and that's ok.

a long time ago when i first started nursing and it was hard, we came up with a motto: "you know the truth".  it still applies.  i know that i'm doing the best i can to give my patients great care, to support my new coworkers, and to make my unit a better place to work.

that's all i have to offer  

and it's taken me six years to realize it, but

that's enough.

how am i gonna be an optimist about this?

today i had my ass handed to me.  twice.  

the first time was by this pregnant patient with a bowel obstruction who refused to see reason and systematically tortured me all shift.  halfway through receiving an MRI to determine what exactly is going on in her belly, she decided she had enough and demanded to go home.  and she remained dead set on this terrible idea even though her entire family and all of the hospital staff told her it was a horrible idea.  after literal hours of trying to bargain and reason and threaten the very real possibilities of sepsis and death, i just couldn't handle it anymore.  she made her decision, i pulled out all of her lines and drains, and she left AMA.  

and it really sucked, because i didn't agree with her decision, yet i was the one that had to take out the PICC line giving her the nutrition that is keeping her baby alive.  and i had to get rid of the NG that is keeping her distended bowel from exploding.  and i had to pull the foley that was showing us her terrible urine output and let us know just how sick she was.  she made me do things that would ultimately harm her and her unborn child, and it made me feel kind of terrible.  

so after this emotional abuse, i was treated to 10 rounds of fighting with an overprotective daughter who refused to let me put a catheter in her elderly father.  the guy is super old with a bowel obstruction, and i couldn't tell how his urine output was because he's incontinent.  i explained to the daughter that we need accurate I&Os to tell us how his fluid balance is, and that we don't want to give too much fluid because of his bad heart, but also that we need to perfuse the kidneys.  i explained that catheters don't stay in as long as they used to, and how there are initiatives to DC foleys asap to avoid UTIs.  and then she basically told me that if we put a foley in him we would never get it out again and "i'm not taking care of a 91 year old with a catheter".   

and she went on and on about how we need to give him a bunch more fluid and she can tell when he needs it and he won't go into heart failure because she can tell and she knows and she watches him because the nurses are too busy, especially the last time he was in the hospital and did i tell you about 12 years ago one time after he had surgery and we had to stay for a few extra hours because he wouldn't pee and i had to have a catheter last year and i would never wish that on anyone because it was so painful and terrible and blah blah BLAH.

and i know she wanted me to agree with her, BUT I DON'T.  and even after i told her like 12 times that i would have her discuss her concerns with the doctor, she JUST KEPT TALKING.  

and then it was shift change, i was way behind with report, and guess who's getting readmitted?????

yes.  so it turns out that when you have a bowel obstruction you will go home and vomit and then go directly to the nearest ED, who will do nothing but place an IV and send you back from whence you came a short 5 hours ago because YOU NEVER SHOULD HAVE LEFT IN THE FIRST DAMN PLACE AND YOU HAVE NOW WASTED ALL MY TIME AND EMOTIONAL ENERGY AND I AM SO FRUSTRATED.

and in sitting here trying to find some sort of moral to this story, i'm coming up empty.  

may tomorrow be better.  goodnight.  

if you don't want to hear me vent you should skip this one.

hey management and associates, why don't you GET OUT OF MY LIFE.  

first of all, you are not even real nurses.  you have no idea what i go through, and could not do my job if you tried.  if you spent one day in my shoes, the tiny blackened piece of your soul that is left would shrivel up and die.

 

you don't know me.  you don't know my life.  

also, i could care less about your administrative BS, or some script you want me to read to introduce myself, or your opinions about how often i should be in my patient's rooms, or where i should give my report to the oncoming shift, or how i teach about medications, or your thoughts about how i should magically be able to infer how each of my patients would like to be treated.

i am tired of you looking over my shoulder.  i am tired of you following me around to listen to me parrot exactly what you want me to say like a good little soldier.  i am tired of forging my signature of one of your thousands of check off/audit sheets.

you. are. dead. to. me.

and here's looking at you, wanna-be floor nurse turned leadership team member!!  you are terrible.  how about you actually read the policies before you spread a bunch of misinformation about what they say?  too much to ask?  just so you know, i will not be following the ideas you pull from the air at a whim.  and when i call you on your stupidity and you have the audacity to suggest that i don't take good care of my patients?  you are lucky that the lord is working in my life and that i'm practicing controlling my tongue, because the wrath that i have for you is bottomless and when i sleep at night i dream about you getting hit by a bus.  what ever happened to clinical assessment skills?  to critical thinking?  to professional nursing judgement?  no, i'm just supposed to shut up and go along with your idiocy.  no thanks.

and you, terrible manager.  you bring nothing but pain and sadness and i am convinced that there is a small trap door in your office that you use to dump the bodies of the people who are "fired", aka disappear and are never seen or heard from again.  you have single-handedly destroyed my will to go on and have made a piece of my soul die.

and you may think that you have won, but I WILL NEVER GIVE IN.  because i have learned the secret, which is to stop caring about the opinions of people who don't understand you and whom you don't respect.  and also:

i just don't care anymore.  i will be fabulous at my job and i will take good care of my patients and i will do it on my own terms.  and you may be able to make me fall in line for awhile, but know that i think you are cold, empty, terrible human beings, and that i kind of hate your guts.  and what you think about me? :

RIP.

easter sunday

the first time i heard screaming during the shift i worked on easter turned out to be some sort of prayer revival.  the second time was the pure hood antics that our unit is famous for.  

we were all minding our own business at shift change when we heard the following: "YOU DISRESPECTING ME (n-word, string of swearing).  THAT'S WHY YOU IN HERE, THAT'S WHY YOU GOT THOSE WOUNDS 'CAUSE YOU DISRESPECTING ME!!".  assuming that someone is about to get the beat down, we promptly called security.  we all gathered outside the door to hear what was going on, expecting this to be some sort of baby mama drama, etc.  much to my surprise, it turns out that the very upset visitor screaming at the patient was actually his mother.  apparently someone had a few too many drinkies at the easter barbecue and decided to come to the hospital for a nice visit totally sauced.  lovely.  

at this point she was crying hysterically and had to be removed from the room by security.  she was so obviously impaired that the officers asked her if she was taking any drugs.  she blamed the whole thing on being drunk, yelling "IT'S THE ALCOHOL!!  THE ALCOHOL MAKE YOU DO THINGS...IT MAKE YOU SAY THINGS!!" and continuing to be hysterical.  poor security took her outside to "get some air" and i thought she left.  about 20 minutes later i get a phone call.  apparently security had been sitting with this lady in the lobby the whole time, and was calling to ask when her daughter (her ride, who had so wisely driven her trashed mom to the hospital) was planning on leaving.  i went to the room and tried to tactfully ask the daughter when she was planning on heading out as her mom was "upset" (aka completely wasted).  after staring at me for a minute like i was stupid, she told me that she wasn't about to "waste her gas drivin all the way out here to be here 10 minute" and that her mom "gon have to wait".  then she proceeding to sit in the room for another 25 minutes until the security officer came back to the room to get her.    

1. don't bring your drunk mom to the hospital

2. seriously, you won't take her home?  aren't you embarrassed at all that security has been babysitting her for the past 45 minutes?

3. and on a holy day?  for shame.  

so the moral of the story is...save the hard drinking for christmas.   or something.  

on passing

i knew that he was dying from the moment i met him.  i was surprised because he didn't look bad on paper when i was getting report, but in person it was clear.  he was an elderly man who had fallen and broken multiple bones in his face, neck, and back.  i could see hear crackly lung sounds the second i stepped into the doorway.  he fought the oxygen mask that was cranked up all the way, and the respiratory treatment he was getting did not appear to be helping.  his color was terrible, his foley had no urine despite diuretics, and it was pretty obvious where this was going.  my suspicions were confirmed when i got vitals and saw an oxygen level in the 70s maxed out on O2.

even in a world where it's somehow ok to try to keep brain-dead people alive, this man was not going to make it.  the question at this point was how he was going to die.  would it be in a few days intubated in the ICU, sedated and maxed out on pressers?  or would it be under my care in a few hours?

the day shift RN and i went to the back room to talk to trauma.  everyone knew that the patient had a terrible prognosis, but i don't think anyone realized how little time we had.  "he is dying now" i told them.  "we need to make sure the family knows what's going on".

the family had been at his bedside the entire time, watching him struggle.  that's a terrible thing to see, but despite their own feelings they were doing the best they could to hold it together.  a granddaughter was holding his hand so he wouldn't pull the oxygen mask off his face.  i stood on his other side doing the same.

i held his hand for over an hour.  my wonderful coworkers took control of the rest of my patients so i could see things through until the end.  trauma came to see the patient, and in quiet panic went to call the palliative care team.  i wasn't sure they would make it in time.

both teams made it to the bedside shortly thereafter.  they were compassionate and clear about what was going on.  the family talked amongst themselves and decided that he wouldn't want to live like this, and they would follow his wishes not to be intubated.  the palliative care team ordered a small dose of IV pain meds and i gave them.

a half hour later, the restlessness stopped.  he took a final breath surrounded by his family, and he died.

i had been about to give him some more meds because he was agitated, waving his arms up towards the ceiling when he hadn't been doing that before.  now it seems to me that he saw something, and was reaching for it.

but of course we can't be sure of that.

his death was hard to watch, especially for the family.  but overall i would say that it was a good way to go.  suddenly and quickly, after almost 90 years of a good life.  a few short months behind his sweet wife who, according to his family, was his reason for living.  there are worse ways than this.

it's a sacred and sobering thing, to be involved in the dying process.  how to guide a family through it is not something that they teach you in nursing school.  it's another one of those things that you pick up as you go along.  more so than anything else, you put aside professional boundaries and just be a human being...a person who has experienced loss personally, and who can empathize.  you do everything you can to make the experience easier, and if you can't, you acknowledge the fact that you know it's really hard.

from the moment i met the patient to the moment he died was a short two hours.  but i've learned that you don't forget important things, no matter how briefly they lasted.

visitors

dear visitors,

this is not your house.

love, the help.

lord help me the visitors are going to make me lose it.  i understand wanting to be there to support someone who's sick, but there are boundaries, people!!  how do you know if you are the annoying visitor?  i have compiled a list of problem visitors and their characteristics below.  

the daycare:
you feel the need to bring 5 kids under 3 to the room, who cry and scream, run loose in the halls, and demand juice and graham crackers.  extra points to you if you come up to the desk and ask for a pamper, then glare at me when i tell you we only have adult diapers.

the two-for-the-price-of-one patients:
you are the visitor who feels that your loved one's hospital stay is a good time to ask medical advice for your own health issues.  chances are you were just discharged from the hospital or intend to go down to the ER while you're here to "get checked out".  you have no problem asking staff to push you around in your wheelchair, take off your shoes for you, or to hook you up to the hospital oxygen.  extra points if you ask me if i can help you go to the bathroom.

the move in and stay:
you don't leave.  EVER.  you bring a good portion of your personal belongings to leave around the room, use the patient's shower and bathroom for your beauty rituals, and take up all of the refrigerator space with your personal food.  extra points to you if i have to ask who the patient is because you insist on wearing hospital gown and slippers.

the cuddler:
you are in the bed (ug, WHY do you need to be in the bed, seriously?).  you make it hard for me to do my job because you are in my way.  extra points to you if you are only partially clothed, and BONUS points if you are caught performing some sort of sex act on the patient by one of the staff members.

the whole damn family:
you are part of a 30 member group of aunts, cousins, and at least one elderly person with an assistive device parked right in front of the door.  you spend your entire visit hunting down staff members to ask for extra chairs, even though you could not squeeze one more person or furniture item into the room.  you make sure that each member of your group asks for a beverage, preferably at intervals so i have to run back and forth to the kitchen several times. extra points to you if you bring a bunch of fast food into the room that you leave sitting around for me to clean up when you go.

the homeless:
you make a habit of sleeping on different people's couches, usually because you are drunk or high most of the time and have no ambition.  you like to latch on to a "friend" or distant relative you barely know and use their hospital room as your new home.  you leave the room only to go get more drunk or high, and then like to come back and snore loudly enough in the recliner chair to wake half the floor.  extra points if i need to wear a mask in the room because you decided to take your shoes off.

sadly i could go on.  in fact just the other day we had to tell a family member that he couldn't sleep on the six foot long bench that he stole from another floor's waiting room and wheeled up to the room on a cart (which he also helped himself to).  no.  boundaries.

so don't be that visitor!!  bring your own snacks!  sit in the chair, don't sleep in the bed!  and for the love of all that is good GO HOME once in awhile, you're driving me crazy.

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.