Public overdoses and my friend is a lifesaving superhero at a all-day-breakfast restaurant.

Public overdoses and my friend is a lifesaving superhero at a all-day-breakfast restaurant.

What were you up to at 3AM? Oh, just looking for an article about the increase in public overdoses of opioids and what that says about the power of addiction, the danger of the fentanyl-laced drug, and the will of people to, despite their dire state, be saved.

I couldn’t find the specific article, but I promise it exists and this is not an academic publication so sue me. The NYT article below about availability of Narcan as a health and safety measure like CPR training and AEDs in public places is good, too. I’m for it because I’m for life saving.

I’m going to tell someone else’s story; I’ve asked permission. This happened recently. Of the six of you who read this five probably know her. To know her is to love her, get ready to love this too, especially if you’re nursey and can do that thing we do where we care about people to a degree that we dedicate our lives to them but at our core lies a daaaark and morbid sense of humor.

So our friend is a recent PhD in nursing. A person who commiserated with me in when I was walking in the valley of clinical care is scary gross by saying “I knew it wasn’t for me the first time I emptied a peritoneal dialysis bag.” She’s an empath to the nth degree. Terrifically gifted in the field of psychology. Destined to be great to innumerable patients and, if there is justice, the wider field of psych/nursing/medicine. She is however not into emergency or critical care.

She’s in a medium sized city in the south, enjoying her favorite breakfast-all-day chain restaurant with her man, just having given their orders to their waiter who looks exactly like you would expect a breakfast-all-day chain restaurant waiter to look. The youngish ones. In the kitchen there is a commotion being made. Staff is peeling away from the dining room, forming a crowd. SOMEBODY DO SOMETHING is hollered. Our friend, the gifted psych nurse, is getting a look from her man (also a doctor of not medicine).

IS ANYONE HERE A DOCTOR?

Shit.

She’s getting the go get ‘em tiger from her fella. She rises, whispers to the backs of the crowd “I’m a nurse.”

SHE’S A NURSE” Hollers her dude with the authoritative bass of a public lecturer. The sea of people parts.

It’s their waiter, passed out on the floor of the breakfast-all-day restaurant kitchen. She is hella smart, so clinical person or not she can handle an OD. She activates that emergency response system (call 911, damn it), asks for an AED (there is none–what?!), checks that carotid pulse for not more than ten seconds (absent), and starts high quality chest compressions times thirty at a rate of not less than one hundred per minute with two rescue breaths between cycles.

Woman saved a life, people. SHE SAVED A LIFE.

EMS comes in narcannons blazing and brings the victim back. Poof. Death-be-gone.

Sigh. So that is our girl. My girl. My nurse friend and mentor. It feels good to know someone this gangster.

In summation: the opioid crisis is real, everyone must learn CPR, Narcan should be in first aid kits, and let’s address institutional cycle of poverty creating helplessness and hopelessness in economically depressed areas such as the stripped-bare resource colonies of the southeast leading to physical manifestations of what might be at the root existential disability and the introduction of opioids.

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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.

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.

Finding primary care.

Finding primary care.

*gets on high horse*

I am a nurse with no small amount of expensive health care related education and experience who works in a health system that has its very own heath plan (partnered, of course) and I promise you it just took me 3 solid hours to find a pediatrician for my kid. AND THAT WAS JUST FINDING A NUMBER TO CALL. There was the extra challenge of subscribing to a HDP HSA (high-deductible plan with a health savings account), but that’s where the smart money is in the marketplace.

After I finally set an appointment got off the phone with the grumpy receptionist from the new pediatrician’s office, I immediately called the old pediatrician’s office to request that my kid’s records be put in le grand queue at the fax machine to be sent to the new doc. I was shut down HARD by this grumpy receptionist. I need a release from the new office first. To be signed by me. And the new office requested a release from the old office. To be signed by me. I have a fax machine app on my phone, but I can’t make this happen.

So we will go to the appointment and take the heat and compromise in care of not having his records at the time he is seen. No medical history at all. I will duplicate a small forest’s worth of paper writing out what my shoddy memory contains of his past years of life. It will be skimmed. No one will be happy.

My morning’s nightmare is comprised of two system failures: Who can I find that will take my insurance (bonus question, at what coverage level) and how do I get my medical records to a new provider.

Here is how this could work better:
1.) Stay within the same health system (Kaiser/Geisinger/Sentara/any odd number of university health systems) so that the records are within the same electronically record management program, the billing is the same, and you can assume insurance coverage is the same.

alas, this is not an option (I moved)

2.) Use a larger brand of insurance. More providers accept them. Makes the hunt easier, does nothing for the transfer of medical records.

also not an option (Are you crazy I can’t afford that!)

3.) Pray for the day that health care reckons with the IT future of an electronic medical record that belongs to the patient, not the health system. Throw in a hail Mary for universal coverage. The first I am convinced will happen. The second not really.

As of now if you establish a record of care with a health system you are held there by the inconvenience of moving to an outside provider. It’s a perverse way to get brand loyalty. The middle-weight systems are (wisely, as the motto is grow or die) consolidating independent hospitals and practices faster than you can say “who bought us?” Health systems are trying to grow as big as health insurance networks and become both payer and provider. I get it. The future of a small number of very large health systems and the demise of the independent practitioner is not the saddest thing in the world. Right now, though, things are getting more complex as dozens of regional players merge and partner and insist on keeping their name on the door. It reminds me of having 4 specialists involved in the care of a critical patient and all I want to know is who is the captain of this ship! But that is another issue entirely. Or is it, really.

To bring it right back to where the confusion started, my insurance card has four company logos at the top. And the website is bad. Also, my human resources person is an animated character. Man that took forever. But now I’m just quibbling.

In the ICU, where we keep you from dying. (Whether you might want to or not)

In the ICU, where we keep you from dying. (Whether you might want to or not)

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I am back in the clinical setting, and boy howdy has there been some moral distress on the unit in the past days. When a patient is extremely frail or ill and does not respond to all available therapy, when they’ve reached the end of their rope, the limits of modern medicine, further curative care (which often is invasive and painful) becomes futile. The medical team calls a conference with loved ones to decide the course of action. Read below from the Jecker article and bear with me.


From Medical Futility, Nancy S. Jecker, PhD, University of Washington School of Medicine.
What is “medical futility”?
“Medical futility” refers to interventions that are unlikely to produce any significant benefit for the patient…Futility does not apply to treatments globally, to a patient, or to a general medical situation. Instead, it refers to a particular intervention at a particular time, for a specific patient. For example, rather than stating, “It is futile to continue to treat this patient,” one would state, “CPR would be medically futile for this patient.”

Why is medical futility controversial?
While medical futility is a well-established basis for withdrawing and withholding treatment, it has also been the source of ongoing debate. One source of controversy centers on the exact definition of medical futility, which continues to be debated in the scholarly literature. Second, an appeal to medical futility is sometimes understood as giving unilateral decision-making authority to physicians at the bedside. Proponents of medical futility reject this interpretation, and argue that properly understood futility should reflect a professional consensus, which ultimately is accepted by the wider society that physicians serve. Third, in the clinical setting, an appeal to “futility” can sometimes function as a conversation stopper. Thus, some clinicians find that even when the concept applies, the language of “futility” is best avoided in discussions with patients and families. Likewise, some professionals have dispensed with the term “medical futility” and replaced it with other language, such as “medically inappropriate.” Finally, an appeal to medical futility can create the false impression that medical decisions are value-neutral and based solely on the physician’s scientific expertise. Yet clearly this is not the case. The physician’s goal of helping the sick is itself a value stance, and all medical decision making incorporates values.

This paternalistic bend on discussion with patients and caregivers–that whether or not an intervention is futile is a call to be made by a medical or inter-professional team–well I’m not a fan. She suggests that the use of the words “medically futile” might disrupt the discussion. In my experience doctors and nurses may tailor language to be more or less jargon-y based on a patient/family member’s experience and education, but there is no reason be opaque when if comes to describing that an intervention will not, in the HCP’s opinion, be of benefit. And it may cause pain and harm. “Medically inappropriate” sounds snobby and skirts the issue–what are we doing here? What would your loved one want? Here is what we can offer (palliative options, less invasive options, what have you). And most importantly the decision is in the hands of the patient or their proxy. For better or worse. (This exempts surgeries, etc, where a level of medical stability is required).

We owe it to them to paint the full picture then allow them the right to choose. In my experience people can handle a lot more than we give them credit for.

The place to make the change is not at the ICU bedside where grief has a hold of the wheel. Encouraging end-of-life preparation for those who are sick and those who will be tapped as caregivers should be normalized in the primary care setting (which, ehem, was sacrificed to pass the ACA).