St. Elizabeths Asylum, Washington, DC.

St. Elizabeths Asylum, Washington, DC.

Lo, I did write thee a splendid piece on my visit to the National Building Museum exhibit on Washington, DC’s great Asylum hospital, St. Elizabeths (no apostrophe). But ay I did it waiting for a surgery to close, needing something to do something with my nervous energy. The patient, when asked the standard pre-surgical question “Why are you here with us today?” (assesses orientation, assures that the patient is informed, confirms procedure), answered “I am dying.” Always believe the patient who says they are dying.

Crash cart at my side, fellow nurse and I finished planning our I-hope-this-doesn’t-turn-into-a-code, I typed out a gem. And upon finishing, ran off to do a thing and lost it.

Instead, here is an excerpt of a letter written by Dr. Charles Nichols, superintendent, to Dorthea Dix (nurse, hero) the greatest advocate for mental health that ever lived whose actions led to the establishment of the hospital, on the selection of a site.

The moral treatment of the insane, with reference to their cure, consists mainly in eliciting an exercise of the attention with things rational, agreeable, and foreign to the subject of delusion; and the more constant and absorbing is such exercise, the more rapid and effectual will be the recovery; but many unbroken hours must elapse each day, during which it is on every account impracticable to make any direct active effort to engage and occupy the patients’ minds. Now, nothing gratifies the taste, and spontaneously enlists the attention, of so large a class of persons, as combinations of beautiful natural scenery, varied and enriched by the hand of man; and it may be asserted with much confidence, that the expenditure of a thousand dollars each year, directed to the single object of promoting the healthy mental occupation of one hundred insane persons, with either amusements or labor, would not be so effectual in recalling reason to its throne, as will the grand panorama of nature and of art, which the peculiar position of the site chosen happily commands. The shifting incidents of the navigation of the Potomac, the flight of railroad cars to and from the city, the operations at the Navy Yard, &c., will continually renew and vary the interest of the scene.

It lifts my iron anchor of a heart to read about this period in time, the asylum movement. Started by Quakers and somehow collecting political support for the mission to create a place, tranquil and serene, to house and heal vulnerable, imprisoned, and cast away persons suffering from mental illness. Public funding! Our government and the people it represents setting aside money to better provide for its poorliest members. Acknowledgement that all people have dignity and value.

**I know you’re thinking asylum? You mean those places where people are locked up and tortured and experimented on? Yes, terrible. But I’ll refer you to the many, many atrocities committed against those walking free: people of colorindigent people seeking care at public hospitals. Medical ethics has an awful lot to answer for. It’s my speculation that we pin it all so easily on asylums, place all our unquiet ghosts there, because of the fear and stigma bound to mental illness. Chew on that. I digress.

Asylums were conceived in goodness. Every pure-hearted reformer may know exactly where the road paved with their good intentions will end up, but I’m glad that they’re trying. We keep trying. We should always be trying.

PS- As Dr. Nichols states, I’m in favor of doing anything that “recalls reason to it’s throne.” Especially in this nuthouse town.

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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.

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:

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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.

 

 

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.

International Women’s Day. 

In the old days, when we were in need of entertainment my spouse might offer up this question:

“What time in history would you most like to live in?” 

“Do I get to be a man? Cause if not I’m not going anywhere.”

I like that I can own property. Maybe I will someday! I am grateful for the sacrifices made by many over the centuries opening vast realms of what was a man’s world to all life creating, cycling with a m-fing celestial body human women.

Nursing is to its core, in all the best and all the worst ways, a traditional women’s profession. Essential parts of a critical care training I did today included tactics for manipulating a provider into completing a task (use their pride), how hard work is mandatory and don’t count on being recognized, and the importance of your intuition. These things I will happily lean into in the workplace. I love women’s work. But God help me I’m going to elevate it. I want recognition with my effort. I want power with my responsibility.

But hey. Now I find the great quandry of the woman in her childbearing years is all up on me. I can’t be all the nurse I want to be, and I can’t be all mother.

When I’m woe is me I turn to my fav lady sage, Madeleine Albright, who I liked before she said that there was a special place in hell for women who didn’t help each other. Now I love her.

I subscribe to her advice (actually I keep a clip from the American Master’s film Women of her on my phone so I always have a little guru with me). You can have everything. But not at the same time. Women’s lives come in segments.  Also you do not have time turn this into a Vimeo clip so you video the thing and post it on your dusty old blog.

Happy Women’s Day! 

What in fact does a nurse use a stethoscope for?

What in fact does a nurse use a stethoscope for?

Daytime television isn’t historically the best place to educate thyself, but isn’t this “The View” moment a great opportunity to explain to our patients what we do as nurses?

So far as I can tell, a lot of everything pretty much everywhere. “Nurse” covers a heap of credentials, too. It may be the CNA or Certified Nursing Assistant who takes your vitals (may use stethoscope!) and assists you in getting fed and staying clean and comfortable in the hospital. It could be the RN or Registered Nurse who dresses your wounds, asks about your pain, listens to your lungs, and behind the scenes communicates how you’re doing to the doctor– including a recommendation for action–and, god love him or her, gets you that pain med you desperately need. And you know what? It may be that the RN who asks about your pain is communicating with an APRN or Advanced Practice Registered Nurse instead of a doctor to get you the proper medicine (Nurse Practitioners, Certified Registered Nurse Anesthetists, and Certified Nurse Midwives fall under the APRN heading and may prescribe medication).

The funny thing about a nurse is that no matter what their title/education/credentials, if it’s within scope of practice, they will take care of patient needs. I’ve seen APRNs change soiled beds. I get care from an NP who has spent hours corralling my records from various specialists in various health systems. (She waited on hold with patient records for me. I love her.) Does the patient need it to receive quality care? Is anyone else taking care of it? Nurses are get it done people.The pros and cons of weakly defined roles and challenges of delegation are a topic for another day. One with less post-surgical morphine, perhaps.

I actually got a cardiologist’s stethoscope for graduation. I’m fancy. When I planned on working in a Neuro Intensive Care Unit I knew it would be useful for my newbie ears when it came to hearing bruits in patients’ carotid arteries. When I start work as a community nurse visiting homes of pregnant women, one thing I’ll use it for is getting an accurate blood pressure to check for signs of preeclampsia. Early detection of high blood pressure in a pregnant woman can save her life and the life of her baby, so I best show up with my tools. She depends on me. Her doctor or midwife does too.

I use a stethoscope since it’s a valuable part of the medical trade. Just like me. Simple as that, really.

Alarm Fatigue – Recent Research About Nursing – Robert Wood Johnson Foundation

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Recent Research About Nursing, December 2014 – Robert Wood Johnson Foundation.

Alarm fatigue UNC study: 

Alarm fatigue occurs when nurses and other clinicians are exposed to a high number of physiological alarms generated by modern monitoring systems. In turn, alarms are ignored and critical alarms are missed because many alarms are false or non-actionable.

In the ICU, parameters for BPs, heart rates, respiratory rates, oxygen saturation, and the like are often outside of normal limits. It is not uncommon for every patient’s monitor to show tachycardia. Or atrial fibrillation for that matter.

Investigators analyzed a subset of 12,671 arrhythmia alarms, which are designed to alert providers to abnormal cardiac conditions, and found 88.8 percent were false positives. Most of the false alarms were caused by deficiencies in the computer’s algorithms, inappropriate user settings, technical malfunctions, and non-actionable events, such as brief spikes in heart rate, that don’t require treatment.

True story: the only alarm on the floor that makes me jump is the one that goes off when the medicine drawer attached to our computer has been open too long.

So to quiet the floor and maybe do a more precise job monitoring the status of ICU patients, smarter technology that will observe for artifact and normal abnormals would be great. For now, we can better manage the technology we have by knowing our patient’s history and tailoring care. If someone is in chronic afib with a resting rate of 110, set the monitor with an appropriate upper limit–also you might might raise the lower limit to alert you if they convert to sinus rhythm. An alarm on a heart rate of 118 on this patient would be meaningless information, but an alarm on a heart rate of 70 could help you identify a stroke risk and prompt appropriate assessments and prophylaxis.

Nurses can often determine the reason for an alarm by looking at the monitor (as of now it’s that alarm that draws them to look) A bad wave form because the O2 monitor is lose, artifact on the ECG leads, heart rate up and O2 sats down ’cause the patient is using the bathroom are common non-urgent alarms.  Rather than blow up the unit with noise, shouldn’t we have an app for that? In my pocket, a phone that vibrates, so I can check it out trouble shoot, ya know?

These are partial solutions but reasonable I’m thinking.

What we’re going to do about those distal occlusions man, I haven’t a clue (IV pump humor!).

ivpump

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