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NurseMe is a trauma/critical care nurse working at a Level I trauma center in It Hurts Here, USA.

Silence is a Felony

2011 December 28
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Posted by Nurse Me

Let’s just forget that it’s been over a year since I’ve written a new blog post. The following article is sure to provoke thoughtful, articulate, intelligent and insightful comments.

A good friend of mine sent me this article which appears all over the internet.  And let me just say:

1.  If this is true, the state should prosecute.

2.  Very little information is provided.

http://www.huffingtonpost.com/2011/12/23/utah-nurses-fired-for-taping-patient-mouth_n_1168164.html

Do This, Not That

2010 December 10
Posted by Nurse Me

“It’s not about me.”

This is my personal mantra that I adopted several years ago. I don’t know how it came about, I think it may have been an epiphany. And it has saved me. Saved me what, you ask? Time. Frustration. Anger. These 3 words and a contraction, when repeated in my head, allow me to take a step back, take a deep breath, gather my thoughts and act rather than react.

Let’s face it, it’s no fun to be sick, injured or in pain (not an epiphany just a fact) and patient responses to the aforementioned phenomena cover a wide range of emotion and behavior (read bitter, angry, rude and accusing). When faced with these types of behavior, one’s natural reaction is to become defensive and a defensive nurse is not something you want.

She came to me late in the evening, too proud to call an ambulance, too far away to take a taxi, too weak to take a bus. She waited for her son to come home from work all the while hoping she wouldn’t grow too tired to breathe. She arrived with her bag of medications, her convertible walker/chair and her “overnight” bag.

She accepted my help to move her from the wheelchair to the stretcher. She accepted my help to change her into the hospital gown. She was gracious and polite in answering my questions related to her medical history and reason for coming to the emergency room. She instructed me on how to fold her clothes and position them in her overnight bag. She told me where I could place the blood pressure cuff, EKG electrodes and pulse oximeter. She told me “I’m a hard stick, they always have to use that machine to find my veins”. She allowed me to assess her arms for the presence but in her case absence of veins* (I did find 2 but one was sclerosed and the other too small and fragile, it would blow at the mere sight of a needle). I informed her I’d get the doctor and ultrasound machine, she was asleep before I exited her room.

The doctor glided in, ultrasound machine in tow.

“Use this arm and make sure you only use Chlorhexadine swabs, 5 of them. I don’t want no infections and I always end up with one every time I come here……Hurry up, I’m tired. I haven’t been able to breathe or sleep well……that 18 will blow my vein, only use a 20…..aren’t you done yet? It didn’t take the last doctor this long to start my I.V…….don’t put that needle down then use it again, get a new one and use more Chlorhexadine…..here, let me clean it, you’re not doing it well enough….”

With the I.V. secure and blood work on its way to the lab, it was time to solicit a urine sample, a sterile urine sample, by means of and I & O (in and out) cath.

“Oh, no! You’re not putting a foley in me, I won’t allow it. You always give me UTIs whenever you put a foley in me.” (This is the emergency department, I have never seen this woman before in my life so the “you” in this instance is a collective one)

She would be receiving lasix, a foley would be so much easier AND would allow her to sleep without the frequent need to pee interuptions she’d soon be experiencing. No foley. She instructed me to gather cleaning supplies, “Get the short towel and use warm water from the faucet, I don’t like when it’s cold down there. And don’t use that soap that you use to wash your hands. Get the soap bottle from the closet with the blue top. I’ll clean myself because you don’t do it right. And don’t forget a second dry towel!”

She let me help her sit up ”not too fast, I’m tired and old and don’t move well. Ouch! Not so rough!” (She was close to 300 lbs, a certain amount of force is required to lift someone of this heft).

“Now get out. I’ll call you when I’m done.”

Whistle, whistle, whistle. Fingers tapping, fingers tapping, fingers tapping. A quick peek behind the curtain. “I said I’d call you when I’m done!”

Attention paid to other patients, a quick swig of water and a brief hazing of a med student later I returned to her room. She was asleep. Guess she’s done cleaning herself.

“Heat up that betadine, remember I don’t like to be cold down there.”

It’s not about me, it’s not about me, it’s not about me…….played in a loop in my head as I prepped her for the I & O cath. And my thoughts wander from a time when I thought she had a sense of pride in wanting to keep herself clean to a time when I thought that she may be ashamed of her filth and odor to when I realized that she didn’t trust me (the collective me) to properly clean her. That kinda pissed me off. So I guess it IS about me. Ha.

*I always believe patients when they tell me they’re a hard stick but I also always look for myself because it never hurts to. Plus I wouldn’t want to lie to the doctor when s/he asks me if I’ve actually looked for a vein.

An Open Letter

2010 November 13
Posted by Nurse Me

Dear Patient/Family Member:

Experiencing a cardiac arrest IS A RELEVANT PIECE OF INFORMATION TO REVEAL DURING YOUR TRIAGE ASSESSMENT. Yes, I know you were referred from a clinic for elevated potassium (7.4), but when we ask you about past or present medical problems, CARDIAC ARREST IS WHAT WE MEAN. We were even specific, “Do you have any heart problems?”, “Are you having or ever had chest pain? Nausea? Vomiting? Sweating? Dizziness? Passing out?”*

CARDIAC ARREST IS A HEART PROBLEM!

Also of note, you should always bring any referral paperwork, test results, discharge instructions from previous doctor, clinic, ER visits, etc. Always.

That way when you ask to go to the bathroom, a frantic, frightened waiting room patient won’t come running to the nurses’ desk screaming that “someone is on the floor and shaking violently.” That way we won’t have to code you on the bathroom floor.

Now for the wife. Please don’t begin your story with “We were making tortilla soup when the lab called and said he should probably come to the ER to have his blood tests repeated and……”

NO, NO, NO, NO, NO! Your story should start with “The same thing happened 2 months ago….” And when we ask you “what was done in the hospital, what did the doctors tell you?”, please don’t say “everything is better now because they did CPR and fixed his heart.”

NO, NO, NO, NO, NO.

PS – I’m sorry your husband is dead.

Sincerely,
Nurse Me

*For all you medical professionals out there, this patient received an EKG and repeat K+ (5.4) via VBG immediately after triage.

F*CK YOU, Shonda Rhimes

2010 November 7
Posted by Nurse Me

The beeps, buzzes and blurps are growing louder and louder as I amble towards the trauma zone. With each step, the activity behind the trauma doors becomes clearer and clearer.

Shit, tonight is going to suck.

“Hey, Nurse Me! Pedestrian vs Auto coming to Rm A. Get in here now, day shift wants to go home.”

Well, waaah. What about when I want to go home and you want to cream and sugar your coffee first???

“ETA?”

“Landing now. It’s a peds (pediatric patient).”

Well, can I at least take my bag off my shoulder and put down my coffee? Guess not. Just like that I’m ushered by the elbow into Trauma A. One eager dayshifter taking the bag off my shoulder, the other taking my coffee. My ears are listening to some white noise (“suction ready? #s4.0 and 4.5 OETTs, blah blibbity blah, epi……..”) as my eyes are afixed to where the second dayshifter is putting my coffee. Aw, she does care, she’s even labeling it for me. Sweet.

It’s behind the label printer. Totally safe there.

The pediatric trauma arrives aromatically enhanced with helicopter fumes. The flight nurse is trying to give report but is wasting his breath. Other than “hit by car” we’ve all tuned out his report, focusing on the flaccid 5 year old in front of us. Phew, he opens his eyes and is moving all his limbs. Phew.

Uh oh. He has a concerning laceration to his forehead as well as a nice goose egg to the left side of his head. This is worrisome but right now he’s awake. He tells me his name is “Petey”.

The dad arrives as Petey, some doctors and I are rolling back from CAT Scan. He collapses to the floor, overwhelmed with emotion and fear. We look at him and make sure he’s breathing and conscious. We/I  really don’t have the time to tend to him right now. His little boy takes priority. Thankfully the Crisis Intervention Team is present and one of them tends to Dad.

I continue focusing on Petey, checking him over for bruises, lacerations, hematomas. It’s a challenge keeping him awake, which is concerning but so far other than the small laceration to his forehead and goose egg to the side of his head, Petey’s looking pretty good. Now please, just don’t vomit.

Mom arrives later, after all the scans, xrays and ultrasounds have been completed. Petey is knocked out but wakes up rather easily and responds appropriately for his age. Good signs.

I start to explain to Mom where we’re at in Petey’s diagnosis. I don’t get far before….

“I watch Grey’s Anatomy so I know what to expect. But where are all the doctors? Why aren’t they doing your job?”

I shit you not. This is verbatim what Mom said to me. I laughed hoping she was joking. She was surprised, taken aback.

I backpeddaled, “Yeah that show is pretty intense, I love the way the characters are written. But aside from how the cases are presented, there isn’t much medically accurate about that show.”

So, in honor of how hard nurses work and how awful Grey’s Anatomy is for nurses, here’s a little letter I wrote and read to a live studio audience.

Dear Ms. Rhimes,

As creator of Grey’s Anatomy, the most popular show on TV you clearly are doing something right, but as a nurse, a real ACTUAL nurse, not a TV nurse, I had high hopes that your show would portray more than doctors getting it on in the on call room and broken penises. But that’s not only how your show goes awry. First, there is no deep, dramatic last breath, that’s pretty difficult to do with a breathing tube in your mouth. Woops, none of Grey’s patients are ever intubated, my bad. No one has ever died in perfect make up as if it’s their last great head shot. There are no pauses for dramatic effect, plain ol’ dying takes care of the drama.

But I will give you this, Ms. Rhimes, you did get it right when you had that kid encased in cement. However, having attending surgeons bicker about their personal issues as they’re chiseling the patient out the hardened cement? No, that’s not where the real drama is.    

Real drama would be McSteamy bellyaching, “I’m a plastic surgeon not a construction worker, dammit!”  And refusing to endanger the integrity of what God intended his prized surgeon hands to do– shape and mold the breasts of soon-to-be hot chicks.

Seriously, Sho-Rhi, not to be a bitch, but resuscitating Patrick Dempsey’s career doesn’t make you a medical professional. So as a real nurse, let me pitch something to ya, Shon.

It’s 6:45 am. I’m already at the hospital. Before I even step off the elevator I hear wailing, lots of wailing. The door opens to reveal literally 100s of members of the Ortega family. Before I can put my stethoscope around my neck, an Ortega running loose in the unit grabs me, waves her hospital badge and demands to know where bed 15 is, because she’s (illegally) accessed the patient’s medical record and sees her “cousin” has been admitted to Bed 15. I say that Manuel isn’t in the unit, he’s in the OR. I just got to work, my Coffee Bean hasn’t kicked in, and things have gone from 0 to 100 in a nanosecond. But this is what I do. I watch this panicked and anxious woman as fear and anger change her face. She demands that the surgeon come speak to her immediately.  I tell her that isn’t going to happen because the surgeon’s hands are currently in her “cousin’s” chest cavity.

Then I’m yanked away by hysterical family members who are freaked out because the patient’s wife has stopped speaking and won’t open her eyes. The patient’s mother is sobbing, holding her hand over her chest saying, “mi corazon le duele.” She starts hyperventilating with the thought of her son’s death.  I try to get her to calm down before she passes out and that’s when the fist fight breaks out. Security’s outnumbered by ornery Ortegas, there’s shouting and tears and public prayer and I look around the room suddenly recognizing a condition that I’ve heard doctors and other health professionals use for years.  So pleased with my diagnosis, I said it….out loud, in what I thought was a muffled voice….in a room full of Mexicans…next to the patient’s sister.

“So, this is Hispanic Panic!”

What occurred next, well… that’s drama, ShoSho.  

Oh, one more thing, family members don’t know about A Camera and B Camera so they look at me in angst and anger, angry that a doctor hasn’t talked to them about the condition of their loved one. The gripe is legitimate, Shonda, and can’t be negated with a glass of nice, cold water.

Now I’m the enemy.

Perpetuating their pain.

Because I haven’t told them whether to sublet Sean’s apt or cancel the lease all together, what to do with Dwayne’s car or why Rico had only $270 in his pocket but he left the house with over 5k.  

And the doctor still isn’t at the bedside. But I am. Standing in front of them. And I do know what they want to know and how to say it. But Sho-Sho, sweetie, you don’t show any nurses on your show, so when I try to tell them, they won’t listen. 

Now ShoRhi, although you’re not scripting my words, I do know how to intelligently & compassionately talk to families.     

It’s what I do in between titrating drips, executing clinical decisions based on hemodynamic data, preventing VAP, Sepsis and ARDS, packing wounds and…. OMG! I gotta pee……, constantly paging the doctor with updates, requesting orders, answering the same question 32 x because the family can’t seem to talk to each other, assisting in emergency bedside surgery, and SHIT!…I worked through lunch again, hanging blood, drawing blood, trouble shooting the Vent, Ventric, and CRRT….

And when I talk to the Dr I say,

“his ICPs were 42-56 with the ventric open to drain @ 20. I gave Mannitol. His CPP fell to 46 I gave 25% x 2 because he’s already maxed out on Levo, Dopa, and Vasopressin. Now his ICPs are 27-32 but I think we’re headed towardsT4.”

But when I speak to the family I say,

“his brain pressures were too high so I gave him medicine to bring them down, it didn’t work as well as I had hoped. I’m not able to turn off the medicines keeping his blood pressure at an acceptable level, we’ve tried everything we know. There isn’t anything left to do.”

They look at me blankly…. “but he’s going to live, right?”

“No, I’m sorry, he’s not.”…..

……OMG! I still have to pee.

So thank you very much Shonda Rhimes, thank you for making nurses more invisible than we already feel and having to work harder to dispell the myths that you create.

Looking forward to working with you someday,

Nurse Me

PS – Petey sustained a mild concussion and was discharged from the pediatric unit 2 days later and in plenty of time to go trick or treating.

The Deathbed Crash

2010 October 28
Posted by Nurse Me

Remember The Monster Mash? Of course you do! Well, here’s my version just in time for Halloween. Please enjoy….. The Deathbed Crash:

I was working in the ER late one night

When EMS brought me a dreary sight

A patient with blue lips and blood shot eyes

Amid the onlookers cries

He was about to crash

He did the deathbed crash

The deathbed crash

It was an ER smash

He did he crash

It caught on in a flash

He did the crash

He did the deathbed crash

From the resuscitation booth in ER night

To the operating room where surgeons fight

The patients arrived without life or limb

For a chance of survival by electric stim

They were about to crash

They did the deathbed crash

The deathbed crash

It was an ER smash

They did the crash

It caught on in a flash

They did the crash

They did the deathbed crash

The banana bags were infusing

The winos had not begun seizing

The ER was filling up fast

Peace and quiet would not last

Gang bangers were sure to crash this party

Crypts and bloods, drunk off Bacardi

Shit was about to get real

With homeboy drop-offs behind the wheel

They were about to crash

They did the deathbed crash

The deathbed crash

It was an ER smash

They did the crash

It caught on in a flash

They did the crash

They did the deathbed crash

Out in the lobby, I heard a cry

Seems like it was from one upset guy

He fell to the floor and clutched his chest

And in a breathless gasp said, “I need a blood test.”

It’s now the crash

It’s now the deathbed crash

The deathbed crash

And it’s an ER smash

It’s now the crash

It’s caught on in a flash

It’s now the crash

It’s now the deathbed crash

I kinda don’t want this night to end

Cuz it seems my deathbed crash helps people mend

Geezers, gomers and even you too

Are not immune to this breakthrough

Then you can crash

Then you can deathbed crash

The deathbed crash

And do my ER smash

Then you can crash

You’ll catch on in a flash

Then you can crash

Then you can deathbed crash

TIME OUT!

2010 August 30
Posted by Nurse Me

4 helicopter runs.

9 gun shots.

5 stabbings.

1 machete (different than stabbing)

1 crushed by car.

1 traumatic leg amputation.

1 thrown from horse.

3 cracked chests.

2 DOAs.

5 ER to OR STAT.

4 deaths.

It wasn’t a full moon, the 4th of July or New Year’s Eve. It wasn’t Friday the 13th or any Friday. It wasn’t the result of a raid, riot or rave. It was just Sunday.

Please stop.

Thank you.

Always Look Behind The Curtain First

2010 August 14
Posted by Nurse Me

Always. 

I’m a nurse but I’m also human. I have human reactions to humans despite patient and popular perception that, as a nurse, I should be morally, ethically and heroically superior. This misconception along with my facial expressions often gets me into trouble.

 “Hey, Nurse Me, can you help me try and start a line?”

“Sure,” I said reflexively.

I’m honored. Someone needs my help and not any someone. A veteran “go to” nurse is having a problem starting an IV and he is asking for my help. Huge ego rush. Huge.

I round the corner with all the excitement of a child at Christmas expecting a cute little bow wrapped puppy under the tree but got dog poo instead. My mouth fell agape, my nose crinkled and my eyes widened becoming fixed on my veteran co-worker in a you’ve-got-to-be-shitting-me stare. None of this is lost on the patient.

 “Yes, I know, I’m big.”

Big doesn’t even begin to cover it. This patient is HUGE. His last recorded weight is 722 pounds!

700 and 22 pounds!

That’s beyond huge, that’s gross.

Obesity shouldn’t be an extreme sport.

Now I know that as a nurse I must be prepared to see any and all sorts of anomalies, and I am. I can look at a maggot infested leg wound and not flinch, mainly because I’m not bothered by maggots. I can watch someone vomit without so much as a facial tic as if Nicole Kidman’s esthetician shot me full of Botox. I can pull brains out of someone’s nose without so much as a gag. And I can listen to someone with kidney stones scream in agony as if I am deaf. None of these things bother me.

But face me with someone who could lose 2.5 times the weight of the average man in America and still be obese and I’m beyond bothered.

How do you let yourself get so fat that you can no longer clean 90% of your body? How do you let yourself get so fat that you have no idea what most of your body looks like? How do you let yourself get so fat that brushing your teeth makes you winded? How do you let yourself get so fat that standing is a near impossibility? How do you let yourself get so fat that you can’t even wipe your own ass? HOW DO YOU LET YOURSELF GET SO FAT?

I want a puppy.

Being that fat isn’t healthy. You have diabetes, joint pain, sleep apnea, organomegaly, high cholesterol, shortness of breath and osteoporosis not to mention the odor. The odor that accompanies the schmegma living in the fat folds that your pudgy little hands and arms can’t clean and deschmegmatize.

Our treatment options are limited. We can’t take you to CT Scan should you require it because there’s a weight limit, 400/450 pounds. You won’t fit in an MRI machine, most xrays can’t be done because not even the maximum dose of radiation will penetrate your fat and we (at least at my hospital) will no longer send you to the zoo to have these procedures done because we now consider that inhumane, degrading and embarrassing for you. (This is not a joke; I’ve actually worked at hospitals where our extremely obese patients are sent to the zoo for scans.  Dumbo comes of the table, my patient goes on the table.) If my partner and I can’t get an IV, you’ll need a cut down. And that shortness of breath with a ”touch of CHF” you’re experiencing is going to require the insertion of a foley (pee tube). I have no idea how you pee and clean yourself at home but here, in the hospital, we really would like to keep you clean and dry, to reduce your already astronomical risk for infection, specifically Fournier’s. I’ve been there before and NEVER want to go back.

And trust me, I’m far from thrilled about having to insert a foley. It will take a minimum of 7 people: 2-3 people to lift and hold your pannus, 1 person to hold and lift your FUPA (fatty upper penis area), 2 people to hold back your fatty thighs, 1-2 people to apply pressure around your penis to get it to pop out like a turtle’s head and finally 1 person to clean you penis and insert the foley. I think I’d prefer a trip to the zoo. And a puppy. All this is swirling in my mind with my crinkled nose, agape mouth and widened eyes.

I take position on the left side of the bed to look for a vein while making idle conversation.

“Are you having any luck?”

“Not yet.”

“Mr. Hut, where’s the best place to find a vein?”

“I don’t know.”

“Why did you come to the hosp…,” my mouth froze in mid sentence, the words trapped by my paralyzed vocal cords. From the corner of my right eye, I see something dark move across Hut’s chest. I look up and lock eyes with my partner with a you-just-saw-that, right? expression on my face. From his return stare, he did. And then the patient:

“I’m sorry about that.”

My partner and I remain speechless, not quite sure of the etiquette in this situation. And even before my brain can unfreeze to think of something to say, there it is, the black blur I thought I had seen is now resting on Hut’s right shoulder.

COCKROOOOOOAAAACH!!!!

In addition to everything else, Hut has cockroaches living in his fat folds.

EEEEEEEEEEEEEWWWWWWWWWWWWWWWWWWWWWW.

I drop my equipment and swiftly exit Hut’s room leaving the veteran behind, quivering and scratching my body as if it were infested with cockroaches. There are 3 things in this world that I have an adverse reaction to and 2 of them just smacked me in the face. I still feel guilty for falling short of my professional responsibilities but sometimes I just have to be human.

Heed my warning young RNs, always look behind the curtain first.

 

If you knew…

2010 August 9
Posted by Nurse Me

….what we knew would you still have a surgery?

Gary was not your typical patient, everybody liked him, which is unusual. He was bright, chipper and charming. He did what we asked him to, even when he was in pain. And even more amazingly he always said “please” and “thank you” despite being in extreme pain. He smiled and waved to everyone. On his required post-op walks he would stop by patients’ rooms to offer support, sympathy and encouragement. He talked openly and honestly about is post-op course which was riddled with complications of effusions, both pleural and pericardial that kept him in the unit 33 days longer than usual and befuddled and beleaguered his surgeon.

He was the mayor of our unit, if mayors were well liked, congenial and sincere.

He NEVER pitied himself even though his crappy heart had 4 vessels (CABG) and 1 valve repaired  (MVR) and the surgery left him languid and short of breath.  He worked hard to get home and we worked hard to get him there. When he was finally discharged home, we rejoiced. Some even shed a tear or two of joy. Finally, a hard fought, befitting outcome.

Or so we thought.

Less than a month at home and Gary was back in the hospital with shortness of breath, a return of his pleural effusion. His surgeon had no idea why. He came by to visit us all smiles, as usual.

“You know, what can I do? You guys gave me my life back. I’ll get better from this too.”

He left the hospital and was back 2 weeks later. This time the news was a little more concerning. Gary would need cardiac stripping. As soon as we heard this, we all had that look on our faces. The look we get when we know that a person isn’t going to wake up from his surgery. Its a rather vacant expression usually accompanied with a sigh. Some even shed a tear or two. This time not of joy. Gary’s incredibly crappy heart in addition to all his post-op complications made this a riskier than usual surgery more than doubling his mortality rate.

I know his surgeon explained the risks to Gary. I know he stressed the risks and that the very surgery needed to save him would likely kill him. Either way Gary was going to die.  It was just a matter of when and how. Every day since Gary’s initial surgery was a struggle for him. A struggle to breath, a struggle to maintain his energy, a struggle to eat. Basically a struggle to live. And I wondered if he remained as happy and upbeat at home as he was in the hospital? So I’m sure the choice to have this surgery was a no brainer for him.

The day of his cardiac stripping arrived and we did our best to remain positive and upbeat, although in my mind all I could think was “dead man rolling”. And as he rolled down the hallway with the OR team, we said things like “see you soon”, “I’ll be here when you get back”, and “you’re in good hands”.

Gary smiled and reached for as many hands as he could. We all knew that would be the last time we saw him smile.

5 hours later Gary rolled back into the ICU, cardiac team, techs, and machines in tow. Lots of machines. There was a ventilator, 2 4-channel IV pumps, each channel filled with a life saving medication of some sort. A Bair Hugger (warming blanket), external pacemaker and oh yeah, the portable bypass machine. This was such a painful sight to see considering the man we had grown to adore. It broke our hearts and his was literally broken. We would give him until the next morning to “recover”. If not, the bypass would be disconnected and we’d let nature take its course.

Dying in the hospital isn’t pleasant. A lot of times you’re connected to tubes and machines, strapped to the bed, unable to speak and who knows if you can think or hear? Your reflexive movements make sense to us but are viewed as “he’s in there” by family members. And speaking of family members, in your hospital death bed you somehow turn into an exotic exhibit of tubed flesh with each family member taking a turn to ogle in wonderment, disbelief, hope, guilt or whatever emotion ties you together.

Don’t get me wrong, plain ole dyin’ isn’t pleasant either and if I were offered a Hail Mary, knowing what I know, I’m not sure I’d take it. I think I prefer to be a hospice kinda girl.

I have no idea if Gary said “goodbyes” to his family or if he remained an eternal optimist. Gary lived in his reality instead of the medical reality I wanted him to. The next morning when we disconnected the bypass machine, I held Gary’s hand and tried to smile as he had always done.

So if you were offered a Hail Mary to save your life would you take it?

Feeding The Fantasy

2010 July 26
Comments Off
Posted by Nurse Me

“Hey girl! How you doing, Adrian?”

I turn around in that way that you do when someone has called you by the wrong name.  I knew no one else was behind me. I also don’t work with anyone named Adrian.

“Oh girl, you’re so funny. I’m talking to you. Who knew Rocky’s wife has a sense of humor?”

Rocky’s wife??

“How’s he doing anyway? I can’t believe he’s got you workin’! But I guess it’s better than being a secretary. But it’s about time you did your woman job and give him some babies. A man that fine has gots to have some babies. What’s wrong with you?”

My woman job?

“I don’t discuss my personal life with my patients. How can I help you today, Janice?”

Janice began to speak and I use the opportunity to tune her out. My mind is processing about a billion things in a nanosecond. An inherent ability of all ER staff. I’m wondering how many of the Rocky movies she has seen? I’m guessing just the one. She’s clearly crazy mentally ill, a bit angry, and volatile. She’s also homeless. The positive luggage sign and distinct aroma are dead give aways. Do I tell her that I’m not Rocky’s wife but a nurse? What’s the best approach? Do I call for a psych consult? What’s the quickest way to get her out of the ER? I bet if I play along she’ll go AMA, she’s too angry to stay. Please don’t have a legitimate complaint. And she doesn’t but she said some magic words in triage (short of breath) which warrants  a clean, dry, warm stretcher and a sandwich, an EKG which has lead her to me. Damn EKG.

“Ok, Janice. Let’s get you changed into this gown.”

“Now hold up, Adrian. I just got back here. Don’t rush me. Rocky has got his work cut out for him. I can’t figure out if you’re brave or stupid. I have to go to the bathroom, I’ll be right back.”

“Well, Janice. You came here for help (not to mention you passed 3 bathrooms on your way here) and I want to make sure you get help in a timely manner. We’re very concerned about your shortness of breath and EKG which means we’re concerned about your heart.”

“Well of course I’m short of breath, I can’t walk. And ain’t nothing wrong with my heart, either. You sure are stupid, Adrian. Can’t you see there’s nothing wrong with my heart? That’s not what I came in here for.”

Actually my xray vision is on the fritz, Janice, maybe Rocky can help me out with that? But instead of answer Janice, I provide her with a urine cup in the hopes that we will find something (legitimate) to treat. You know, to make her trip to the ER worth her while.

“Ain’t nothin’ wrong with my pee either, stupid bitch.” She takes the cup from me anyway and walks to the bathroom.

With Janice out of my sight, I’m able to think and process. I don’t even know where to start. Any attempts I make to address Janice’s issues are thwarted with ascerbic condemnations and dizzying digressions. How do I help her with the time I have? The resident isn’t having any luck, either. We’re stuck on a carousel. And I feel guilty for taking advantage of someone’s mental illness because (1) it’s the easier thing to do and (2) it humors me. And in the ER, we use any opportunity to leach out humor. So I don’t correct her delusion. She seems happy and cooperative there.

 ”Kill her with kindness,” I tell myself, “because killing her would be wrong.”

Once she’s back from the bathroom, I again ask her to change into a gown.

“Don’t rush me, I said. I just walked a long way and I can’t walk.”

Janice plops down on the stretcher in a life-is-exhausting huff and makes a move with her hands for her head.

“NO! NOT THE TURBAN! PLEASE DON’T TAKE THAT OFF,” I scream in my head. There’s no telling what was underneath her head wrap. Years of matted, gnarled hair? An infected abscess that emanates its own aroma and is sometimes accompanied by maggots? A sandwich? A ferret? No, for the love of olfactory senses everywhere, NOT THE TURBAN.

She was wearing a very stretched out v-neck. The turban would have fit through.

“Now how am I going to get the shirt off my head, then, huh?”

“You’re right, Janice? I’ll step out and give you some time to change.” And to my surprise, Janice’s head is clean shaven and without maggots, abscesses or ferrets.

“I didn’t say you could leave. Rocky really needs to beat some manners into you. I’m a victim of rape for 37 years and I know people who could use a good rape to set ‘em straight. Rocky will get right on that, don’t think just cuz he’s a fighter he won’t. So don’t go disrespectin’ me by doing things I didn’t tell you you could do.”

Oh dear.

“Ok, Janice. Would you like a social worker or someone who can help you deal with your rape?”

“What would I want that for? Don’t be tellin’ me what I need? Rocky really needs to teach you how to talk to people. And you better listen.”

“Ok. I would like to draw your blood so we can run some tests for you.”

“I want 20 dollars for my blood.”

“Janice, this is a hospital. We don’t pay people to draw their blood.”

“You know, Adrian? I was really likin’ you til now.”

Janice stretched out her arm, pointing to the only vein she’d let me use.

 ”Hurry up,” she commanded me.

I finished drawing Janice’s blood  and before I could secure her IV, she was snoring. Finally, the real reason for her ER visit revealed. And I was happy. Now I can get back to my patients who will let me help them.

Two hours had passed and traumas came, went and died. It is time for me to check in on Janice and draw some more blood.

“Janice, Janice,” I softly say in her ear as I have a hand on her shoulder.

Janice jumps.

“Huh? What the…..Who told you you could wake me up? I didn’t give you permission to wake me up.”

“Well, Janice, I have to draw another blood sample from you to send to the lab.”

“Nuh uh. You still haven’t paid me for the other bloods that you took. I didn’t come here to be taken advantage of and be disrespected like this. I’m a victim of rape for 37 years, I know what being disrespected is. You better back the fuck up bitch before I beat your ass. And I’ll do it to.”

If I had any belief in Janice’s words as more than just words and in Janice’s physical abilities (afterall, she couldn’t even walk), I would have called a Code Green. Instead, I reminded her that she came to me of her own free will and she could leave that way as well. I felt comfortable doing this for several reasons: her cardiac enzymes and BNP were negative, her chest xray was clear, she didn’t have a white count, nor did she have any open, weeping, infected skin sores.

“Well, Janice, if you don’t want to stay, you don’t have to.”

“Damm right I don’t. Get me my clothes you fucking whore. You may have married well but you let your career go to shit.” (This is my favorite comment from Janice that night.)

Janice left AMA, under the supervision of two of our finest deputies. As she walked away continuing to verbally berate Adrian, I was saddened. Our homeless is such an underserved, forgotten and abused population. Most are mentally ill, drug addicts or both. Most have been victims of crime. Most have a chip on their shoulder or carry a grudge. Most have more than one medical problem. Most exploit the very system that is designed to help them. Most want off the streets but our system is overwhelmed so they seek refuge in an ER if only to get a warm, dry place to sleep for a couple of hours, more if they’re actually willing to stay. Most lash out because it’s the only way they know how to communicate. I don’t take this personally. I just think what Adrian would have done. And I think she, too, would be saddened that she wasn’t able to help Janice. But like I said, how well can you really help someone in a nanosecond?

Beginning of the End

2010 July 8
Posted by Nurse Me

The emergency room is not the place for palliative care.* Emergency nearly screams fixable problem. Or at least its an amnesty of hope. People walk in and expect to walk out, most of the time with a prescription. People look at me with hope and expectations. “Patch me up. I’ll be on my way.” Hold on, not so fast. You were just called back to the hospital from the radiology department to receive the results of your MRI.

Not good.

And there you sit and wait, and wait, and wait for an available physician to see you. Not going to see the doc who ordered the test, it’s after hours. Not going to see a doc who knows anything about you. Going to get turfed. Turfed to people who don’t know a thing about you or the conversations you’ve had with your primary physician. Gonna make you rehash your entire medical history. And we most likely won’t ask you how you feel about it.

We all know the results of the MRI. Saw it on the computer. It’s ugly. So sorry. And no one in the ER wants to break the bad news to you, we wanna wait for the specialist, not your specialist, mind you. It’s after hours. And our on-call specialist is currently seeing other consults, you’re on the list. Be right with ya.

“Well, how has your father been feeling?”

“He’s in so much pain, but he won’t say it. Sometimes he doesn’t know his words.”

“Does he have vision problems? Balance problems? Walking problems?” 

Yes is the answer to all three of those questions and remarkably, he looks well.

“I’ll introduce you to the neurosurgery resident when he gets here.”

Wow, that scan is ugly.

Neurosurgery arrives, “We can’t operate. Well, we can but we won’t. If we try to take out the tumor, he’ll lose his ability to speak and write. He may not even wake up. And there’s blood vessels involved. We can radiate to shrink the tumors and give him steriods for the inflammation. It could give him a year, I don’t know, its probably less.”

This is the conversation that Neuro had with me, I don’t know what he said to the patient and his son but it probably wasn’t much different although probably a little more compassionate.

I left a voice message for Palliative Care.

This wasn’t the only time I left messages for Palliative Care that week. There would be 2 others, I guess it was my theme of the week.

They came to me with yellow eyes. Not “lemonade” yellow or “sunshine” yellow but a bruised yellow.

Not good.

They came to me with huge bellies, overdue pregnant bellies, but they were not pregnant women.

Not good.

They came to me with skinny arms and legs, like the pictures of starving bloated children we see on the TV ads for Save the Children. Only they were not children.

Not good. (Not good even if they were children)

They came to me with aged, wrinkled faces well above their 62 & 39 years, respectively.

Not good.

And all I could see was his face, superimposed on theirs like a haunted house hologram.

Not good.

But I was prepared to take care of these two men who had destroyed their bodies and lives through the excessive consumption of alcohol, because of 8 specific weeks last summer.

It’s been a year since a dear friend, talented musician and one of the most likeable, well-loved men died as a result of alcoholism. And I haven’t talked about it or written about it. And I’m faced with it everyday. The “it” being death and dying.

I thought that somehow my being a nurse would benefit me in helping my friend and his family through his hospitalization. I don’t know if it did. It was the most challenging experience of my life and career to date. As a friend I was grieving and as a nurse I was holding his hand, as well as a lot of others, helping them understand his diagnosis, prognosis and treatment options. We all knew what the outcome would be although most of us prayed for or asked for a miracle. As a nurse, I suppressed the friend, not wanting to show the friend’s fear and anxiety that the nurse didn’t have “The Hail Mary,” that the friend (and nurse) knew their would be a funeral in the near future. Talk about a split personality!

But it was because of this experience that I am no longer afraid to have the “death conversation” with a patient or family members. I mean, who wants to be the one to have that conversation? No one. But it’s part of the job. And according to an article on Yahoo, a neglected part of the job. And come to find out, sometimes families and patients especially, are relieved to have someone ask about their feelings towards their illness, death and dying. Who knew?! Certainly not most doctors and nurses, we like to avoid that issue because doctors have a “save” mentality and nurses want to “heal” and neither of us want to be emotional.

“We just left We’ve Done All We Can For You Hospital but his breathing isn’t getting better and he’s not eating, so we came here.”

“What did WDAWCFYH tell you about Rocky’s illness?”

“They said that his liver was almost completely gone and now his kidneys aren’t working great either.”

Rocky’s brother-in-law hands me the discharge packet from WDAWCFYH. There’s a pamphlet for palliative care with a business card inside.

“Do you understand what they told you?”

Blank stare as tears form in the corner of brother-in-law’s eyes. Mine too, for Rocky’s face morphed into a hologram image of my friend. I take a deep breath, pause….

“Ok. So you know Rocky is dying and you’re looking for a way to save him?”

The brother-in-law nods his head.

I talked about transplants and clinical trials and quality of life versus quantity of life. I didn’t feel I needed to “soap box” about alcoholism and its devastating effects. We were both looking at it. I talked about what being tethered to a hospital bed would look like and feel like. I talked about how each family member would turn towards every health professional who would walk through his brother-in-law’s hospital door with hope in their eyes and love in their hearts wanting to hear that his liver had miraculously healed or that he would get a liver transplant. I talked about how conversation would eventually become nothing more than idle chit-chat as the build up of ammonia from a failing liver would take his consciousness. I advised the brother-in-law to encourage his family to “say what needs to be said” with Rocky but more importantly to listen to what he has to say. For the moment, Rocky was fully aware of what was happening. But time was short and he knew it. I could see it in his eyes. And he said it.

I was speaking from my own personal experience. And that was the first time I allowed myself to do that. I got through it and I don’t know how. But I do know that in those 8 weeks during which I watched my friend slowly die, I learned more about myself from him than ever before. For the first time since becoming a nurse, death became personal. And I do know that my patients and their families benefit from that experience. I love him and hate him for that. And I miss him terribly.

RIP, TA.

*In my hospital and most others, Palliative Care is synonymous with Hospice since it is only called into service when we see patients who are at the end of their lives.