talking RN

Safety

2009-09-13T18:00:00.001-04:00

Check this out:

The Josie King Foundation

Theresa Brown gives NY Times readers a peek into the world of nursing

2009-08-19T21:14:00.001-04:00

Check out the awesome work of Theresa Brown, R.N.

Keeping the faith

2009-06-23T10:29:00.002-04:00

I see her as I step off the train.

She is sitting on a bench, slumped over several plastic bags and wearing a heavy winter coat, complete with furry lined hood drawn up over her head. I can't really see her face at all. It is June; coat weather seems entirely unimaginable.

I look at her and I want to fix it so bad, whatever it is that has caused her to be sitting on a bench wearing a winter coat in June with all her worldly possessions around her. As if "it" is just one fixable thing...

The rest of us are walking briskly past, all books and briefcases, earphones and telephones.

I am on my way to school. I miss actively working with people every day... God, I miss it. I go in and take my exam. It is a hard one. Then I retreat to the library to work on a paper, but write about her and how I feel instead. I try to keep the faith that this will be worth it, and I'll be glad I did it when someday I am back to work again...

Pondering the reasons we wait so long to make the call...

2009-06-03T11:07:00.004-04:00

Check out this nice piece in the NY Times by Paula Span:

Avoiding the Call to Hospice

Maybe you shouldn't crack the chest

2009-04-28T11:59:00.001-04:00

"We can't let families be present for resuscitation," he told me. "We crack the chest."

Well, maybe you shouldn't.

Vicarious Posttraumatic Growth

2009-04-11T19:35:00.004-04:00

Who knew? There is already a name for the reason I love my work... "The term vicarious posttraumatic growth describes the phenomenon of clinician growth that results from witnessing positive sequelae of other people's experiences of trauma. This may include the clinician's feelings that his or her own life has been enriched, deepened, or empowered by witnessing the patient's or family's posttraumatic growth." (Kearney, MK et al. JAMA 2009, 301:11) WOW! I nearly fell out of my library chair when I read this... This type of enrichment is at the core of the powerful draw I feel to work with patients and families in crisis.

I discovered this term in this very interesting 2009 JAMA article by Kearney and colleagues titled Self-care of physicians caring for patients at the end of life. It is not only relevant for physicians, however. In the section on burnout, they describe six areas of work life that contribute to the burnout phenomenon. They are workload, control, reward, community, fairness, and values. Only a quick examination of nursing work life is needed to confirm that nurses are an extremely high risk group. Let's look at some of the areas.

Workload
Where do I start here? The nursing workload is off the charts on so many levels: physical, emotional, and spiritual. It is also extremely challenging mentally, but this tends to be more energizing than depleting, unlike the other three!

Control
Imagine having zero control of your work environment. Zero! You have no personal space (maybe a locker somewhere far away if you're lucky, but that's just to keep your valuables from getting stolen, since you can't ever get away to access it during the day). All kinds of other providers come in and, naturally, need to use the workspace to see the patients for whom you are caring. Now that I am one of these "others," I am often a recipient of the very icy treatment many nurses give to people. I am aware that I, too, have been guilty of this in my role as a nurse. I think one reason for this kind of behavior may be the lack of control over the environment, including personal space, but also the inability to control one's own workload and workflow.

Reward
Perhaps for nurses we might substitute respect here, specifically that not given by other HCPs. The other day a physician was teaching a session in my ACLS renewal class. He was discussing team dynamics during emergency situations, and making the excellent point that a team leader should always be open to hearing ideas from any member, regardless of his or her role. Two heads are better than one, you know? So he says, "I would never say, 'That's stupid, you're just a nurse, you don't know anything!' That's just not appropriate." The implication was not that it was untrue, but that saying it is not okay.

I'll leave community, fairness, and values for a less cranky day!

Must-read from Dallas Morning News

2009-01-08T09:35:00.002-05:00

At the Edge of Life is an incredible series written by Lee Hancock, with beautiful photos taken by Sonya N. Hebert. At the center are the clinicians and patients of the Baylor University Medical Center's Palliative Care Team. Thank you Dallas Morning News!

Rolling down the window in December

2008-12-15T16:54:00.005-05:00

I sit at the stoplight, behind the shiny car with the "Spoiled Bitch" sticker. He is limping in the median, like he does every day. He moves slowly up and down the long turn lane at this apparently lucrative intersection. It hurts to watch him walk.

I fish around in my pockets for a little money. The light cycle is on our side today, so I roll the window down as he moves close to my car and hand him the coins. We nod at each other, like always. The arrow turns green and I follow the spoiled bitch into the intersection. I wonder if she has ever rolled her window down for anyone.

Our city is full of homeless individuals, struggling with mental illness, substance abuse, past traumas, and so many other things. It gets very cold here. People pitch tents and tarps in plazas and line up outside churches in the afternoon, hoping for a meal.

Sharing at the stoplight may not be the most sustainable way to give, so we try to help in other ways, too. But I think rolling down the window sometimes is really important. When you see the same individuals-- face to face-- day after day, it keeps you present in the reality that this doesn't just go away. What looks to us like an unbearable crisis is just a continuation of daily life for another. That is true for so many of our fellow humans.

Let us always remember to roll down the window in one way or another.

Living with ourselves and our work

2008-11-19T09:18:00.002-05:00

Beka has started a good discussion over at Medscape's In Our Own Words about compassion fatigue. Reading her thoughts and all the comments made me thinkg of something fascinating that happened the other day in our critical care course. Now, pretty much all the students are trauma/ER/ICU nurses looking to work in these settings as APNs. We were having a lecture on care of the critically ill elderly patient and discussing a really good article (Marik, P. Management of the critically ill geriatric patient. Crit Care Med 2006 34(9):S176-S182.) Anyway, I mentioned that I really liked the fact that Marik talks about how we need to reconsider the way we measure outcomes-- i.e. not survival to hospital discharge, but survival at 6 months or 1 year, or even more importantly, return to previous level of functioning. This, then, would give us some more helpful information about *actual* outcomes, and help health care providers, patients, and families evaluate whether therapies can really be of benefit! So I said this, and the room came alive. Suddenly, hands were going up everywhere, people wanting to talk about these very issues. Nurses need and want to discuss this, and the opportunities are not there. It was amazing to watch the discussion. Now, every unit has informal ways of venting and releasing tension, expressing horror and outrage at our daily activities. But we also need opportunities that are structured, have focus, and offer us some kind of hope for change and improvement! We don't usually get that in the break room during an often abbreviated lunch. I was heartened to see that my classmates want to talk about these things... there is hope, and change is possible. How, exactly, I don't know yet...

How to save a life

2008-10-01T14:47:00.000-04:00

He was about twenty when he overdosed on something and fell out hard in the yard. He lay there cooking under the hot desert sun for quite awhile before somebody found him, and by then he was in rhabdomyolysis. This is basically the rapid breakdown of muscle cells. It commonly occurs when someone is "down" for a long time without moving. As the muscle cells die, all the proteins are released and circulate in the blood, clogging up the kidneys and causing major problems.

This kiddo was sick, terribly sick. He was one of the first really sick patients I ever cared for, on CRRT (continuous dialysis) and all that. He had a ventilator and a million drips, of course. His friends sat at his bedside constantly, radio playing. As you know, the commercial stations usually play the same 8 songs over and over, so you will hear the current popular tunes several times during one shift.

At that time, "How to save a life" by The Fray was playing all the time. I'll never forget listening to it as we worked intently, trying so hard to support his body while waiting to see if it could recover.

It could not; he would not. After days of sitting on chairs next to his bed while the radio played, his friends and family said good-bye.

I was surfing the radio today when I happened upon that song. I always kinda liked it from the start. I think for the rest of my life, whenever I hear that song I will picture that patient, that room. I will feel the cool temperature of the hospital air on my skin, smell the soap, and almost reach to do my hourly checks. I will go back again and again.

Reality Show: Life After Transplant

2008-07-25T21:54:00.002-04:00

So I had an idea the other day for a new reality show. It would be called Life After Transplant. It wouldn't be very popular, I'm afraid, because so much of life after transplant is not that fun. I'm sure today's TV producers would only consider implementing a pseudo-reality version, anyway, kind of like the physician-centric medical shows. If they did that, they could include all the fun, happy parts but go ahead and portray it as a reality show anyway; they're really good at that.

The idea came while I was rounding with the MICU physician team in my role as charge nurse. The family of a man with end stage liver and kidney disease had elected to forego further curative treatment, remove him from the transplant list, and transition to comfort care only. He was not vented but nearly unresponsive and had very low blood pressure that we had been fighting with pressors. The Native American family notified us by quietly shaking their heads "no" to the nurse when she entered the room to restart continuous dialysis. The MICU team came and a discussion was had. Soon after, the liver specialists appeared on the unit. They were "very disappointed," they said, moving about with stern faces that clearly expressed their disapproval.

Inside the room, our attending was talking with the family. I could faintly hear him citing numbers and statistics, possibilities, the way this particular physician always does. The residents waited outside. Wouldn't they want to observe and maybe even participate in these kinds of conversations? I was mystified by that, as I always have been.

The reality show idea surfaced and I immediately shared it with the residents. They looked at me, perplexed. Now, I'm not saying I'm against organ transplants, or anything of that sort. I'm merely noting that the realities of medication regimens, rejection episodes, and consequences of lifelong immunosuppression are not what transplant teams advertise.

Consider this: A few months back we cared for an amazing woman who was 10 years out from a lung transplant. She had done remarkably well for 9 and 3/4 years. She carried her pills in a large box, way, way bigger than anything sold for the purpose of organizing medications. It was one of those plastic cases composed of many small squares that teenage girls use to organize their jewelry-making supplies. Each square held pills of a different shape and color.

This woman had lived to see her son grow up and get married and had many wonderful adventures in her post transplant life. She told us very clearly that, while she was beyond thankful for the time the transplant had given her with friends and family, she would not even consider doing it again.

There are so many things worse than death. I say that acknowledging that I don't know death myself, not at all. Sure, I've seen it many, many times-- been present for the changing, the leaving, the crossing, whatever you want to call it. But I've only seen it from this side, so I can't really know for sure. Yet there is something in us, something that responds to an apparent, perceivable peace that tells those of us who witness-- truly witness-- grave suffering, and the passing of lives, that death is not the worst thing that can happen to a person. Or maybe we can only say it seems unlikely that death is worse than some of those things we do know.

So much mystery.

All I know is, that would be one not-very-fun reality show. But it would be real, and it sure would be educational.

Anonymous, are you out there?

2008-03-06T20:43:00.001-05:00

The comment from Anonymous on Pulmonary Hypertension just popped up, and I really hope she got to read on and see A little of this, a little of that, where I reported that Gina had come to visit post transplant, feeling good and on her way home. I don't know how or where she is now, but I like to envision her feeling good and carrying on normally with her family.

It's easy to get excited and think everything is grand when organs become available and are successfully transplanted. But the fact is, receiving a transplant is the beginning of a new way of life for everyone. Strict medication regimens, episodes of rejection. Of course, it depends on the organ; some are easier to swap out than others. So there is life, but the quality is highly variable.

On that topic, last week I cared for a man in his seventies who recently had a major abdominal surgery for treatment of cancer. The procedure he had is an extensive one. He spent 15 days in the hospital, went home, and came back with major complications requiring an urgent procedure in interventional radiology. Later that day, as I was monitoring him after the sheath was removed from his artery, he looked at me and said, "Why didn't anyone tell me about all this?"

"All this?" his wife and I said together.

"The tubes. No one told me I'd be going home with tubes weeks after my surgery." He was referring to the drainage tube and the feeding tube he and his wife had been maintaining at home.

Now, this is a good time to note that we patients don't remember most of the information we are told. So, the surgical team could very well have given excellent explanations prior to surgery. But, he still had a good point! He was not even remotely prepared for his experience, had no idea how significantly his quality of life might be impacted. And we must ask, then, how someone can give informed consent when they know so little about what to expect? It is not enough to talk about the procedure that will be done. Every effort must be made to share the quality of life issues that will be apparent in the immediate postoperative period and further along. To wit:

"They told me it would be a big surgery, but I didn't know what that meant. I had no idea it meant all this," he says, gesturing vaguely at his belly. He looks up at me sadly and says, "Do you think I'll need chemo after this?"

"I have no idea," I say honestly. "No idea. It sounds like you have some good questions for the surgical and medical oncologists. Sounds like you could use some more information to have an idea of what's coming up next, and what your options are." He nodded vaguely. "Every time you are presented with a treatment or procedure, I encourage you to ask lots of questions. Things like, how might my life change during this treatment? How long do you think it might last? How might things be different if I choose not to do it? With every choice, there will be benefits and drawbacks, and gathering more information can help you decide how to make use of the resources available so you can hopefully live in a way that is acceptable to you."

When I get back to work, he'll likely be gone. I really hope he gets some good time at home, free from complications and treatment related miseries.

To return to what prompted a response to Anonymous, I realize many of my descriptions are not very reassuring, but they are honest. They are my version of honest, of course, because we all have our own unique version of reality. I know that sometimes I may favor one side of the story more, but that's part of the therapeutic process that the writing is for me. Principally, I feel like we owe it to ourselves and our patients to do our best to be honest, all the time, about everything.

development

2008-01-09T11:21:00.000-05:00

It's amazing, now, to see how I've changed. I am in the circle now, I am not afraid. If the team doesn't make room for me, I find my own way in and create a space for myself. I say what needs to be said. If I am not sure about something, I ask, no longer feeling that I can't afford to display any weakness. I am confident in my abilities and knowledge, and in my role. If I know something needs to be done, I push for it and I give reasons why.

I'm not sure the proper way to describe it, but I guess you could say I've finally actualized into this role. And now I'm ready for something different! What is that?!? I'm not sure I want a job where I will always have to force my way into new circles. Besides, my individual body can't really tolerate this kind of work, so I guess it works out just fine.

MICU RN reappears

2008-01-09T10:54:00.001-05:00

Where have I been?

Still in the MICU, working away. But also, applying and being accepted to graduate school-- yay! And shifting to a new way of relating to my work, and my identity as a nurse. Getting a little distance. Considering a variety of trajectories and weird assignments, much like Beth over at PixelRN.

Why?

Well, sometimes the things that happen are so heinous, so horrific, that there is no room to relive them on the page. At least not for a while. Constant, minute by minute crisis management can be draining, to say the least.

Being a nurse is an awful big part of who I am. That can be fine, but it can also be dangerous when the role takes me into places no one should really have to go. So I've been figuring out how to make a little space for myself, I guess.

Hopping on here I noticed several pieces that I had drafted and never posted, so I'll put them up now.

Case management

2007-11-02T13:08:00.000-04:00

I was hanging out with a buddy a while back, a nurse case manager. This was part of my quest for a new kind of practice, one that is still engaging, challenging, and meaningful, yet not terribly damaging to my body. I'm fine with the exposure to infectious diseases and hazardous chemicals, but the 13 hour shifts with a total of a twenty minute break are getting old. Sure, that doesn't happen every day, but it happens often enough. What's scary is we have excellent staffing-- of this I am sure-- when compared with our peers. Most importantly, and like zillions of other nurses out there, I'm having back pain. It's not magically going away. Every day at work, even with the utmost care, I push, pull, bend. I lean over patients for lengthy periods of time. I hurt.

Anyway, what is a case manager? Well, he spends his days going back and forth between patients, providers, hospital administration, Medicare, Medicaid, private insurance companies, skilled nursing facilities and rehabilitation facilities. This is the real deal. This is the heart of our health care system, and without this work your care cannot happen. Not in our system, anyway. It is incredibly tedious and in many ways disheartening.

When you are admitted to the hospital, someone (read: the nurse case manager) actually has to go through a big fat book put out by Medicare and make sure you meet enough criteria to qualify for "inpatient status." He or she may need to call your medical or surgical team and advise them that they *might* adjust the prescribed medications and interventions in order to meet criteria, or change the plan of care. Plain and simple, to some degree, payors are dictating our care. It's gross, it's complex, and it's unfortunate. While case management is important and necessary in our current system, turns out it's not for me. Gets my hackles up too much.

Death of a homeless woman

2007-07-11T17:08:00.000-04:00

Three weeks in ICU, she was. No one could ever find any family. The cops even came and took pictures, sent them off somewhere far away. It was a dead end.

This GI bleed was the one that killed her. After her blood pressure dropped and she started seizing on the floor, she wound up in the ICU. She got continuous EEG and her blood pressure supported with medications requiring constant monitoring and frequent adjustment. Someone checked her blood sugar and urine output every hour.

Sarah was homeless. She couldn't get this kind of attention if she begged for it. She got a ventilator for three weeks, got liters of fluid drained off her swollen abdomen. They used a needle at first, but then the fluid just kept coming and coming, leaking out the tiny puncture hole from its endless source.

We turned her, cleaned her, talked to her. K. washed and braided her hair when the EEG monitoring was finally discontinued. Eventually, I stopped talking so much to her. What was there to say?

It was agreed by all that there was no hope for a meaningful recovery. The day she died, Sam stopped all her drips and took her FIO2 down to 21%-- room air. The ventilator kept giving her breaths, but it didn't matter. She couldn't live without the support. Sam had to take his other patient to CT scan, so as charge nurse I kept an eye on her.

There was no family to take care of this time. I talked to her again, told her it was okay and she would not have to worry anymore. She would not hurt or have to be afraid. Sam returned from his field trip, and we were there, quiet, when she went. I turned off the vent, we looked out the window. It was the kind of day she might have spent at the bus stop or outside a drug store, soaking up the sun.

You are the project

2007-07-11T01:38:00.000-04:00

I work steadily on your belly, applying paste under the sterile plastic wrap anywhere I think there might be a tiny leak. The suction catheter tucked inside gurgles away. We are so close now: all day, with each turn the fluid has poured from one place or another. We have changed your linens a million times over. Now we have a plan.

"The skin can fail just like any other organ," our wound care clinical nurse specialist reminded me as we finished up an hour long creative problem solving session at your bedside. I had just shown her your new pressure ulcer.

"It's our fault," I had said.

She eyed me skeptically. Outside, she reminded me about you:

You are 86. You've been living in a skilled nursing facility (SNF), i.e. a nursing home, for about six months already. You've been receiving nutrition solely by IV (total parenteral nutrition, TPN for short) all that time because your body is unable to absorb any nutrients from your gut. They think you have Crohn's disease but no one is too sure. TPN by itself puts you at increased risk for infection. For one thing, there's all that sugar flowing through your central venous catheter 24 hours a day. Bugs love that. Plus, you miss out on all the immune system activity that is normally stimulated by activity of the gut.

You've been spending most of your time in bed since well before your admission to our hospital. A chronically ill 86 year old who is spending more that 50% of his time in bed is unlikely to live more than about two more months.

Then there's the giant abdominal wound you have, thanks to the surgeons who thought an exploratory laparotomy was a good idea when the nursing home staff brought you to our ER with low blood pressure, a firm belly, and increased lactate level in your blood. You've been to the OR 4 times so far, and you will go back again. They have removed your entire colon. The first ileostomy never worked, so they took that down and now you have that cavity, there on your right, about two inches deep that wells up continuously with warm, pinkish fluid. On the left is the newer ostomy. It looks like it might be a keeper.

In our institution, any surgical patient over 80 is an automatic nursing referral to a dietitian, and for good reason. Surgery is a major insult to an already weakened being. The reserve is low.

We turn you religiously, painstakingly positioning your every part. We float your heels, check your many lines, tubes, and wires to ensure they're not pressing into your skin. Still, you break down in areas where we can't completely eliminate pressure. Your skin also has stretched, blistered, and split open from the liters of fluid we poured in to keep your blood pressure up. It didn't stay long in your blood vessels without much protein to hold it in, creeping instead into the spaces between cells and blowing you up like a balloon. Once open, your skin erodes quickly and steadily.

The constant pouring of liquid from your abdominal wounds doesn't help, either. Skin hates to be wet, this is why TV ads pitch high tech diapers to moms and dads.

Back at your bedside, I put down the paste. I have been working intently, so focused. I look up at you from my project, and you are still there, eyes open. I see the tears that come out and roll down your right cheek sometimes. I bolus you with extra pain medication, hover close to you and stare into your eyes, wondering what they are saying. I don't know how to apologize. I can't. I try anyway.

What was this surgery for, anyway? They thought you really wanted a few more great months in the nursing home?

During rounds, I stand firm when the surgery team wants to decrease your pain medication so you might be more awake. I describe your tears, your deer-in-the-headlights look. They relent. I describe my interactions with your family members, offer to facilitate a meeting to discuss "the plan." They agree in words but don't commit to anything concrete. They tweak your antibiotics based on your latest cultures, and move on.

I return to my project.

Bellyache

2007-06-19T18:32:00.001-04:00

In the morning before he went to work, she reported that her belly hurt.

When he got home that afternoon, she was on the floor, unresponsive.

At the hospital, they rushed her into the OR for an exploratory laparotomy, where they didn't find anything of note. There was a lot of swelling, though, so they left her abdomen open and just closed the skin on top. 5 big black X shapes made of thick suture held her together.

When we arrived the next morning, she was getting worse. Her lactate level was high, a sign that cells are trying to make do without oxygen. We picked up where the night crew left off. While I started the vasopressin drip, my newly graduated RN orientee manned the double spike tubing, hanging bag after bag of fluid to squeeze in with a pressure bag.

Her belly was looking bigger and bigger, her blood pressure not coming up. We implored the surgical team to return to the bedside once again. As the chief resident arrived she began to drop her heart rate.

He grabbed a pair of scissors and cut the big black Xs. The contents of her abdomen erupted, welling up as liquid poured down her sides and soaked the bed. The smell was warm and not quite right. With his sterile gloves he poked around a bit. We all watched the monitor for signs that perhaps she liked this relief of pressure.

There was no improvement.

While her loved ones waited outside the curtain, we placed the sterile plastic wrap over her open belly and covered her with blankets.

Serial blood gases indicated she was increasingly acidotic and her lactate level now into the teens. We kept pouring in the fluids, blood products, and powerful medications. Boxes from amps of sodium bicarbonate were littered all over. The fluids were leaking rapidly out of her vessels, and she began to puff up dramatically now, like some strange alien creature distantly related to the Michelin Man.

The family was large and loud. Her husband developed chest pain and shortness of breath, and was wheeled off to the ED for evaluation. One daughter became terribly angry upon realizing that her mother was lying on a wet bed. I explained over and over that we couldn't move her mother right now because she would likely die immediately as a result. It was painfully clear that everyone wasn't prepared for that yet.

She was far too sick for transport to the OR. Lactate now >15, the highest value our equipment accurately measures. Her belly was welling up higher and higher, like a great mountain in the center of the room. A niece developed an asthma (panic?) attack, and was next to leave for the ER. About this time a grandchild returned wheeling Grandpa, who had left against medical advice when they tried to admit him for the chest pain.

Things were getting worse by the minute. The room was packed, the wailing nearly continuous. One daughter, who had been designated medical power of attorney by the patient, agreed to refrain from shocks and chest compressions (CPR). She was nearly beside herself, declaring that her siblings were second guessing every choice she made. She felt she had to leave it up to her father whether to continue aggressive support. There was yelling back and forth across the bed between various members of the family.

"Dad, you've got to let her go! You're just prolonging things now."

"Shut up and leave Dad alone. It's his decision!"

"I need to get out of here, I can't take this," he said.

"Dad, you can't! You have to stay here with her. You cannot leave her."

About this time, a very pregnant granddaughter turned to me and asked, "Is there somewhere I can throw up?"

I ushered her into the tiny bathroom where she sank down beside the toilet. "We need more nurses for this family!" I exclaimed as I scrambled to care for my patient. The pregnant one was escorted out, not a moment too soon.

"How will I ever live without her?" her husband cried in anguish, the chaplain by his side.

"Daddy, we'll take care of you," the angry one said.

He started to leave. "I need to get out of here, take a smoke," he said.

I was watching the monitor closely as he said this. I knew it was time to get my amps of epinephrine and atropine in my hand and ready to go. I stopped him with a hand on the shoulder. "It looks like she might go at any minute now. We have tried everything we know to stop this process, but we are out of options. Do you want to stay? It is okay either way."

He shuffled back to her side. I called the ICU resident to come, and when her heart rate suddenly plummeted, I pushed the atropine. She didn't respond to that, but some epinephrine gave her a heart rate and pressure for about 4 minutes. Then she went nearly asystolic-- flat line. I pushed another amp of epi and got the same result. All their eyes were fixed on the monitor.

"She may keep responding temporarily like this for a while, but we can't fix the underlying problem," explained my colleague who had joined us at the bedside. As I prepared to push the 3rd epi, her husband said, "Stop. No more."

It was hard to zip the body bag closed, her belly was so big.

When those patients finally “die,” it becomes apparent just how fuzzy the line between alive and dead is. If a patient has a heart rate on the monitor of 30 with a pressure of about 21/18, are they still alive? You won’t be able to feel pulses with that, though there is technically a pulse pressure. Do you wait for the last physical beat of the heart? That comes before the last electrical activity of the heart. If you see 25 complexes a minute but the blood pressure is 4, when shall we stop calling it pulseless electrical activity and start calling it dead? How about 12 and a BP of zero, or shall we say less than six per minute? We must pick a time. If we didn’t have a monitor, we’d call them dead when we couldn’t feel a pulse. But since we do, families, nurses, physicians all stare up at it and keep pushing drugs, waiting for it to show us what we already know.

why sometimes i don't say much

2007-06-19T18:25:00.000-04:00

I haven't been posting lately. It's not that I don't want to. Well, sometimes I don't. It's too hard. What does one say? Sometimes there are no words left to describe the atrocity when it's all said and done. Sometimes I have lots to say, but the stories are so outrageous, so painful, so heartwrenchingly unique, and I fear the monster that is the HIPAA police. Sometimes they are in the national news.

Don't get me wrong-- it's not that I actually believe that what we do is so special and different. But, I worry that just once someone will see themselves, or someone they know, in the story and it will really be them. Sure, I know I could change more details, but sometimes I can't stand not being true to the story. That is where I am as a writer, I think. I somehow feel that I'm not telling the whole tale, the real truth, if I alter too many things.

So that's why.

Things I can't live without/wish I had

2007-02-28T11:36:00.000-05:00

So I've been tagged by PixelRN. Without futher ado, here is my list.

The four things I cannot live without:

1. The coolest pharmacist in the world. T. is our unit pharmacist, and she rocks it like no other. She is buzzing around all the time, keeping track of all those little things nurses and physicians sometimes lose in the midst of everything. Her incredible knowledge base and fantastic cooperative attitude make our patients safer and my work a more joyful place.

2. Dr D. This is the kind of attending who spends hours in family meetings her first day on service. When D. is on, families and patients are not regarded as an afterthought, somehow disconnected from the task of maintaining physiological stability at all costs. Not only are her people skills fantastic, but clinically she is top-tier. I'm not sure exactly when she does it since she is always on the unit, but sometime she is busy reading up on the latest ideas. D. listens to patients, families, nurses, and respiratory therapists. She listens, period.

3. Skin prep. It sometimes keeps my patients from literally falling to pieces, and keeps those central line dressings intact just a few more hours when the patient is an oozy mess. I am a huge fan.

4. The therapy and security dogs. When I see them coming, I run for my Milk Bone stash in the break room!

5. An expert respiratory therapist. More than once I have been majorly rescued by a super-RT. Their specialized knowledge is invaluable, and when we work together we are amazing!

Okay, so that was five. Too bad.

Now, what do I covet? Honestly, many many things. If I must pick one, it shall be this:

A culture change, so that we might stop regarding death as the ultimate enemy and put pain and suffering in that place instead. How things, then, might be different.

I'm really glad PixelRN tagged me. As I started putting down all the things I cannot live without, I realized just how many things I love about my work enough to share them with others. The list is a lot longer than five!

Now, I shall tag PaedsRN at Cricoid Pressure and TC at donorcycle.

What happens at my work

2007-02-20T22:40:00.000-05:00

You know what happens at my work?

People occasionally get feeding tubes in the wrong place, like a lung.

People who can't speak for themselves sometimes have decisions made by someone who was not their first choice.

Mothers and fathers and wives and sons cry, sob these heart-wrenching sobs that permeate to the core of every individual within earshot.

People get out of bed for the first time in months.

Ribs are broken by resuscitative efforts.

Skin splits and peels, gives way to the intolerable tension created by the fluid leaking out of vessels and in between the cells.

Egos sometimes determine the ventilator settings.

We leave exhausted, and we leave some people feeling better.

Wow!

2007-01-18T13:29:00.000-05:00

If you didn't catch today's Here and Now on NPR, click right over to check out Robin Young's feature on the nursing shortage. Mary Jane Williams, an Associate Professor of Nursing at the University of Harford, and Suzanne Gordon, author of Nursing Against the Odds and coauthor of From Silence to Voice: What Nurses Know and Must Communicate to the Public, were guests on the program. In addition to discussing the shortage of practicing nurses and the projected increasing demand in the coming decades, they also highlighted the dire shortage of nursing faculty. They explored the bizarrely inaccurate media portrayals of nursing, noting how these influence the actual public image of the profession, and they reflected on how this relates to our current nursing shortage. They highlighted the tireless work by Sandy Summers and company over at the Center for Nursing Advocacy. Perhaps most importantly, they discussed the real nature of nursing work and it's primary importance to patient health and safety. Highly unusual, I'm afraid. Thanks, Robin!

A must read

2007-01-14T19:23:00.000-05:00

Wow! Barbara Ehrenreich has done it again! The same woman who brought us the phenomenal book Nickel and Dimed has busted out with Pathologies of Hope, in the February notebook section of Harper's Magazine.

Barbara starts the piece with this: "I hate hope," and proceeds to blast "positive psychology" and it's overly enthusiastic followers. I'm so glad to hear someone pointing out that pushing people to "be positive" can be terribly destructive, especially when they are fragile, vulnerable, and under stress or in crisis. Maybe if we could as a culture swing back in this direction, fewer people would have to tolerate being told that they could surely get well/be successful/etc. if they would just be more hopeful. This kind of thinking is not reality based, and I have seen it be a source of great stress for more than just a few patients.

Right on, sister!

a little of this, a little of that

2007-01-10T23:49:00.000-05:00

Where to start? Why haven't I posted in awhile? Well, because there's too much to say, and not enough all at the same time. Maybe we'll just start with some simple updates. There has been some exciting news lately!

First, just before Christmas, I was in a patient's room when another nurse came to the door and said, "There's someone here to see you."

"Who is it?" I said, but she had already walked away. As I finished up and washed my hands, I figured it was probably one of the therapy dogs, since they know to look for me and beg for me to get out my secret stash of Milk Bones.

But walking to the charge desk, instead I found Gina. Gina! You remember Gina, who teetered on the edge while waiting for new lungs and finally received them. There she was breathing nothing but good old room air, walking unassisted with her family. She looked so different! No longer the cachectic woman I once knew, this Gina was round and puffy, the poster face for steroids.

"I'm doing really well," she said. "I came to thank you all. We're moving out of our apartment here in town and heading home for good next week."

She and her husband were all smiles. We were too.

Then, just the other day I ran into the medical student who I had worked with when I cared for Rosa, the woman from Mexico. The student had continued to follow Rosa after she was transferred out of ICU. Turns out, Rosa became just one of those people who squeaks through without dying or becoming disabled and slides quietly out the hospital door into a nation full of opportunity. She was healthy enough to leave the hospital independently, so this attentive student found her some clothes and shoes. Rosa's husband hired someone to safely transport her deep into middle America. The student helped her get outside to the right place at the right time, and off she went.

Now, on to the reason I'm not writing too much these days. I'm not exactly sure what it is, but I think it has to do with the fact that these stories, these dramas, are so infinitely complex, so thick with loss, joy, and unknowns, that they are hard to package up neatly. Even when I give myself permission not to do the whole thing justice, it is still really hard. So sometimes I just go about my work, processing things internally but not forcing that next layer of sorting out that might be required to write coherently.

Sometimes, when you are tired through and through, there is honestly nothing left for such luxuries. When you work in a profession where hard, good work is rewarded with more responsibility but often no more money or power, that can feel very defeating. This is coming from someone who now has the joy of being charge nurse.

Now, don't get me wrong. Sometimes being charge is really cool. If it's a really weird day and we're actually adequately staffed, the charge nurse stays out of ratio (i.e. does not take a patient assignment). Instead, he or she is the helper bee, scurrying around looking for fires to put out, people to help. You're the go-to guru for any problems, whether they be clinical issues, interpersonal issues, material/supply issues, safety issues, etc. It's all fair game. So, when the unit is humming along, nice and busy but staffed adequately with enthusiastic, energetic, smart nurses (like so many of my colleagues are), that job is really fun! I get to run around and do whatever is needed, problem solve all kinds of wacky stuff and learn a lot in the process. I get to make sure everyone gets to eat lunch, which I think is hugely important! Having people who get to take a thirty minute lunch break during an intense twelve hour shift of monitoring and responding to the needs of unstable patients is an obvious plus for safety, right?!?

But what about those days when things aren't so cute? We're short a nurse (or two, or three) so I've got an assignment that I can just barely manage. I can see my colleagues struggling too, and there's not too much I can really do for them or our patients, besides run faster and faster. We have to do the best we can. What's really frustrating about these scenarios is that we have basically zero control of what is happening. We can say to the nurse house supervisor, "This is not safe. This is scary. We are uncomfortable with this." Or, "We're stretched to the limit right now. We're okay, but we cannot safely take another admission into the unit with our current staffing." But, all we can do is say it. We have no actual power in these negotiations. And anyway, we're so busy, we hardly have time to pull our heads up above water and look at the total picture of our surroundings.

It's kind of frustrating when you realize that you get stuck in this bad position precisely because you do good work. Serving as a decision maker and resource for the unit is great. But being forced to put aside your good judgment (perhaps the very thing that earned you this post), battle hard and often unsuccessfully for your staff and your patients, and make no additional money is pretty crappy, don't ya think? No wonder so many intelligent, motivated nurses choose to pursue advanced practice. It's not necessarily because bedside professional nursing does not satisfy their need for challenge, investigation, and reward. Rather, perhaps it's because they are uncomfortable taking on increasing responsibility along with minimal control over things in which they are quite expert, minimal recognition of their contributions by other disciplines, and stagnant financial compensation. There will be no easy fix for this nursing shortage.

By the way, you might be interested to know that the National Labor Relations Board recently ruled in it's "Kentucky River" decision that permanent charge nurses in a Michigan hospital are considered "supervisors" and are thus ineligible for union protections. This potentially leaves these nurses in a very bad spot. You can learn more about this in the January issue of American Nurse Today, the journal of the American Nurses Association.

Heavy load

2006-11-06T12:52:00.000-05:00

Christine was somewhere in her fifties. She was one of my first giant patients, weighing close to five hundred pounds. Everyone complained about her; she used her call light to ask for help with things a normal sized human would be able to do alone. But she was polite, gracious, and attempted to maintain some independence within her physical limitations. She was in for a congestive heart failure exacerbation. Naturally, she had diabetes and joint problems as well.

During her two week stay, I found myself caring for her a lot. Man, did I learn some things from Christine.

One day, she wanted to talk about her weight. Specifically, how she got this way.

"My mom died when I was pretty young. My father would use food as a way to have power and control over us. When we didn't behave how he wanted us to, he would send us to bed with no dinner. This happened a lot. I remember creeping downstairs in the middle of the night to get a piece of bread for me and my sister to share. I would ball it up in my hand, take it up to our room, and we would pick off tiny pieces, making it last as long as we could. Afterward, we would still be hungry, but I would feel a little better because I was taking care of us. Our father would tell us that these restrictions would help us to stay thin and beautiful.

"When I got older and began to have control over what and when I ate, I chose to assert my independence and freedom through food. I cooked big, elaborate meals for my sister, and later for my two children and now ex-husband."

Listening to Christine made me remember a study I ran across one time that found that a startlingly large percentage of obese women have a history of abuse in their past. There is a significant amount of evidence that points to a link between childhood abuse and obesity in adulthood.

Christine was one of many patients who taught me early in my nursing career that there is always a story, and there's a lot more to it than we usually think. Every human is at the center of a giant web that only he or she knows. When I can remember this, it helps me to talk less and listen more.