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.

 

 

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.

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.

Why Health Care Tech Is Still So Bad – NYTimes.com

I interviewed Boeing’s top cockpit designers, who wouldn’t dream of green-lighting a new plane until they had spent thousands of hours watching pilots in simulators and on test flights.

via Why Health Care Tech Is Still So Bad – NYTimes.com.

Let me tell you about my favorite provider. She faces me, each of us at right angles to each other at her computer desk, and writes everything down on a yellow legal pad. She goes system by system, like a quality shift hand-off report. We use the computer to review labs. She never prints out “educational information.” I get handwritten notes and web addresses as needed. She talks and writes fast, with military precision (active Air Force) and maintains eye contact. She pauses and sits back in her chair to look at me when she senses I’m holding back or is working to figure out a complex set of problems.

Her pad is on the table between us, and I can see everything she is writing. I sometimes correct or edit it. It is never longer than a page.

Duplication of work you say! Well, with Alice there is no time lost, no errors made by the anguish of garbage in garbage out. We draft it together. Then it goes in the permanent record.

The big hurdle, the big secret… she works at NIH. Where time and dollars aren’t the exact same thing.

Just a thought. PSST she is also a nurse by training <3.