working aboard the titanic

lately there's been another wave of people jumping ship, and i can't figure out why it's so upsetting to me.  there's the fact that i spend more time with my coworkers than i do with my own family.  the fact that we both laugh and cry together, that we bitch and vent and support each other.  that we are a small, peaceful gang bound together by terrible shifts, mutual struggles, and 70+ hour weeks.  so when someone decides to leave it's always hard.  it changes the dynamic, and it's difficult not to feel abandoned.

yes, i realize that i cannot officially take it personally when people choose to change jobs.  officially.  but in the land of turnover, where i have lose 70 coworkers in the past 7 years, somehow all my angst feels justified.

but it's more than that.  i feel like every time someone leaves the floor to go somewhere more glamorous or dramatic like the ED or the ICU, they have this air of superiority.  they are going to DO SOMETHING THAT MATTERS.  they are going to SAVE LIVES, all massively transfusing people and cracking chests at the beside while all i do is pass apple juices and push dilaudid.

and, yeah, i'm more than a little defensive about my job.  floor nurses are hugely under-appreciated and taken advantage of.  when the ICUs are short-staffed it's 'dangerous', when we're short it's 'busy'.  they have a locked door and visitation policies, we have the whole damn fam.  they collaborate with doctors, we go down fighting for our patients and are seen as an annoyance.

what i do matters too.  being able to look at a patient and know how they're doing without a billion monitors is an unsung superpower.  so is balancing the care of 5 different patients.  and it's not as exciting as floating a swan ganz or running codes all the time, but it's still important.

but more than anything, the mass exodus from the floor has made me come face to face with my own insecurities.  because is it really the people who are leaving who are making me feel inferior?  or is it the fact that deep down, i know i should be doing more than what i am?  i'm having a hard time figuring out if i'm happy or just comfortable.  do i resent the people who are moving on because i'm just jealous?

in short, i know i'm being a hater but i'm tired of saying goodbye to people ALL THE TIME.

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.