Happy nurses week my people of the people.

Happy nurses week my people of the people.

Here is what I know about nurses in year two of my practice: We are the strongest threads in our community quilt. Binding the diversity of incomes, ages, and cultures together with help, healing, and unconditional (sometimes tough) love.

We can simultaneously hold a cynical view of our fellow man and have the deepest reservoir of hope in humankind. That is to say we will complain bitterly while suffering twelve hours of abuse by a certain patient, and then stay four more hours to see them through when their condition deteriorates. We need to see them through.

If I am your nurse, you are my very own one. I will protect you, I will defend you, I will advocate for you. I’ll go toe to toe with the provider who endowed my hospital if I feel you are being hurt. If you need it, I might even bring you secret coffee from my very own stash. You must know—it is to you I will always be true. Not because you’re nice, though please consider being nice, but because you’re mine. If the building caught on fire I’d sling you over my shoulder and carry you down the stairs. (This isn’t policy, just a metaphor. Trust we have better evacuation plans). I’m not special. I’m “just a nurse.”

I’ll recognize you when I see you out in the world and under light less harsh than hospital fluorescents, but you likely won’t remember me. I don’t need you to. I’m one of many clad-alike interlopers palpating and auscultating and delivering medication. Our time together is sacred and secret. I’ll acknowledge your return to health in silence, with a smile that is overjoyed to see the color in your cheeks. You’re back at work or running the aisle of the grocery after your wild, beautiful children. My chest fills with pride as I think: She’s one of mine! Look at her, so well!

I don’t know any nurse who feels differently. We are for patients. What a noble group of people to share a name with. Every day I find time to do a little jig of joy to celebrate my membership in this club of tough, tender advocates for humans. Doing work that cares little for glory and much for justice. It’s the only gift I want.

Happy nurses week to all of you, you magnificent beings.

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In which a childhood friend’s hospital hardship pulls me up short.

In which a childhood friend’s hospital hardship pulls me up short.

Friday night at the hospital knocked me off this high horse I’ve ridden lately. I’ve been on a big patient advocacy, let me share my story jag. Despite feeling like I’ve had every experience possible in the U.S. health care system (and some in Canada, Mexico, and the Republic of California), I really haven’t. And I’ve walked the halls of the hospital where I work long enough to become unfeeling to a lot of the suffering. It’s human, it’s survival, I’m still disappointed.

After removing someone’s problematic accessory organs in the OR Friday night I got a message from a friend, someone I haven’t really known since childhood, saying her dad was sick and she was there. I regretted not checking my phone earlier. I had already changed out of my scrubs, so riding the staff elevators to her floor I knew I was going to get the reception of an after-hours visitor. Chilly. I tried to hold my name badge conspicuously, but surely enough there were all those familiar unwelcoming looks. The you better not be here to make trouble side-eye. The it’s too late for your kind of nonsense head shake. I have been the the side-eyer. The head shaker. Damn.

I really don’t understand how we fit all the furniture plus two very sick people in those tiny hospital rooms. Maneuvering in to visit is human tetris. I hug my friend, take off my glasses and squat down to see if her father remembers me through the 20+ years and the onset of dementia. He kindly says hello. Asks again about necessity of the IVs. The stay overnight.

It was hot. Heat rises. We were high up. I would be in a perpetual sweat when I worked that floor, but fool that I am assumed it was my constant motion. Families complained, and though I may have apologized for the inconvenience I quickly dismissed it. Sorry about the heat but right now I’m trying to stop you from bleeding out internally. There is a famous meme that I am now ashamed to admit to using like a mantra:

image-5571ba9223c84

Damn again.

I was there briefly, only long enough to say hello and I’m sorry. To steal a fan from my home unit. Those shoe box sized white electric fans are the only hospital commodity more stolen than pillows. Soon the tech was hefting my friend’s father up and off to the bathroom, shaming him for walking three feet on his own (NO ONE WALKS ALONE is a safety campaign at my hospital as well as an apocalyptic vision of the future). Physically keeping him cornered until he crawled safely back onto his bed, the only surface a patient may occupy. As a nurse I’ve done this too. DAMN DAMN.

I understand and have embodied nursing’s motives for the way we treat patients. There are so many and their needs so great. The gown and the industrial linens, the bedside commodes and 3+ identifying armbands that become a patient’s most significant identity dehumanize but serve a critically important end. Hospital survival. Name, allergy, fall risk. Limb alert. Anticoagulation. Difficult airway. Oh god what have I become.

My friend is like me, a woman working in the caring professions derived from the great Lillian Wald. She’s a pro. She gets it. Just before leaving I leaned across the narrow hospital bed, now safely occupied, held my friend’s hands and whispered to her. I’m sorry I can’t help you. This is why I became a nurse and not a social worker. This human stuff is too hard! She replied, “This is why I became a social worker and not a nurse. This hospital stuff is to hard!”

It is too hard. But heaven help me. I’ll try to do better.

 

 

Valentine’s for broken hearts

Valentine’s for broken hearts

There is this utterly sensible trend in health care where the providers of the highest acuity care seem to have the least first hand experience as patients. The first time a coworker commented “Sometimes I wish I’d been in the hospital so I’d know what having an IV placed felt like,” I was flabbergasted. Are there adult people that have avoided IV sticks? Yes, many. It makes sense that my colleagues are largely younger and healthier people, considering how tough the gig is on a body. Poor sleep habits, stress, inflexible schedules, repetitive back wrenching… it’s in the job description. But this lack of direct experience opens an even wider gap of understanding between provider and patient. They have no shared medical experiences. And medical experiences aren’t about the pain of the IV stick. It’s the subordination to your providers, a previously robust identity reduced to your name and birth date on your bracelet (plus fall risk meaning now you can’t even toilet yourself). How people cope with what we take away from them defines what kind of patient they appear to be.

So on this Valentine’s Day, Galentines for my feminist warriors, day of grumpiferous mourning for me, a tweet from Lucy Kalanithi reminded me to urge all health care people to read Paul Kalanithi’s When Breath Becomes Air. In this memoir Paul is able to recount in what feels like real time losing his identity as a promising neurosurgeon to cancer. His doctor self gives way and he becomes the patient. Being previously a young and healthy person, and falling victim to the trick all healthy people play on themselves (the way I am now is the way I will always be), his realization that his is terribly ill is heartbreaking. The chapter in which he discusses his scientific mind’s understanding of survival curves, trying to square the data with his individual, not-yet-a-statistic mortality, it rings so bitterly true.

Here is Lucy Kalanithi’s beautiful valentine to him. It speaks to living with loss. If you’re on twitter follow her post haste (@rocketgirlmd).

What Lucy says about grief and loss…blarg my heart. We have been a house in mourning for the past 14 months. My mother lost her true love and partner. I lost my father. I sometimes feel like I killed my father since it was my chest compressions that sent him out of this world, but that’s another post. If dad were here this February 14th I sure as shit would be sitting as his feet complaining about the quality of available suitors while he half listened until I wound myself down, then I’d get a “you’re fine sweetie girl”and a pat on the back and I would be fine. And he and mom would watch garbage TV and laugh at really stupid jokes and drink wine out of tumblers and genuinely enjoy one another.

In remembrance of the love between my parents I’m attaching my eulogy. All of us Crawfords were so lucky to get so very much of him.

So to bring it on back health care people of the world, depending on the statistics you go by we are somewhere between 60-80% likely to have someone’s loved one in our care as their life ends. Think about what it felt like to be Paul, what it feels like to be Lucy when someone asks to bring their baby into the ICU. Or tapes pictures all over the walls. Or changes their mind about end of life care 16 times. People often need guidance, and we can draw from training and experience to offer it. Maybe what has happened in your own life, or a book you read, is helpful. Keep that. Get rid of the rest. Like I said at the beginning: It’s a tough gig.

Culpeper cardiologist accused of striking hospital nursing director | News | dailyprogress.com

Culpeper cardiologist accused of striking hospital nursing director | News | dailyprogress.com

A Culpeper cardiologist faces a misdemeanor assault and battery charge stemming from a reported confrontation with a female nursing director inside Novant Health UVa Health System Culpeper Medical Center

Source: Culpeper cardiologist accused of striking hospital nursing director | News | dailyprogress.com

Hi Doc! I hope you get fired. And fined. Props to the nurse admin who pressed charges. I’M WITH HER.

I trained at this rural community hospital. It was not an extraordinarily hostile environment. In my limited experience it was probably a 4/10 on the pain scale of abuses nurses suffered at work. Still, I’m not surprised by this repulsive development. Workplace violence, mostly verbal, is a reality of hospital work. At UVa Culpeper there was almost no interaction between MDs and RNs. The general view of nursing was that this was a group of low class, poorly educated, lazy to the point of obstructionist women. A recipe for disaster.

Nursing should be a force to be reckoned with, different but equal to medicine. Respect and autonomy are harder to come by in community hospitals–but this is a battle worth fighting. It should be noted that difference between community hospitals with minimal nurse autonomy and governance and large academic medical centers, particularly Magnet organizations, is massive. Wherever they are, nurses must be empowered as professionals to participate in advancement of their own practice. We have an important job and we have to be nailing it: know the orders, read the notes, understand the clinical picture (plan even!), be engaged enough to know the why of every drug and intervention. Be twice as good as the doc. You know what I’m saying. Do it backwards in high heels.

I see two practices for improving our situation as a historically subordinate profession: 1.) (Dare I say it?) We are stronger together. Active nurse governance at your hospital. Sit on committees. Insist on getting paid for this time, because this is not the PTA and we are not volunteering. THIS IS A PROFESSION. 2.) Get to know each other. Inter-professional education has shown anecdotal promise, even if the studies aren’t strong. Hospital administrators, you can facilitate this at non-teaching hospitals. If you work at a teaching hospital you’ve got the advantage of working with baby docs. Share your experience, and they will often share their shiny new medical knowledge. Either way, just talk to people. Regardless of their credentials they are in fact people. Here are some topics of discussion to get you started: kids, dogs, mortgages, food, car repairs, patients. It’s hard to hate (or hit) someone whose humanity you recognize.

Bedside nurse personal

Bedside nurse personal

It’s a strange thing this working in a hospital. Your professional environment is people who are having the most painful, out of control times of their lives. Or maybe, and often in the medical-surgical ICU where I work, the realization that this is how their life is going to end. It’s heavy stuff. I love heavy stuff. I love being a critical care nurse.

I’m not that great at it yet. I started in February, oriented for 4 months, took patients while I did 9 months of additional training and education.  I use a lot of support from fellow nurses, pharmacists, physical therapy, speech therapy, and I couldn’t do hardly a thing without respiratory therapists. Some attendings are sent from heaven. Others can go well you know where. I’ve had a handful of very, very sick patients which have stayed with me for nights in dreams where I complete the tasks I wish I’d gotten to during my shift. I’ve had many not terrifyingly sick but fragile patients who kept me less occupied with medical needs and more busy with human needs: company, anxiety, hunger, bathroom stuff.

Bedside nursing and shift work? I thought it was something to be suffered through. But like the intensivist I respect and will one day impress always tells me: “You are wrong.”I have no desk. I’ve sent maybe 2 emails. I never know what I’m walking into, but I know it’ll be over and up to the next shift in about 13 hours. This is a relief (out of my hands) and a responsibility (don’t leave a mess for your coworkers).  I’ve never looked forward to work the way I do now. I also regularly come home and lose my mind. I have sworn I was going to quit at least 3 times. I have a new resume for every season. But the deeper in I get, the more I feel the need for the creativity, chaos, and appallingly funny bedside world.

Aside from the heaps of scientific and human condition knowledge I’ve gotten in the past year, bedside nursing has been a self-improvement miracle. Accomplishments I’m most proud of:

Stern voice always at the ready. “PLEASE DON’T PULL THE TUBE OR YOU’LL DIE.” “YOU HAVE TO STAY IN BED OR YOU’LL FALL AND BLEED OUT OF YOUR HEAD.” “NO EATING WITH THE BIPAP ON OR YOU’LL CHOKE TO DEATH.”

Always at the ready to receive the stern voice. “WHAT DID YOU DO TO MY VENT?” (Nothing I believed you when you said you would eat me if I changed the settings), “WHY HAVEN’T THE CULTURES BEEN SENT YET?” (No chance on peripheral access, gonna need that central line order I mentioned…) “YOU MESSED UP.” (Happens all the time. Tell me what I can do to fix it).

Learned to deliver a come to Jesus moment. I’m getting used to being the punching bag for upset, confused, desperate patients going through the worst of what life has to offer. People’s feelings have to go somewhere. But if your feelings are getting in the way of my care we’re going to have a come to Jesus. There’s the I’m going to come down on you like a ton of bricks with teeth and nails and repressed Catholic rage CTJ: “YOUR YELLING AT ME IS MAKING YOUR WIFE’S BLOOD PRESSURE DANGEROUSLY HIGH AND KEEPING ME FROM DOING MY JOB so please go to the waiting room and I’ll call you when we’re settled.” Alternately, the you are panicking so let me tell you exactly what you are going to do to get through this CTJ: “Your mother is dying. Please stop texting your vacationing siblings. Now is the last time you get to hold her hand and talk to her. It is going to be okay.”

As this first year as a critical care nurse comes to a close, I am so happy to be a humble and regularly humiliated newbie in my place. Hospital people are my people. And I plan on staying put for some time to come.*

*I will still look for a job selling insurance every time they float me to the step down unit.

Shift work for me, Shocking for you.

Shift work for me, Shocking for you.

My patients are often too sick to speak, much less ask questions about how their care plan is progressing. Yesterday I was lucky to have a patient with family at the bedside. Children that were young and healthy, and based on not subtle comments had the advantage of money and power thus the ability to control everything in their environment. Under normal circumstances. Things had rapidly deteriorated for their mother over the previous 24 hours and frustration with serial specialists painting differing pictures was high. It was very important times for therapeutic communication.*

For caregivers and family with loved ones in the ICU, there are two basic questions:

How did this happen?
To a nurse or a doc the handful of illness we see in the community hospital (pneumonia, sepsis, organ failure, stroke, all of the above) run a well worn path and are nothing to get excited about. To the family of the patient, their loved one was watching baseball two days ago and now we’re telling them to hurry up and sign a paper giving permission to place a central line and intubate. Mom is unrecognizable from the edema in her face and her toes are turning blue. How did it happen so fast?! Family members will show me pictures on their phone insisting that I note the date stamp, “look at her, she was fine!” And she was, until she wasn’t. The turn of events, the speed, the randomness of having some soup go down the wrong pipe into the lungs or reaching for the door handle and noticing you can’t feel your hand. We aren’t able to reconcile it.

As the nurse, validate that this is a catastrophic change. No one is running around screaming STAT! but it’s is as serious as it gets. Permission to be shell shocked. Run through the series of events that got the patient to ICU. Do it again. Answer questions. Do it again. The brain is a non-stick surface when people are experiencing a trauma. ICUs are traumatic.

What next?
This is a toughie, but everyone wants to know. Ask loved ones if they would like your nursing assessment, and if so, share it. People are intelligent until proven otherwise. Your mom is very sick. Here is what we are doing to help her breathing/kidneys/heart/infection. If she gets worse here is what it might look like and the interventions that may be considered. If she gets better here is what it might look like and what the next steps would be in recovery. Tell them what modern medicine can do support their body through acute illness, and where the end of the road is with these interventions. Offer resources. Talk about what the patient was like in health, and what they would want.

If the patient is stable remind family that things can change very quickly but their loved one is in a place where there are professional eyes on them every moment. They are as safe as can be guaranteed. Now might be the time to get sleep since however the ICU stay ends, be it in acute care and recovery or in planning a memorial, laying a body to rest, and grieving, they are going to need strength for the next part.

And you know what? Tell the family what the numbers on the monitor mean. They stare at them for hours not knowing what this alien language is besides scary and important. When you go to silence an alarm like you do twenty million times a day remember to explain why. The lead fell off, the probe is not reading properly. Nurses see the bad wave form and know the data is garbage, but patients and families hear the alarm and think emergency. Communication, comrades.

*Different people are going to want different amounts of information at different times. Nurses assess that first, K? What’s appropriate and when is a soft skill. One pro-tip, and this counts for life as well as nursing: you don’t know how they feel. Don’t say that.

Good Lord “Mercy Street”

Good Lord “Mercy Street”

I’m obsessed with our image. On a scale of 1 to Gray’s Anatomy (1 being no pain, Grey’s Anatomy being the worst pain you’ve ever felt in your life), most portrayals of nurses on TV and in the movies land in the 7 region. The faces pain scale really works for this:
Pain scale

A few years ago PBS began airing the BBC period nursing drama Call the Midwife, a darling and coherent if sentimental portrayal of post-war era midwives working from a convent in East End London. I like this one even if later episodes did risk giving me cavities. Maybe it reads as authentic because it it drawn directly from the not fictional nursing memoirs of Jennifer Worth, who lends her stories and her name to the main character. Nursing is a real thing in this series.

I guess it was inevitable that in the wake of its success America would give nurses a stab with the new PBS series Mercy Street, about a Union Civil War Hospital set in (my hometown) Alexandria, Virginia. Oh my hopes were high! This show is, so far, unforgivable. It hurts worst. I could feign indifference when it came to the laughable accents, the absurd and awkwardly drama-less rape scene in the first half of the second episode (give me time to love the characters if you’d like to break my heart!), but the characterization of the only actual nurse as the mean and heartless foil for our two sweet and well meaning hero nurses is so disgusting that it can not stand, man.

The uptight bitch nurse is to be hated because she trained with Florence Nightingale in the Crimean War and is suuuuch an expert at things like sanitation and wound care. She is so bossy about telling new nurses how to do things in a safe and evidence based way! The lady knows what she is doing professionally and seeks to better her field and improve the health outcomes and safety of the soldiers in the hospital’s care. What a B. I bet she hasn’t had sex in forever, she’s such an ice queen. Nope. In the second episode we see her sleeping with her boss, the corrupt doctor! So that’s how she got the gig.

Our two heroes are nurses who have no training or experience, but never you mind. They have the calling to serve their fellow man. To provide comfort in times of need. They have tender feminine hearts and strong womanly wills and as god as their witness they shall never let a boy die without a soft hand to hold! They will try to get some food for these soldiers too!

I said I could overlook the accents, they have nothing to do with nursing, but let me just tell you that the southern hero nurse is a native Alexandrian (a city two miles from DC) but makes sounds like her cotton plantation just caught on fire. Robert E. Lee did not sound like Blanche DuBois. Or Blanche Devereaux. But this woman does.
blanche

So. I’m sure our hero rookie nurses will use their female intuition and woman-in-a-man’s-world grit to become invaluable assistants to the doctors they work with. But I won’t be around to watch.

I’m going to watch Nurse Jackie.

PS- I tried to find the script writers on IMDB to no avail–but there were about 1200 costume consultants. The costumes are fantastic. The script? What script.