Today's Last Patient of the NIght....

.....was in his mid 30's, had a host of medical problems including stroke, alcoholism, diabetes and, since he was with his mummy, I am assuming he also had an impressive list of social deficiencies. It was 10:45 PM.

He needed a note because he missed his court-ordered community service.
The reason?

"I just didn't feel like going".

uh huh....

What Does That Mean, Anyway?

People often talk about how nurses are doing "God's work". Most days I disagree.

I do not believe it is "God's work" to take verbal abuse from a 39 year old with back pain (chronic) who plays football (every Sunday) and shows up the following Monday (every week) with excruciating pain. Why were we getting verbal shit? The physician, having looked up the patent's last five visits prescribed possible chiropractic treatment, ice and heat, ibuprofen and to moderate his activity; it was suggested that perhaps playing tackle football was not in the patent's best interest. Further, the patient was told that the physician was reasonably sure that none of the Patriots presented to the ER on Monday after a game looking for Vicodin. The patient was, of course, outraged and demanded the name of the physician's boss so he could complain; and, since he didn't get any treatment (except for some common sense advice) had no plans to pay for the visit. Oh, and he left his free-care application in the room.

I sure don't feel like it is "God's work" to look up the number of Medicaid for an able bodied 18 year old female who didn't have insurance but was too old for Healthy Kids and not in school. She had presented for a lump and bleeding "down there"; turns out it was a friction injury. Naturally she insisted on having her skanky boyfriend present for the inevitable pelvic exam. Why do these young girls go for these bozo's? Blecch.

For that matter, it surely cannot be "God's work" to put up with morons who twist a toe, ankle or elbow, or break a fingernail and high-tail it to the ER without first attempting ice, elevation or ibuprofen. If you are walking on it, using it to hold your cell phone to text message the world that you are in the ER, or slugging down a gallon of iced coffee from Dunkin's, it most likely NOT fractured. Especially if this is your 5th or 6th visit for a silly complaint this year. It is disheartening that there is so little common sense in the world.

You cannot convince me that it is "God's work" to document 30 (THIRTY!!) allergies for one patient, relatively few of them actual allergies; the only things that were missing from the list were "clouds" and "dirt".

On the flip side, there are some instances when I feel that, while perhaps not "God's work", I can glean, ever so slightly, a sense of satisfaction or accomplishment. To be honest, it is precisely those instances that keep me doin' what I do; in a sea of rude, unappreciative, nasty, stupid, violent, threatening patients and family members that strain my sanity and keep my eyes in a continuous roll, I am occasionally able to use my experience and skill to achieve something positive.

I kinda have a tendency to hold on to those moments like a lifeline on those days that I want to slap the ears off someone.

(This is my 100th post by the way, and I wanted to keep it as upbeat as possible!)

"Pink is My Signature Color"

Oh, lord, did I have a flashback.

I was asked to do a blood draw in the outpatient lab on a "tough stick", something I am always happy to do; if it can get done in one rather than repeatedly poking the patient, I am all for it. As is the patient, I'm sure.

She was elderly and was decked out completely in pink from head to toe, including a little pink cloche hat (who even knows what a cloche hat is, anyway?). Sorta like this:

In fact, exactly like this but with only one flower.

Mae was so cute and tiny. Pink flowered blouse, pink sweater, pale pink pants and pink flats with a clip-on flower. She had on bright pink lipstick and had the most beautiful clear blue eyes with a devilish twinkle.

Mae was sporting a sassy pink cane with pink breast cancer stickers, and a pink ribbon breast cancer pin or three. Because she'd had a mastectomy some years ago, we were only able to use one arm--hence the difficulty.

I introduced myself and told her that I was there to help Lynn, the lab tech, get her blood test done.

"So, they called in the top dog, eh?", Mae said with narrowed her eyes and a slight curve of her lips to indicate she was teasing.

"Well, let's see what we can do; no promises, OK?"

She studied me with her little head tilted under the cloche, glancing at me out of the corners of her eyes; the last time I saw an expression like this, it was done by Essie who tortured me in my very first job as a nurse.


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I had taken my State Boards (now called NCLEX) out of my home state, thanks to our nursing school director giving us the wrong deadline for application...idiot. So, I was able to take this two-day test (now done by computer with the results immediately available) in the state of NH where I went to school, I could take it with my friends which was a bargain. The downside was that the tests were only given twice a year in those days. If you failed, you were done for six months. In addition, the results took about 4-6 weeks, which was torturous to say the least. But, if you were fortunate enough to get a job, you worked as a glorified nurses aide and could do everything except pass meds; it was worth the crappy pay, and you could also do charting and sign your name "EDNurseasauras, GN" (for graduate nurse).

Since I was back in my home state of Massachusetts, I not only had to wait 4-6 weeks to see if I had passed or not but had to apply for a reciprocal license so I could practice in Mass., which was another 4 weeks or so. In the meantime, I was hired at a rehab hospital. One day of orientation, one day following the RN around, and then I was on my own for the next three weeks, expected to take a full patient care assignment of 6 or 7 patients, which my nursing program had prepared me to do (yeah, diploma programs....the bottom of the food chain as far as education, but prepared to be a nurse right out of the box). Management was biding it's time until I received my Mass. license so I could be in charge. Yes, as a puppy nurse with merely a couple of hundred hours of experience I was to be the sole RN on the floor with one LPN and 4 aides. Three months of 30 hour weeks as a charge nurse in my Leadership course, the finale of my education had also prepared me for this as well. Hind sight only makes me realize how potentially dangerous it could have been, however, it all worked out and we all managed together to give good care.

Although it was a rehab hospital, there were relatively few patients with rehab potential on my floor. We had head injured young people in comas who were complete care and needed tube feedings, etc.; respiratory patients who were basically sent there to live out the rest of their lives on oxygen; a couple of men with cerebral palsy who were wheelchair bound and total care because of their contractures; one woman with some mysterious paralysis-type of thing with a bed-sore that needed to be packed a couple of times per day. There was one brain-injured man who had tremendous mood swings and angry outbursts caused by prolonged oxygen deprivation. He had experienced a cardiac arrest and survived, but in those early days when we had just started not letting people die by doing CPR there was perhaps a lag between the the length of time he was "down" and when he was "saved". He certainly was not the same 43 year old person he had been before he was admitted to my unit as his anguished family constantly reminded me.

I also experienced my first death as an RN. With a nurse's aide who was afraid of dead people, I performed post-mortem care using the directions in the shroud kit. Yes, we used a toe tag. Heidi, the aide, was also my roommate at the time. She had nightmares about this.

There were several older adults with dementia; these days, such patients would not be placed on that kind of floor, but that was the 1970's after all. One of these was Essie Poisson, who was in her late 80's or 90's. In her occasional moments of lucidity she would talk about her days dancing in the Ziegfeld Follies, elaborate Broadway musical shows with gorgeous young women, beautiful costumes and headdresses with towering plumage. Essie, like Mae, was usually dressed all in pink.

Of course, in Essie's less than lucid moments, everything was a fight. The most stressful part of my evening was 1) getting Essie into bed and 2) getting Essie's dentures out.

Essie would give me that side-glance, narrow-eyed, "bring it" devilish look and challenge me to remove those dentures; it may have been stressful for me, but damn if it didn't seem like the highlight of Essie's day. I do believe she looked forward to it.

Essie would resist the removal of those dentures with more enthusiasm than I thought possible in a woman of her frail appearance; underneath lurked steel armor and determination to match.

She shrieked "help, police, murder!!" with all the gusto she could muster, but the dentures ultimately spent the night in a denture cup in a marinade of Polident; she never drew blood but that didn't stop her from trying.

Once in her nightgown, fluffed, puffed, lotioned and soothed, Essie behaved as if nothing was amiss and would always politely ask for a cup of custard before she went to sleep. I retreated, drained, to the nurses station for a cup of coffee and begin my charting. What I really felt like was a stiff drink.
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So with nostalgiac if not fond thoughts of Essie in my mind, I drew little Mae's blood.

But out of habit I kept my eye on those teeth....

Convention

I needed a little time to process and think a little before writing about this topic. Southern Cathy and I headed to San Antonio last week for the Emergency Nurses Association (ENA) annual convention. It was a first time occurrence for us both; we had heard that it was very much a carnival informative and a party atmosphere great opportunity to network with other ER nurses. Although not a Texas native, Cathy spent a few years there so she was a great resource for getting around and seeing the sights; as it turns out, we had a blast. I didn't count on the doing as much reflection on my nursing practice as I have.

We basically spent 2 full days in lectures; all were interesting, informative and provided new knowledge we otherwise would not have been exposed to. Some were clinically oriented, some were skills-based, many provided food for thought. I had an opportunity to hear about the experience of a combat nurse who had spent time in Iraq, an excellent speaker who deserved and received a standing ovation after her presentation. I wound up (quite by accident) in a class that taught us how to care for the Transgendered patient in the ER simply because I was in the wrong place at the right time, but had listened two of this nurse's previous lectures and LOVED her. There were classes about policies that supported staff against violence, how to protect yourself from lawsuits (documentation, documentation, documentation), and sudden death in young athletes. I especially liked "10 Ways Not to Get Fooled at Triage".

Cathy and I chose different classes and exchanged what we had learned about during breaks. I came out of the experience with with a somewhat new attitude towards ER nursing in general and my own practice in particular. It was empowering to be among my peers, many with fewer years of ER experience, some with many more than my 34 years. There were nurses from small ER's such as mine, and others from enormous medical centers and Level 1 trauma centers. Yet at the end of the day we were all pretty much doing the same job, had many of the same concerns, and want the same things from our managers and administrators.

The common theme among the nurses that I met will come as no surprise: nurses are nobody's priority. We, as a group, are consistently being asked to do more with less, forced to follow the agenda and direction of individuals who make the rules but have nothing to do with clinical decision-making or patient care. I dare say that if they ever knew which end of the bedpan went where, it has long since been forgotten. Nurses are at the bottom of the food chain, the first to sacrifice or be sacrificed. Yet we are at the front lines of patient care, often in spite of of administrators, managers, and individuals who have been placed erroneously in leadership positions. Yet all of the nurses that I met were committed to being better, learning more, providing top-quality care. And you know, the lecturers had a mountain of alphabet soup after their names but had great ideas for us front-line nurses. These are movers and shakers that seem to be missing in the work-a-day life of a nurse, absent from the front lines but working behind the scenes. These are nurses who are intelligent, confident and get things done; their leadership inspired me. As I listened, something struck a chord with me.

I am not a manger, but I am a leader; I can be mouthy and negative, bitching about how unloved we are when I'm frustrated, or simply caught up in small bull-shit annoyances, such as sticky notes that berate nurses for missed secretarial tasks. I can be a Pied Piper, whipping my co-workers into a frenzy of indignation, or soothing them when they are over the top and overwhelmed. I can go hog-wild with practical jokes and suck others into my vortex of lunacy. I can cajole people into doing things they might not think of or even consider doing without my encouragement.

I have encouraged some of my coworkers, mainly Mikki, to be less fearful and intimidated by one of our physicians. You know the type: the all-powerful demi-God who fails miserably as a team player and was most certainly voted Most Likely to Get the Snot Beat Out of Him in high school; generally unhappy, lacks adult social skills, etc. He's just a guy, kids. Not likable, not an especially good doctor, and not good for nursing. But get on your big girl pants and stop giving him the power to lord it over you for heaven sake!

My take-home from this conference is this: I have learned that leadership is a powerful thing, especially if it is used for good instead of evil.

Procrastination

I have been taking courses to finish my BSN for 3 years now. Since I had a busy summer planning my Alaska trip and also needed to take 2 CLEP's, I put off my final course until October.

October looms; I had a wonderful trip to Alaska with Mr. Ednurseasauras, got out in my kayak a bit, spent lots of days at the lake, and studied very little for the CLEP exams. Lazy? Maybe.

I could spend the next week studying like mad, and probably pass both CLEP's so that I could start my course the first week of October and then graduate in December.

I just can't face it. I'll take the CLEP's then start the last course in January!