In or Out of the Box

Before I was a nurse, I was a musician. I loved both the muscle memory, physics, and technical side or playing the clarinet as well as the artistic and emotive side. I was only ok on the first part, but I’d like to think I was pretty decent at the second. A college professor once told me, after playing a Brahms piece, that he thought I was too young to have broken my heart. It was a compliment from him, I promise. 

Nursing students often hear the phrase “the art of nursing.” They build up nursing as this all-mighty force combining science and art. No. They’re really pointing towards compassion and empathy. The science of nursing is the technical stuff we do, knowing the meds, physical acts to take care of the patient, analysis of their signs and symptoms. The art of nursing is the compassionate care of the patient. Really? Society is so low that we call it an art to treat another human being with common decency? Talk about lowering standards, humanity. But it’s not an art form. It’s the simple act of doing what’s best for another, instead of what’s best for me. (Hospital administrators, take note: it’s not all about the Benjamins.) So with all this talk about the art of nursing, I was excited in nursing school. I thought I’d found my dream job of combining two things I loved. Boy was I wrong. 

There is no creative thought in nursing. There’s tons of analytical thought. Is this the right med for this patient at the right time? How do I best support this patient’s shoulder with a torn ligament while we ambulate today? That gurgling noise while they sleep is new, how do I fix it? This patient’s pH was 7.1 and a lactic of 6, what’s next? Their urine has slowed down the past two hours, what could be wrong?

There are no creative answers to those questions. There is no creative, outside-of-the box thinking that goes along with it. There is established research, there are protocols, there are order sets that give us the answers to those questions. I rely on knowledge banks in my own and colleagues’ memories to find the answer. I rely on the internet. (Don’t judge me. I googled a particular splint style yesterday which I’d never heard of. That is not condoning your use of google to diagnose your cold as HIV. Wrong virus.)

I have no creative outlet as a nurse. Especially in the ER and ICU. I’ve seen it in a few places like rehab nursing or sometimes surgical nursing. (Yeah! Surgery! How to fit a round peg in a square hole that is your patient’s abdomen. And every abdomen is different, so the next solution will be as well. Surgical nurses and scrub techs are HIGHLY undervalued in the healthcare world. They rock.) But the lack of creativity and the lowsy staffing of experienced nurses means I do tasks. And some days that’s all I can think about: Which task is the most important and gets priority over the others? More analytical thinking. No creative thinking. 

This is taking its toll on me. The blog helps me think through and vent at times, but it’s not an outlet of any real means. There’s no interaction with anyone, there’s no give and take. Thoughts and advice are welcome.

All Holy Empathy

I’ve been through a lot of hospital orientations in the last 6 years I’ve been a nurse. As an agency RN, most hospitals require at least a shortened version of their orientation from HR. I’ve been through two full orientations as a staff nurse. Every single one of them emphasizes, not hand hygiene, not protocols for blood transfusions, but customer service. How to make your patient and their family happy. This is because Medicaid and Medicare are basing a large chunk of their reimbursement on patient satisfaction. My response to that? 

ZDoggMD shot a video for his Against Medical Advice recently on empathy and why it’s ruining healthcare. He’s a tad bit over dramatic, but also quotes research by Paul Bloom, a MIT Psychologist Here and Here. Take a minute to listen to ZDogg and read through Bloom. 

I don’t agree with everything they preach. But the idea of self preservation by healthcare providers is a reality. Dark humor in the face of tragedy. Distance. Cursing. Drinking. Smoking. All those things healthcare tells you is bad for your health? We do those things. It’s how we stay sane. It’s how we deal with stress. It’s how we keep doing our job. 

My hospital HR staff tells me that I need to feel the feelings of each of my patients (empathy), because anything else is seen by my patients as condescending (sympathy). Who wants to be looked down on or judged by their healthcare team? I don’t. Their theory makes sense. I see 12-80 patients a day. I work four days a week. That’s up to 320 patients a week, not including their family members. My hospital is asking me to take on each and every one of their emotions, both good and bad. Seem feasible? 

At the end of the day, I am physically exhausted. I am mentally exhausted. Feeling 80 people’s emotions during highly volatile time in their life after the physical and mental exhaustion? I put my foot down. I draw the line. I demand some sanity for myself, for my loved ones I go home to. My administration, my HR team, sit in their offices, interacting with the same 8 people week after week and this system works. It does not work on the scale that is an ED, or anywhere else inside the hospital or clinic. 

Sexual Assault

Sometimes my job sucks. It’s just miserable. I’m not talking about the crazy days we’re running our butts off. I’m not talking about the drug seekers. I’m not talking about the difficult sticks, grumpy triage waiting lines, or having to lift that 500lb patient. I’m talking about the really miserable days when you’re crying as you try to start an IV. I’m talking about those days you come home and just need a hug from a safe and trustworthy person. I’m talking about those days you’re exposed to the victims or perpetrators of some horrendous crimes. The crimes you see on Law and Order SVU and wonder why they’re allowed to talk about it on TV. Those patients come to me. Those patients are in my ER. Every day. 

In OKC, the hospitals rotate SANE (Sexual assault nurse examinations) monthly. This is our month. I’m not a SANE nurse. I thought at one point that I would like to be trained for it, but I’ve quickly stopped that silly idea. I am simply not strong enough. Or too empathetic. I’m not sure which. But I take my work home with me and you can’t take home SANE work. 

I can’t post the things I saw this week. I believe they’re all under investigation, and I couldn’t tell the story without breaking HIPPA laws. But it hurt. Human beings shouldn’t be treated this way. The flippancy of how it’s happened shouldn’t be a cultural norm. 

Another person actually said the phrase “boys will be boys” to me this week. I wanted to smack them. This is not a childish activity. These are criminal offenses which people have committed suicide over. They alter a person for the rest of their lives. They change who you are for ever. 

These are not cases where someone “was asking for it.” Do you know what asking for it means? It means one person asked if they could have sex with you and you responded with a yes. Other than that, no one is asking for it. Ever. Not how you dress, not how you act. Not asking for it. None of those situations were even involved in the cases I worked with this week, but the victim blaming was still there. It’s as if that’s the only excuse some people can come up with as to why something this horrendous would ever happen. 

A couple weeks ago, a parent brought in a daughter for a saddle injury. This is where, usually, a fall occurs and you bruise your pelvic bones in the saddle area. This girl had lost balance on a gym set and dropped herself on to some monkey bars. The story seemed legitimate and the child and parents were acting appropriately, so no one suspected abuse. We still had to do a pelvic exam to check for injuries. The doctor (male) and me (female) were in the room, along with the mother during the exam. We’re required, regardless of age, to have a witness during the exam. The doctor started by explaining what he was going to do and then proceeded to explain that this is not normal and that the only reason it’s ok is that he’s a doctor, I’m a nurse, and her mother was present. Then he showed her his and my badge, and added that the girl should ask to see the badges of anyone who asks to do this type of exam. I wanted to hug him. 

I don’t know if there’s a point to this post. But a lot has been boiling up lately that I need to get off my chest. I push and push my way through my shifts with a smile on my face, going through motions because that’s what I have to do. But I cry on my drive home. 

Doctors from the Nursing Perspective

I’ve worked with some wonderful doctors in my career. I’ve worked with some horrendous doctors in my career. This post is not about horrible doctors, but to throw some perspective in there, I’ve had bloody scaples thrown at me from across a surgical suite. 

I’d always heard the ER was a crazy place to work, and it is. What I love about it though, is that my doctors are sitting next to me. Well, almost so. They have a small alcove in the center of the nurses’ station, but it’s not full walls, more like grids, so everyone can hear and almost see what’s going on everywhere in the unit, but hides the doctors from inquisitive patients and family members. The benefit? They see and hear everything their nurses say and do for the patients and I think it has changed their perspective on our field. 

Friday, as I ate my sandwich while charting, my doc asked for an update on my patient. “She’s ready to discharge, just waiting on the fluids to go in.” “Can we put her on a pressure bag?” (This is a bag around the fluids that is pumped up and all it does is literally put pressure on the fluid bag to make it go in the vein faster.) “Sure! Let me go grab it.” “Don’t worry; eat your lunch, I’ll do it.”

Jaw drop.

Last week I walked in to my patients room for the first time as the doctor and his scribe were walking out. “They’ll need a line and labs, a few swabs, and an EKG,” he said to me. “But I’ll be right back.” As I wheeled the EKG machine in the room, he returned with a warm blanket for the patient.

Jaw drop.

Things like this happen every day I work in this Emergency Department. It could be this department, in this hospital. I’ve worked on units where the medical director made a point to hire doctors who were true team players and respected the entire team. And I’ve worked on units which the opposite was true. It could be an ED thing in general, but I don’t have the experience in emergency work to tell that yet.

I recently read an article (https://www.uchealth.org/today/2017/03/14/a-morning-in-their-shoes/) in which a medical residency program required the newly graduated doctors to follow a nurse for a shift. I genuinely think this is a must for hospitals, and for every part of the healthcare team. I would love to shadow a doctor for a day. I know I learned a ton as a circulator in the OR in that I was the one answering their pagers when they were scrubbed in to the field. The look of dismay when I read the page stating the patient’s potassium was 4. (Smack dab in the middle of normal.) The sheer number of patients doctors see and are charged with the care of each day is almost at a horrendous level. 

Our workflows are drastically different and to have a better understanding and empathy towards those differences can mean the difference in a good or bad patient outcome. Working together with respect of eachothers’ time and energy is critical. 

Heroin

Today I gave my patient alcohol wipes to take home with him. He’s a daily IV heroin addict and had the characteristic nodules across each arm from hitting up.

I told him he had to quit. But then I told him that I knew it wasn’t going to happen any time soon. So here’s what I made him promise instead: throw out all the use needles in his house and only use new ones from here on out, and always clean his skin before hitting the vein. 

Some battles will be won in a day. Other battles will not.

Perks of a Miserable Job

As some of you know, I’ve left travel nursing and gone permanent! Whaa??! Why would I do such a thing?? Experience. I want to be a flight nurse and after gaining the great ICU training and experiences travel nursing offered, I need ER experience as well. No ER in their right mind would take an agency nurse with no ER experience, so I went perm. Whew. Crazy ride. The ER is a totally different beast than the ICU or OR. They’re all crazy in their own way, but the past month of orientation has been to learn how to deal with the flow of the ER, the turn over, the balancing of three full-blown sepsis workup patients with a code stroke coming in just for giggles. Life has been crazy. And I’m bad at it. I’ll get better with time. I know that logically, but it’s been a while since I’ve been the newbie and it’s caused an amazing amount of stress and mental challenges. I don’t enjoy being bad at something, so jumping out of my comfort zone like this is, while great for me, painful.

That’s why, when my friend Freya RN sent me this list, it came at a perfect time for me. I love nursing. It was a great decision to change careers, and with all the pain, it’s still worth it. Enjoy.

 

1. I get to do cool shit – chest compressions, advocating for my patients, educating them about something that seems scary and isn’t.
2. Nurses have the best sense of humor, especially the peers you work with at the bedside. Who else is going to come help you clean up poop and silently laugh with you when the patient farts.
3. We have the BEST pranks at bedside. Think of the possibilities – urine specimen cups, chocolate candies, morgue carts.
4. If I get tired of working in the ICU, I can just as easily switch to ER, NICU, L&D, PACU, etc. without getting another degree.
5. I get to be there with my patient and their family for the highs and the lows.
6. I can name every crayon in the Crayola box for nurses – Upper GI bleed red, lower GI bleed maroon, coffee ground emesis, stool sample brown, etc.
7. I can provide comfort to my patients that no one else can, there’s something reassuring about a cool, calm and collected nurse taking care of you.
8. I get to hear the coolest diagnoses (such as, “Big Mac Attack”) and the weirdest stories as to how a patient got sick.
9. I get to work with so many other professions at the bedside and learn from them.
10. Every once in a while, you get a thank you from someone for doing a job that is many times thankless, and I hold those moments near and dear to my heart.

Babies Teaching Babies

Our first collaborative post! A dear friend of mine, who would like to remain anonymous as Freya, RN, contributed the below post. I’ll be posting another of hers tomorrow as well. Keep a look out!

I find it hard to organize my thoughts regarding this topic. It’s been the bane of my existence for the last year, and I’m running thin on my patience and my understanding at the moment.

I am by no means an experienced nurse. I’ve been a nurse in the ICU for four years and I’m getting tired of babies teaching babies. I was a new graduate in the ICU. I’ve been there. I should be more empathetic. The thing is, I was raised by nurses who had 5-20 years of experience in the ICU alone. I always had someone with more experience than I do to rely on. Someone who could help me with my critical thinking and decision-making process. Now, with my few measly years of experience, I’m a top dog at many of the hospitals I’ve worked at.

I have worked in situations now where I am one of the most experienced nurses on a busy unit. These new nurses are so intimidated by working in the ICU that some of them don’t ask questions. If they do ask questions, they feel more comfortable asking their peers and it becomes and issue of the blind leading the blind.

I’ve overheard some conversations that I’ve interjected myself into, just to be able to guide these nurses in the correct direction. Recently I heard a nurse of less than 6 months ask another nurse of only a year if she had to call the doctor back to clarify whether the doctor wanted a heparin drip with or without boluses (HUGE difference). The nurse she had asked said “I know what I would do, I’d just order it this way.” I couldn’t help myself (and probably looked like the biggest jackass in the world) – I walked over and I sad, “I would 100% call the doctor and clarify. It sucks that you didn’t think to ask the first time about the boluses, but really he should be putting in the orders anyways. Think of it this way, after paging and talking to him a second time because of this, you’ll never forget to do that again.”

I’ve heard some scary things out of these new nurses mouths, and I honestly believe it is because the person training them has only been out of nursing school for six months to a year. I’ve offered to train new graduates while in a permanent position and I’ve not had a student for the last five or so months while these babies are training babies. I believe it has been due to my complete honesty and my expectation that if you have a question for me, you’ve thought about the patient, the problem and have thought about what you would want to do. I do not give out answers for free, I train nurses to THINK. You cannot be an ICU nurse without thinking. 

 The scariest part of this whole thing is that management doesn’t seem to find an issue with nurses that have 6 month of experience, training new graduates in the ICU. There are always better nurses than others at any level of experience in the hospital, but I feel we aren’t setting up our new graduate nurses to succeed when the people training them have barely had time to be nurses themselves. The blame isn’t all on management and the higher ups though. The issue is that more and more bedside nurses don’t stay at the bedside. Bedside nursing is no longer a career – it’s a stepping stone. It’s a starting place for CRNA, NP and other advanced nursing careers. Many new graduates start out in the ICU with the plans of being a nurse practitioner by the end of 3 years. I can understand the appeal, a lot less physical labor, less time with the patients, more knowledge, and (what it’s ALL about) better pay.

The more these stepping stone nurses come into the work field, the more older nurses begin to leave the bedside. They leave because staffing becomes difficult and patient to nurse ratios become unsafe when turnover becomes so high. They leave because the people they work with are inexperienced and a danger to their patients. They leave because they can’t physically bear turning a 300 lb+ patient with only the assistance of one other person (and that is the only person they could find after ten minutes of searching.) To be honest, I LOVE bedside nursing, but I don’t blame these nurses. I’ve experienced the issues, I’ve heard the excuse of “It’s been worse before,” and I keep coming back. I’m not sure if that just makes me a glutton for punishment, a martyr, or more likely, a silly gal with a heart for helping others.

The Fight for the Code Cart

I love circulating and scrubbing liver transplants. Kidneys/pancs at great too, but the livers are fascinating. The organ does so much for our bodies and when it fails or is damaged, the multi system consequences are disastrously….fascinating? Yeah, that’s the word. I’ve learned my sickenly morbid enthrallment with pathophys is almost an industry standard. At least, most other RNs and MDs don’t give the sketchy side-eye when I mention how much I love things like HIV and liver failure.

I’m on call over night for the transplant team with my favorite scrub tech, and really my favorite team from anesthetist to residents to surgeons. Notified at 9pm, set up at 3am, roll back at 5am. Of course we’re delayed. Most are, due to either the donor liver transport if it’s out of house, or the recipient arrival, cooperation, or labs.

The week prior, this same team had run the smoothest code I’ve ever seen in any situation. It was beautiful, a work of healthcare art. And we were proud of it. The experience had brought the whole tam together in a way unparalleled throughout the unit. The transplant room is also one of the trauma rooms, so it houses a code cart 24/7. We check all code carts every 24 hours, regardless of use. Prior to a transplant, I double check the daily check. Another reason the OR allowed me to release all OCD tendencies I might have ever had.

At 6am, my patient rolls back. This guy has active LBBB and lives in afib. Regardless of heart history, the most dangerous part of most surgeries is intubation and extubation. With livers, repurfusion beats them out, but only barely. Anesthesia resident, propofol given, blade in hand to intubate, is disrupted as the OR door flies open. One of the night nurses, an overweight woman who will pay cash to other nurses to take her surgeries so she can continue sitting in the lounge, walks in and begins to unplug the code cart. She says nothing, makes no eye contact.

“Tom,” I said, holding my hand up to pause the confused resident. “Hold on and bag him for a minute.” He breaths for my completely sedated patient. I ask The nurse what she needs from the cart and inform her of the obvious, our impending intubation. She ignores me and begins to wheel the code cart out of the room.

I run across the room, intercepting her and stand between the cart and the door.

“Sandy (our manager), wanted the cart brought into the core.” I point out the three other carts we keep in the OR and relay my patient’s heart history. She seems unphased and repeats the managers request, pushing the cart past me. At this point, the phrase, “pry it from my cold, dead hands” might have exited my mouth, but it all became a haze. I ended up physically removing her hands from the cart, plugging it back in to the wall, adding an emphatic, “it stays. If the manager has a problem with that, she can come speak to me herself.”

She left. We intubated.

Shortly after, while anesthesia placed lines, I was inserting the catheter. Doing so left handed, I left my back to the door. So when I hear the door open, I make eyes toward my scrub and he interprets it correctly to keep an eye on the code cart. My manager walks up behind me.

Sandy always wears hospital scrubs, but I’ve never seen her scrub or circulate a case. Rumor has it she did open hearts about 15 years ago. Since then, she has suffered from the middle-management curse of forgettting all knowledge one learned at the bedside  but being forced by upper management to act as if they hadn’t.

“Are you ok?” Sandy asks. I pick up my patient’s penis in my right hand, holding it upright and refusing to make eye contac. The last thing this patient needs is a UTI from breaking sterile technique.

“I’m good. My patient’s pretty sick, but I’m good.” Still no eye contact as I twist the catheter until it pushes into the urethra.

“I heard there was a misunderstanding over a code cart.” I hit the prostate. More twisting of the catheter.

“No misunderstanding. She tried to take the cart, I explained the severity of my patient’s condition, and I kept my cart.” Up to the hub, no urine out. I take my non-sterile hand and push on the bladder.

“Oh. I knew the team had used this code cart last week.” Healthcare art. “And I wanted to make sure it was ready for the next transplant.” Seven days of scheduled surgeries and now she’s worried about it. What about the hip replacements all day yesterday? Those can bleed almost as much as a gunshot wound to the spleen.

“Sandy,” more bladder pushing, “we check those code carts every day.” Finally! Urine! It’s gross, thick and red-tinged, but urine. I hate to think what this guy’s creatinine is. “It’s been checked seven times since the last code, plus an 8th time by me this morning before the patient rolled back.” I secure the catheter to the leg, bend down to hang the bag on the table, and stand back up to finally make eye contact. “And we don’t have to move a code cart to check them.”

She looks at me. She looks at the catheter. The room is silent; everyone’s eyes down to whatever they’re working on. Her face morphs from chastisement to fake bubbliness. I get more nauseous from that than the smell of the liver being prepped. “Ok! Looks like you’ve got everything under control here!” Yes, now leave us alone, I say, internally impersonating Grumpy Cat.

As the door closes behind her, a slow whistle comes from the surgeon’s prepping the liver. “Oh shut up, Schmitty.”

No code that day.

The Come to Jesus Talk

The come to Jesus talk is a conversation in which you lay it all out there, expose the truth, the reality of the situation, and usually the direness of it. I’ve given these talks more times than I can remember and mostly to drug addicts. Although, patients with heart attacks and heart failure come in a close second. I’m blunt. “If you don’t stop smoking, you’ll be dead in three months.” That patient’s HF was so bad, his only option was hips surgery, which no one would do unless he stopped smoking 2 packs a day.

Most of these talks are met with feigned interest by the patient, some with serious looks, some with shame. 25% of people who have heart attacks make lasting changes. Only 25%. What am I working towards as a nurse? What difference am I making? Are these CTJTs making any difference? I do my job, both as a nurse and as a Christian, give these people the knowledge and tools to help themselves and improve their lives. And most of them blow me off. I’ve learned to let it roll off my shoulders. If I let it bug me, my own stress level would ruin me and be unmanageable. Self preservation.

“Broken wrist. Only history is positive for meth.” Greaaaat. Meth withdrawal. My favorite. My look of annoyance must have shown since the night nurse giving report quickly added, “he’s not your typical meth head. Really nice guy.” Sure. My skepticism proved unnecessary, since, while I can usually spot a meth user 60 ft away, I would have had no idea without that positive lab report.

After a few days of having this patient on the unit, we had developed a good rapport. He requested his family not be told about the meth, so the day I discharged him from the hospital, I waited till his mom left, pulled up a chair, and asked him what was going on. The twenty minute conversation that followed broke my heart. His out of control ADHD, leading to his meth addiction, it seemed miraculous that no one knew about it. He started and still ran his own successful business, functioning normally in society. And that’s after ten years of daily meth use. 

“It will catch up with you,” I told him. “Drugs leave a trail and you cannot hide from its devastation. It will take your family, your job, and every other facet of your life.” He didn’t roll his eyes at me. We talked about the next steps, how to fight it. I gave him the literature, hidden in his boots, so the family wouldn’t find it. 

I didn’t cry. Until I got home. This talk didn’t roll off my shoulders, it stuck there like a monkey. “He still had a good life, a life worth saving,” my then-boyfriend assured me. “Some people are more worth saving than others.” Whew. I hate hat explanation. All life is worth fighting for, worth saving. I truly believe that. That boyfriend and I eventually broke up due to our differing opinions on abortion and other end of life issues, so looking back on those statements, it makes sense coming from him. It wasn’t a good enough answer for me though. I don’t decide who is worthy of saving.  I simply save as much as I am capable of saving.

The question though, is why do some stick with us more than others. Was it the good rapport I had with this patient? Was it the similarities I saw between us, the common ground in life? Was it the impressive and unorthodox nature of his drug addiction? Was it the hope that he could be one of the few that survived? Is it my own personal level of empathy on any given day? If you have an answer, please let me know. And let me know how to combat it, how to continue letting that monkey roll off my back.