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.

Advertisements

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.