Thursday, February 22, 2007
Change of Shift is up!
(Time flies!) Over at Protect the Airway! See you there (okay, once I'm back down from the mountains I'll see you there...)
Wednesday, February 21, 2007
Things I cannot live without:
ApgaRN tagged me for a meme It started here, with someone named Shane, who I have not had the opportunity to meet yet, but shall do so. An online magazine called Inc is interviewing an entrepreneur per month and asking what each cannot live without. Shane is asking the question: What can't nurses live without? Each nurse answers, taps two more. I'm thinkin this sounds fun.
Nurses aren't 'thing' people. We don't become nurses because we're all about the Stuff. Beth at PixelRN cites good things, that aren't 'things'. I've been reading apgaRN for awhile, and she's not all about Things, either. L&D nurses are all about moms and babies.
I, for one, cannot live without my roadtrips to the desert. See Betelgeuse for latest pictures. But this is not a thing and I do not own it.
And you who read this know me, at least a little. I used to be an entrepreneur. I was literally JustCallMeJo Consulting. (Okay, not literally, substitute JustCallMeJo for my actual name.) I made six figures. I had a $250/hr accountant who finagled my taxes for me. I had stuff. I still have some of that stuff. Now I'm a nurse.
But the question posed is what Stuff I can't live without. Speaking as a person who has downshifted, downscaled and minimized, I can tell you. I'm a stepdown ICU RN. This is what stuff I require:
1. Pilot Precise Black Rollerball Pen
This is not just my favorite pen (I also have red) to use at work for my charting. This is at minimum what I need to tell my stories. I bring out gestures and things I see or feel or think through my oil paintings, and through my quilts, through tiny stitches, and sometimes with my killer watercolor pencils and on occasion through handmade books and often with my good Canon totally NOT automatic camera and sometimes through nitric acid zinc plates and sometimes with watercolors (though everybody tells me my watercolors are heavyhanded). But this is what I need at minimum, have always needed. I am not a writer. Nancy Dancehall is a writer. Writingweb is a writer. Esheep is a poet, (and I'd link you to his blog if he did anything with it.) I know real writers and real poets, and I'm not them. But I need to write, too. I use words. I have to. If I had nothing else...no stacks of cotton fabrics, no linseed oil and turpentine, no pigment...I'd need a pen. Paper would technically be handy, too, but as fine and fancy of a paper snob I can be (artists.), I can use bumwad (newsprint) just fine in a pinch. This post is about what one can't live without right? Need a pen. This is my favorite kind.
2. Body Butter
Technically, I can live without this, but I really would prefer not to. Satsuma is the best kind, though coconut, vanilla spice, and brazil nut are lovely as well. My hands are showing the beginning signs of being not in my 20s anymore (not bad since I'm 35), and it's all the handwashing at work. Satsuma soothes the savage beast and not only do I slather it on my hands and arms at work, I often come home, soak my shift away, slather my whole body with the stuff and sleep blissfully.
3. I'm really sorry about this one.
This is a venti caramel macchiato with soy. I drink one every work day. I switched to soy just in January. Read a book about protein links to cancer, some phD. I'm a lacto-ovo vegetarian and have been for many years, and so now I'm decreasing my milk, though I have no intention of getting rid of it. This is sugary frothy goodness. I require caffeine. After I slam one of those, I drink roughly 20 ounces of plain black coffee through a typical shift. If I ever stopped caffeine, I think I'd have a cardiac arrest or a sudden brain infarct and die instantly. I do require coffee, even on days of no sugary frothy goodness. As I type this, I am drinking a cafe mexicano at my coffeehouse.
4. And last but not least:
Littmann Cardiology III, hunter green, engraved.
I love lung sounds. Still workin on my cardiac sound skills, and it's kind of cool to find a good murmur, of course. But lung sounds? Love em. Not just rales and rhonchi, but give me 'tubular' and post-lobectomies and wheezes and egophony. Love it.
What I Covet:
This is tough. Really tough. Because I am a happy person right now. And what I've got is what I want. I know this is weird. People who want what they've got don't tend to holler that from the rooftops because it's boring and un-American.
I'd like an iPod, but I don't seem to get around to buying one. I'd like a new laptop, as this one's six years old and won't play Civilization anymore. (Best computer game EVER.) I'd like a rosegarden. I have 14 bookshelves full of books and I when I die, NancyPants's husband O can have it all and sell it from his store.
What I do want is a cup of coffee and a window through which I can watch the world. If there's an abscence, it's for lack of a person to sit across the table. I wrote about these things when I started Betelgeuse, and you don't have to follow the link because it's more of my long-windedness. I don't covet someThing. There's a case to be made for the idea of coveting the keeping of what I already have, but. I'm workin on that whole sittin-on-a-zafu and reading Way of the Bodhisattva. No, really.
Now I get to ping two people. Whee! I'm gonna tag Mother Jones, because she's always got good stuff to say. And I'm gonna tag Janet at Chocolate and Raspberries, particularly since she's started to post photos and she's really got a good eye.
Meme fun. Pop over and see what they come up with.
Nurses aren't 'thing' people. We don't become nurses because we're all about the Stuff. Beth at PixelRN cites good things, that aren't 'things'. I've been reading apgaRN for awhile, and she's not all about Things, either. L&D nurses are all about moms and babies.
I, for one, cannot live without my roadtrips to the desert. See Betelgeuse for latest pictures. But this is not a thing and I do not own it.
And you who read this know me, at least a little. I used to be an entrepreneur. I was literally JustCallMeJo Consulting. (Okay, not literally, substitute JustCallMeJo for my actual name.) I made six figures. I had a $250/hr accountant who finagled my taxes for me. I had stuff. I still have some of that stuff. Now I'm a nurse.
But the question posed is what Stuff I can't live without. Speaking as a person who has downshifted, downscaled and minimized, I can tell you. I'm a stepdown ICU RN. This is what stuff I require:
1. Pilot Precise Black Rollerball PenThis is not just my favorite pen (I also have red) to use at work for my charting. This is at minimum what I need to tell my stories. I bring out gestures and things I see or feel or think through my oil paintings, and through my quilts, through tiny stitches, and sometimes with my killer watercolor pencils and on occasion through handmade books and often with my good Canon totally NOT automatic camera and sometimes through nitric acid zinc plates and sometimes with watercolors (though everybody tells me my watercolors are heavyhanded). But this is what I need at minimum, have always needed. I am not a writer. Nancy Dancehall is a writer. Writingweb is a writer. Esheep is a poet, (and I'd link you to his blog if he did anything with it.) I know real writers and real poets, and I'm not them. But I need to write, too. I use words. I have to. If I had nothing else...no stacks of cotton fabrics, no linseed oil and turpentine, no pigment...I'd need a pen. Paper would technically be handy, too, but as fine and fancy of a paper snob I can be (artists.), I can use bumwad (newsprint) just fine in a pinch. This post is about what one can't live without right? Need a pen. This is my favorite kind.
2. Body Butter
Technically, I can live without this, but I really would prefer not to. Satsuma is the best kind, though coconut, vanilla spice, and brazil nut are lovely as well. My hands are showing the beginning signs of being not in my 20s anymore (not bad since I'm 35), and it's all the handwashing at work. Satsuma soothes the savage beast and not only do I slather it on my hands and arms at work, I often come home, soak my shift away, slather my whole body with the stuff and sleep blissfully.
3. I'm really sorry about this one.
This is a venti caramel macchiato with soy. I drink one every work day. I switched to soy just in January. Read a book about protein links to cancer, some phD. I'm a lacto-ovo vegetarian and have been for many years, and so now I'm decreasing my milk, though I have no intention of getting rid of it. This is sugary frothy goodness. I require caffeine. After I slam one of those, I drink roughly 20 ounces of plain black coffee through a typical shift. If I ever stopped caffeine, I think I'd have a cardiac arrest or a sudden brain infarct and die instantly. I do require coffee, even on days of no sugary frothy goodness. As I type this, I am drinking a cafe mexicano at my coffeehouse.
4. And last but not least:
Littmann Cardiology III, hunter green, engraved.
I love lung sounds. Still workin on my cardiac sound skills, and it's kind of cool to find a good murmur, of course. But lung sounds? Love em. Not just rales and rhonchi, but give me 'tubular' and post-lobectomies and wheezes and egophony. Love it.
What I Covet:
This is tough. Really tough. Because I am a happy person right now. And what I've got is what I want. I know this is weird. People who want what they've got don't tend to holler that from the rooftops because it's boring and un-American.
I'd like an iPod, but I don't seem to get around to buying one. I'd like a new laptop, as this one's six years old and won't play Civilization anymore. (Best computer game EVER.) I'd like a rosegarden. I have 14 bookshelves full of books and I when I die, NancyPants's husband O can have it all and sell it from his store.
What I do want is a cup of coffee and a window through which I can watch the world. If there's an abscence, it's for lack of a person to sit across the table. I wrote about these things when I started Betelgeuse, and you don't have to follow the link because it's more of my long-windedness. I don't covet someThing. There's a case to be made for the idea of coveting the keeping of what I already have, but. I'm workin on that whole sittin-on-a-zafu and reading Way of the Bodhisattva. No, really.
Now I get to ping two people. Whee! I'm gonna tag Mother Jones, because she's always got good stuff to say. And I'm gonna tag Janet at Chocolate and Raspberries, particularly since she's started to post photos and she's really got a good eye.
Meme fun. Pop over and see what they come up with.
Saturday, February 17, 2007
Code White
If you understand end-stage hepatic failure already, you don't need to look at the prelude post. You know how horrible it is. Otherwise, some of this might make more sense to peruse if you have the time/energy/interest/stomach for it.
A code white is a patient who is bleeding out in my hospital. Though nobody actually called a code white, this is what it was.
This is not the story of Sarah Johnson in room 42. 'Sarah Johnson' is not even close to the woman's real name, and we don't have a room 42. You don't know this patient and you never will. This is the story of what I learned about nursing, what I learned about how nurses learn, as I watched Sarah Johnson's body implode and I watched a team of people Sarah Johnson didn't know keep her alive.
I am bad at fiction, so what I'm telling you is true. Or at least, what I saw. These are the people I work with. It is my hope they don't hate my guts for writing about them. It is my hope, actually, that they never find out. But that's possibly not likely in the long run as I've showed a handful my desert pictures over on Betelgeuse. Dammit. So, in alphabetical order, I give you:
A, the monitor tech/unit secretary
D, travelling ICU RN
M, ICU RN, precepting P
P, ICU RN, orienting
R, SDU (stepdown) RN, who'd been my preceptor
and JustCallMeJo, yours truly, SDU RN
**************
Something big was happening in 42. It didn't take a genius or special spider-sense. I could see men in button down shirts with angry expressions on the phone at the other end of the nursing station. Doctors. Angry. Bad sign. I could see A, whose back was to me, typing furiously with a chart to his side, and the back of his head looked a warmer shade than normal. I could see P, hurrying in and out of 42, brow furrowed. I could hear the phone, and the phone, and the phone. M was calmer, but she was clearly busy...talking to A about paging this person, that person, clarifying with this MD this order, that order. I saw one of the docs I knew, one I'd seen intubate somebody before. She was wearing a scrub hat. Bad sign, meaning intubation was happening again. And I could see R, who was listening to D give him report, but whose eyes kept going up to 42. R is usually in the thick of things of a crisis, and was clearly keeping tabs on what was goin on.
I decided the best thing to do was my job. There was such a clusterfuck of people at 42 that what was needed was not me. Unless shouting and running happened, and then I would run, too. When bumping into P or M in the medroom, I told them, "If you need anything, let me know, my patients are fine and I can help." They said thank you, they're okay. M said this kindly, P said this with dubious belief. Or maybe that was just her stress level. Neither M or P knew me at all.
I noticed that R got his admit across the station from me, and B, the resource nurse was helping him and apparently nobody else. This is a bad sign because it meant that neither P, M, or D was available to lend a hand. Everybody is around to lend a hand when an admit comes. So I poked my head in, though by the time I got there, R had his patient settled.
I tried to stay out of the way of 42. Traffic slows because of rubberneckers. And I don't know enough to be useful. But as the evening progressed, one by one, MDs began to leave and the tension level decreased a little. I listened. I hovered, and I gathered that Johnson was bleeding, had been bleeding. P and M were back and forth, in and out of the room. P: "Where the hell are my platelets?!" M: "A, would you page respiratory for me please?"
(Rehab just called me. Can I come to work there tonight?...Er...sorry, been up all day. Besides, got a hot date with my best friend and her children today.)
D and R were doing their own thing. R busy, D mostly goofing off. I saw R hopping on the phone to page people for M and P. Getting stuff, helping. D hovered and told me that the patient was "bleeding so much that she had a yankauer up her ass". This is horrifying until you see how eminently practical and oddly humane it is. Would you rather have the patient bleeding out of her ass and lying in it because she's so heavy to move, have her family see her in that state...or would you rather find a way to keep her cleaner, even if it's a little, um, unorthodox? It sounds so horrible. It is horrible. So is the alternative.
P came out of the room at one point and I was the only one sitting there. Her expression said that I was clearly not her first choice. "JustCallMeJo, do you know where the blood bank is?" Yup, sure do. "Would you take these units down for me please because I'm only supposed to give them if her crit is x and we may not need them until midnight." Sure, I can do that. So I did, came back, loitered more. Maybe I could do something else. Learn something.
I caught little things. A needed to eat, and with his face that color, clearly needed to step away from the desk. There I was. "Will you watch monitor so I can get some food?" Sure. So I watch monitor, notice nothing more than occasional PVCs on two of R's patients, and take a huge number of calls for P/M. "M, Dr. Somebody is on the phone for you about Johnson." She nods, "Thanks. Johnson is P's patient, and I'll let her know." It was a gentle correction.
And I thought about that gentle correction. Here's a woman who can clearly handle this patient. She'd need help, of course, because no patient this complex gets better because of any one person, including and especially not because of any MD. Don't make me laugh. And what is this nurse doing? Holding up another nurse, supporting another nurse, one with less experience. And she did it....gracefully. I admire that. A good mentor is rare.
P needed more from the blood bank, and I was there again. "I need 2 units of FFP now, and see if they'll give you those two units." "Right. Two of FFP, two units if they'll give them." I returned with my hands full of stuff, which allowed me my first real look into the room.
love of god.
Bright lights, beeping, whirring. The patient was intubated. There was blood, yes, and oozing fluids. She was covered by a gown but she had what looked less like vaginal bleeding as what had been vaginal gushing. She was yellow. She was huge. She was massive, actually. X's marked the place on her feet where pulses would be if you could feel them. And there was a bank of IV pumps no less than five feet wide. Think about how wide five feet is. She had no less than seven lines infusing into her just from the IV pumps. And there were five lines hanging from the ceiling that were run-as-fast-as-you-cans, platelets mostly. Blood products and blood products. On the other side of the bed, there was a small fridge-sized portable dialysis running. (I didn't know this was a dialysis machine, I had to ask.) The patient had a tube down her throat, a ...let's see octo? lumen? subclavian in her right side...what do you call a subclavian with two or three "chicken feet", foley of course, the suction, and a vascath in her femoral, filtering blood, and oh, I think another miscellaneous IV bank in her left arm, too.
She was yellow and unconscious.
And seeping. Fluid seeping from her skin.
It appeared that either the bleeding was under control or the suction was taking it away and dumping it into tanks under the bed.
P and M were deep in conversation about some charting thing when I timidly walked in and handed them the blood stuff. "Thanks," they said, and then I kinda just didn't go away. I put my hands behind my back to not touch anything and I looked at the IV banks. Vasopressors, insulin, a few meds I didn't even know. "Is it, um, okay, if I look?" M nods, smiles. P shrugs, sure. P is focused on learning and stressed because well, this is her patient. She's digging this patient out of a deep fucking hole. I get that. I respect that.
So I try and stay out of the way, and listen. A GI doc is coming and gonna scope her and see if he can stop the bleed. I had to refresh my memory of hepatic failure later, but even as I heard that news, my eyes went huge because I was thinking: esophageal varices. I mean, the GI tract is really really fragile right now, right? This is risky, right? So my eyes popped and I shut up. Probably I just don't know what I'm talking about. I shut up, I listen. This is my job today.
P hung one of the platelet bags, and in a voice I hoped sounded unobtrusive, I asked, "So...P...you can just slam those in? You don't need to do a specific rate...?" She looks at me as if just noticing me for the first time. "Yeah, you can just run it with a bulb like this." "Because we at the opposite of caring about CHF type stuff, right?" "Yeah, her fluid volume is so low right now, it's hard to get a pressure."
And after that, P looked at me with less dubiousness. Maybe it occurred to her I wasn't a toad, nor was I a fluffy bimbo, and she had stuff she could teach me and I was more than willing to learn from her. At least, I hope that was it.
I tried to not get in the way, but I felt like I could watch. D hovered as the GI doc came in. D was having a ball. D was like this imp, buzzing in my ear. "I love this stuff....I love it when I'm so busy I can't even leave the room to take a piss....this is a great learning experience for P."
It wasn't just D that offered to teach me things, either. M said at one point, "You know, JustCallMeJo, she's got a really good example of scleral edema." P nodded, "Yeah, JustCallMeJo, come here and see this." I stood behind her, gloving up. P gently opened the patient's eyelid to show me, and then stepped back to allow me to do the same. My god. Her EYEBALL was swollen with pocketed fluid. There was something comforting to me about just gently touching this woman's forehead. I was careful. Her goddamn eyeball was swollen with fluid. I don't know what it is about things wrong with eyeballs that is just so fucking wrong.
But no time to think on this. We had things to do. Or rather, M and P had a lot to do, and I had getting out of the way to do. The GI doc arrived. Gowned up, machines brought in, things to move out of the way, more blood to get...
It was D who looked out for me. No special reason why that should be unusual, but R'd been my preceptor, and it seemed strange without him. Especially when What's Happening was in room 42, and in my limited time I've been on SDU...R thrives in a crisis. No time to think about it, though. D called me to come stand in a good spot and buzzed in my ear. When the doc would ask for something, D would hop up and get it. M and P were too busy. Handy, as I realized I still don't know my unit so well as to know where to find say, a tongue depressor. Who uses a fucking tongue depressor in ICU? Somebody who needs to open an unconscious patient's mouth, that's who. M and P were so slammed busy with the five foot wide banks of IVs and getting blood, slamming it in, trying to keep a blood pressure...I'm not sure that either of them got to actually see what was happening with the scope itself. P got to look up once. I'm not sure M saw it at all.
D was my running commentary. My eyes were riveted on the theatre happening in front of me, but I was listening. Once in a while, I'd fetch something. I would go eyeball my patients here and there, make sure they were breathing and doing fine. It helped a lot to know that A was at the tele desk. But I tried to be present as much as I could for the scope. (This scope = laproscopic exam from esophagus through duodenum) Some things D said I knew, some things I did not. "They're probably in the pyloric now...I've seen people come back with this and be completely fine after a transplant..." At one point, I think he was watching me and not the scope, and he said, "Welcome to ICU." I acknowledged I'd heard, but I was still looking.
Art school. You learn to look well. You learn to memorize gestures and colors.
I kept wondering to myself why R didn't hang and watch, too. Like I said, R's usually in the thick of things, and I was puzzled but I let it go. I tried to nudge him a little once or twice, but the effort fell flat. Possibly his new guy was a handful and he had a brief moment of respite, or there were already enough cooks in 42. After he'd lended a hand early on, he stayed out of the fray...fray-adjacent. I may be misreading, but there might have been brooding involved, brooding of unknown origin and no doubt not my business. I like R, he's a good guy and a good nurse, far better than me. He's certainly been patient with me. He belongs in ICU and due to life factors, he's not there at the moment. I let the invitation to come see the scope sit there, and then well...back into the fray.
The GI doc closed a bleed and he and his RN left. The scope showed a clot as huge as my hand in her stomach. It had been a helluva bleed. I'm not sure if he got IT, but he got one.
Cleanup time. This was something I felt like I could do, I know how to help, so I did. It took six of us to change the patient's linen, full of blood. And the second we got new sheets under her, the new ones began to darken with more blood. I could also take out the biohazard, I knew where that went. I can take out the trash, too, I know where that goes. More blood tubing? I can bring two types of blood tubing. So now I have learned which blood tubing is needed.
We were beginning to unwind. Sarah Johnson was gonna stop bleeding. Or at least slow the bleeding. This was what was unwinding. We saw the clamp. We got blood slammin in, and plates and expanders, and milk of amnesia so she never knows. Dialysis pumping it out and 14 or 15 lines pumping it in. Sarah Johnson is gonna make it through the night and today was definitely P's day.
Nobody knows that it's P's day but those of us who were there. She nailed it. She really did. I overheard her and M debriefing much later in the night, a really important thing to do after all that. "What would I have done if I had to do that by myself?" And you know what M said? "You would have had JustCallMeJo and R and D to back you up." She's right, and I think that's the best part of everything I learned that day. Had she been alone, I would have backed P up as best I could.
P was bulletproof at the bedside. Yeah, she was stressed, yeah she asked M stuff, her nerves were jangled, and M and D were rolling much better with the situation. But she got the job done, and that is *all* that matters to Sarah Johnson's family.
M was bulletproof because she didn't step in and do FOR P, she did better. She stepped aside and let the RN who will become another awesome person taking care of patients of this complexity do the job. This is not stuff you can learn from a textbook. This is stuff you can only learn by being there, and doing it. Somebody's very mortal coil is depending on you and the team of people you're with, and so this isn't something you can really practice. You do.
Think it's the doctors who "save lives"? Yeah whatever. They play their part, they go home.
Besides, I prefer the term "stopping someone from dying." Life saving is for pastoral types.
I fetched stuff. I took out the biohazard, I watched. I helped turn and asked questions. And what was cool is that D was there to buzz explanations to the least person in the whole group, i.e. me, the chick who took out the trash. And that chick was grateful to take out the trash, ...just to be there.
And A? A kept the chaos at bay. The static and noise of phone communication and flying orders and nonsense of delayed blood product and get me a respiratory therapist and no time to delay because this woman is bleeding to death. A rolled with that and also, by the way, watched the heart rhythms of 12 other patients.
R joined us as the cleanup happened. It's possible that he was having a completely different patient crisis, of which I wasn't even aware.
Sarah Johnson's alive (or was when we left), survived the night and neither she nor her family will know what was involved to make that so.
You have no idea how proud I am to be the person who fetched the extra blood tubing.
During cleanup, D went back to his goofing-off self, munching out of a bag of popcorn. ("I'm really hungry. Is that weird to be hungry after I just watched a GI scope?" "I think it's healthy.") He asked me, "So is this better than rehab?" Rather than answer, I grinned back. A grin that wasn't just 'yes' it was 'hell fucking yes'. It was a dirty grin, an evil grin and I didn't actually intend to flash it at him. So I turned back to fiddle with the biohazard bag, but not before the point was made.
And I didn't sleep. I was awake 23h. And this post is a poor reflection of what happened. I don't think I really caught it all. It's an echo of an echo two days later.
I don't know if Sarah Johnson is alive today. When I told Katie the cliffnotes version of this story, she said, "Well, you can't....maintain that kind of thing, can you...? Putting all that blood in nonstop? I mean, what's gonna happen?"
I don't know. I really don't know.
I know it'll happen again sometime. Liver failure does. And I'll know which blood tubing is the right one, and where to find sharps containers.
That's worth something to somebody, isn't it?
A code white is a patient who is bleeding out in my hospital. Though nobody actually called a code white, this is what it was.
This is not the story of Sarah Johnson in room 42. 'Sarah Johnson' is not even close to the woman's real name, and we don't have a room 42. You don't know this patient and you never will. This is the story of what I learned about nursing, what I learned about how nurses learn, as I watched Sarah Johnson's body implode and I watched a team of people Sarah Johnson didn't know keep her alive.
I am bad at fiction, so what I'm telling you is true. Or at least, what I saw. These are the people I work with. It is my hope they don't hate my guts for writing about them. It is my hope, actually, that they never find out. But that's possibly not likely in the long run as I've showed a handful my desert pictures over on Betelgeuse. Dammit. So, in alphabetical order, I give you:
A, the monitor tech/unit secretary
D, travelling ICU RN
M, ICU RN, precepting P
P, ICU RN, orienting
R, SDU (stepdown) RN, who'd been my preceptor
and JustCallMeJo, yours truly, SDU RN
**************
Something big was happening in 42. It didn't take a genius or special spider-sense. I could see men in button down shirts with angry expressions on the phone at the other end of the nursing station. Doctors. Angry. Bad sign. I could see A, whose back was to me, typing furiously with a chart to his side, and the back of his head looked a warmer shade than normal. I could see P, hurrying in and out of 42, brow furrowed. I could hear the phone, and the phone, and the phone. M was calmer, but she was clearly busy...talking to A about paging this person, that person, clarifying with this MD this order, that order. I saw one of the docs I knew, one I'd seen intubate somebody before. She was wearing a scrub hat. Bad sign, meaning intubation was happening again. And I could see R, who was listening to D give him report, but whose eyes kept going up to 42. R is usually in the thick of things of a crisis, and was clearly keeping tabs on what was goin on.
I decided the best thing to do was my job. There was such a clusterfuck of people at 42 that what was needed was not me. Unless shouting and running happened, and then I would run, too. When bumping into P or M in the medroom, I told them, "If you need anything, let me know, my patients are fine and I can help." They said thank you, they're okay. M said this kindly, P said this with dubious belief. Or maybe that was just her stress level. Neither M or P knew me at all.
I noticed that R got his admit across the station from me, and B, the resource nurse was helping him and apparently nobody else. This is a bad sign because it meant that neither P, M, or D was available to lend a hand. Everybody is around to lend a hand when an admit comes. So I poked my head in, though by the time I got there, R had his patient settled.
I tried to stay out of the way of 42. Traffic slows because of rubberneckers. And I don't know enough to be useful. But as the evening progressed, one by one, MDs began to leave and the tension level decreased a little. I listened. I hovered, and I gathered that Johnson was bleeding, had been bleeding. P and M were back and forth, in and out of the room. P: "Where the hell are my platelets?!" M: "A, would you page respiratory for me please?"
(Rehab just called me. Can I come to work there tonight?...Er...sorry, been up all day. Besides, got a hot date with my best friend and her children today.)
D and R were doing their own thing. R busy, D mostly goofing off. I saw R hopping on the phone to page people for M and P. Getting stuff, helping. D hovered and told me that the patient was "bleeding so much that she had a yankauer up her ass". This is horrifying until you see how eminently practical and oddly humane it is. Would you rather have the patient bleeding out of her ass and lying in it because she's so heavy to move, have her family see her in that state...or would you rather find a way to keep her cleaner, even if it's a little, um, unorthodox? It sounds so horrible. It is horrible. So is the alternative.
P came out of the room at one point and I was the only one sitting there. Her expression said that I was clearly not her first choice. "JustCallMeJo, do you know where the blood bank is?" Yup, sure do. "Would you take these units down for me please because I'm only supposed to give them if her crit is x and we may not need them until midnight." Sure, I can do that. So I did, came back, loitered more. Maybe I could do something else. Learn something.
I caught little things. A needed to eat, and with his face that color, clearly needed to step away from the desk. There I was. "Will you watch monitor so I can get some food?" Sure. So I watch monitor, notice nothing more than occasional PVCs on two of R's patients, and take a huge number of calls for P/M. "M, Dr. Somebody is on the phone for you about Johnson." She nods, "Thanks. Johnson is P's patient, and I'll let her know." It was a gentle correction.
And I thought about that gentle correction. Here's a woman who can clearly handle this patient. She'd need help, of course, because no patient this complex gets better because of any one person, including and especially not because of any MD. Don't make me laugh. And what is this nurse doing? Holding up another nurse, supporting another nurse, one with less experience. And she did it....gracefully. I admire that. A good mentor is rare.
P needed more from the blood bank, and I was there again. "I need 2 units of FFP now, and see if they'll give you those two units." "Right. Two of FFP, two units if they'll give them." I returned with my hands full of stuff, which allowed me my first real look into the room.
love of god.
Bright lights, beeping, whirring. The patient was intubated. There was blood, yes, and oozing fluids. She was covered by a gown but she had what looked less like vaginal bleeding as what had been vaginal gushing. She was yellow. She was huge. She was massive, actually. X's marked the place on her feet where pulses would be if you could feel them. And there was a bank of IV pumps no less than five feet wide. Think about how wide five feet is. She had no less than seven lines infusing into her just from the IV pumps. And there were five lines hanging from the ceiling that were run-as-fast-as-you-cans, platelets mostly. Blood products and blood products. On the other side of the bed, there was a small fridge-sized portable dialysis running. (I didn't know this was a dialysis machine, I had to ask.) The patient had a tube down her throat, a ...let's see octo? lumen? subclavian in her right side...what do you call a subclavian with two or three "chicken feet", foley of course, the suction, and a vascath in her femoral, filtering blood, and oh, I think another miscellaneous IV bank in her left arm, too.
She was yellow and unconscious.
And seeping. Fluid seeping from her skin.
It appeared that either the bleeding was under control or the suction was taking it away and dumping it into tanks under the bed.
P and M were deep in conversation about some charting thing when I timidly walked in and handed them the blood stuff. "Thanks," they said, and then I kinda just didn't go away. I put my hands behind my back to not touch anything and I looked at the IV banks. Vasopressors, insulin, a few meds I didn't even know. "Is it, um, okay, if I look?" M nods, smiles. P shrugs, sure. P is focused on learning and stressed because well, this is her patient. She's digging this patient out of a deep fucking hole. I get that. I respect that.
So I try and stay out of the way, and listen. A GI doc is coming and gonna scope her and see if he can stop the bleed. I had to refresh my memory of hepatic failure later, but even as I heard that news, my eyes went huge because I was thinking: esophageal varices. I mean, the GI tract is really really fragile right now, right? This is risky, right? So my eyes popped and I shut up. Probably I just don't know what I'm talking about. I shut up, I listen. This is my job today.
P hung one of the platelet bags, and in a voice I hoped sounded unobtrusive, I asked, "So...P...you can just slam those in? You don't need to do a specific rate...?" She looks at me as if just noticing me for the first time. "Yeah, you can just run it with a bulb like this." "Because we at the opposite of caring about CHF type stuff, right?" "Yeah, her fluid volume is so low right now, it's hard to get a pressure."
And after that, P looked at me with less dubiousness. Maybe it occurred to her I wasn't a toad, nor was I a fluffy bimbo, and she had stuff she could teach me and I was more than willing to learn from her. At least, I hope that was it.
I tried to not get in the way, but I felt like I could watch. D hovered as the GI doc came in. D was having a ball. D was like this imp, buzzing in my ear. "I love this stuff....I love it when I'm so busy I can't even leave the room to take a piss....this is a great learning experience for P."
It wasn't just D that offered to teach me things, either. M said at one point, "You know, JustCallMeJo, she's got a really good example of scleral edema." P nodded, "Yeah, JustCallMeJo, come here and see this." I stood behind her, gloving up. P gently opened the patient's eyelid to show me, and then stepped back to allow me to do the same. My god. Her EYEBALL was swollen with pocketed fluid. There was something comforting to me about just gently touching this woman's forehead. I was careful. Her goddamn eyeball was swollen with fluid. I don't know what it is about things wrong with eyeballs that is just so fucking wrong.
But no time to think on this. We had things to do. Or rather, M and P had a lot to do, and I had getting out of the way to do. The GI doc arrived. Gowned up, machines brought in, things to move out of the way, more blood to get...
It was D who looked out for me. No special reason why that should be unusual, but R'd been my preceptor, and it seemed strange without him. Especially when What's Happening was in room 42, and in my limited time I've been on SDU...R thrives in a crisis. No time to think about it, though. D called me to come stand in a good spot and buzzed in my ear. When the doc would ask for something, D would hop up and get it. M and P were too busy. Handy, as I realized I still don't know my unit so well as to know where to find say, a tongue depressor. Who uses a fucking tongue depressor in ICU? Somebody who needs to open an unconscious patient's mouth, that's who. M and P were so slammed busy with the five foot wide banks of IVs and getting blood, slamming it in, trying to keep a blood pressure...I'm not sure that either of them got to actually see what was happening with the scope itself. P got to look up once. I'm not sure M saw it at all.
D was my running commentary. My eyes were riveted on the theatre happening in front of me, but I was listening. Once in a while, I'd fetch something. I would go eyeball my patients here and there, make sure they were breathing and doing fine. It helped a lot to know that A was at the tele desk. But I tried to be present as much as I could for the scope. (This scope = laproscopic exam from esophagus through duodenum) Some things D said I knew, some things I did not. "They're probably in the pyloric now...I've seen people come back with this and be completely fine after a transplant..." At one point, I think he was watching me and not the scope, and he said, "Welcome to ICU." I acknowledged I'd heard, but I was still looking.
Art school. You learn to look well. You learn to memorize gestures and colors.
I kept wondering to myself why R didn't hang and watch, too. Like I said, R's usually in the thick of things, and I was puzzled but I let it go. I tried to nudge him a little once or twice, but the effort fell flat. Possibly his new guy was a handful and he had a brief moment of respite, or there were already enough cooks in 42. After he'd lended a hand early on, he stayed out of the fray...fray-adjacent. I may be misreading, but there might have been brooding involved, brooding of unknown origin and no doubt not my business. I like R, he's a good guy and a good nurse, far better than me. He's certainly been patient with me. He belongs in ICU and due to life factors, he's not there at the moment. I let the invitation to come see the scope sit there, and then well...back into the fray.
The GI doc closed a bleed and he and his RN left. The scope showed a clot as huge as my hand in her stomach. It had been a helluva bleed. I'm not sure if he got IT, but he got one.
Cleanup time. This was something I felt like I could do, I know how to help, so I did. It took six of us to change the patient's linen, full of blood. And the second we got new sheets under her, the new ones began to darken with more blood. I could also take out the biohazard, I knew where that went. I can take out the trash, too, I know where that goes. More blood tubing? I can bring two types of blood tubing. So now I have learned which blood tubing is needed.
We were beginning to unwind. Sarah Johnson was gonna stop bleeding. Or at least slow the bleeding. This was what was unwinding. We saw the clamp. We got blood slammin in, and plates and expanders, and milk of amnesia so she never knows. Dialysis pumping it out and 14 or 15 lines pumping it in. Sarah Johnson is gonna make it through the night and today was definitely P's day.
Nobody knows that it's P's day but those of us who were there. She nailed it. She really did. I overheard her and M debriefing much later in the night, a really important thing to do after all that. "What would I have done if I had to do that by myself?" And you know what M said? "You would have had JustCallMeJo and R and D to back you up." She's right, and I think that's the best part of everything I learned that day. Had she been alone, I would have backed P up as best I could.
P was bulletproof at the bedside. Yeah, she was stressed, yeah she asked M stuff, her nerves were jangled, and M and D were rolling much better with the situation. But she got the job done, and that is *all* that matters to Sarah Johnson's family.
M was bulletproof because she didn't step in and do FOR P, she did better. She stepped aside and let the RN who will become another awesome person taking care of patients of this complexity do the job. This is not stuff you can learn from a textbook. This is stuff you can only learn by being there, and doing it. Somebody's very mortal coil is depending on you and the team of people you're with, and so this isn't something you can really practice. You do.
Think it's the doctors who "save lives"? Yeah whatever. They play their part, they go home.
Besides, I prefer the term "stopping someone from dying." Life saving is for pastoral types.
I fetched stuff. I took out the biohazard, I watched. I helped turn and asked questions. And what was cool is that D was there to buzz explanations to the least person in the whole group, i.e. me, the chick who took out the trash. And that chick was grateful to take out the trash, ...just to be there.
And A? A kept the chaos at bay. The static and noise of phone communication and flying orders and nonsense of delayed blood product and get me a respiratory therapist and no time to delay because this woman is bleeding to death. A rolled with that and also, by the way, watched the heart rhythms of 12 other patients.
R joined us as the cleanup happened. It's possible that he was having a completely different patient crisis, of which I wasn't even aware.
Sarah Johnson's alive (or was when we left), survived the night and neither she nor her family will know what was involved to make that so.
You have no idea how proud I am to be the person who fetched the extra blood tubing.
During cleanup, D went back to his goofing-off self, munching out of a bag of popcorn. ("I'm really hungry. Is that weird to be hungry after I just watched a GI scope?" "I think it's healthy.") He asked me, "So is this better than rehab?" Rather than answer, I grinned back. A grin that wasn't just 'yes' it was 'hell fucking yes'. It was a dirty grin, an evil grin and I didn't actually intend to flash it at him. So I turned back to fiddle with the biohazard bag, but not before the point was made.
And I didn't sleep. I was awake 23h. And this post is a poor reflection of what happened. I don't think I really caught it all. It's an echo of an echo two days later.
I don't know if Sarah Johnson is alive today. When I told Katie the cliffnotes version of this story, she said, "Well, you can't....maintain that kind of thing, can you...? Putting all that blood in nonstop? I mean, what's gonna happen?"
I don't know. I really don't know.
I know it'll happen again sometime. Liver failure does. And I'll know which blood tubing is the right one, and where to find sharps containers.
That's worth something to somebody, isn't it?
Liver failure: prelude to 'Code White'
You need to read this post to understand the one I'll be writing down next. Because, now that I'm pulling my thoughts together, there are two big things I learned about as a nurse this week. One is a few things about clinical pathophys and presentation of liver failure. The other is a few things about how nurses treat and respond to the crisis of liver failure, and in this case fulminant liver failure.
Liver failure is a bad way to go. Most nurses can tell you there are better ways to go than others, and liver failure is not a good one. If you're considering alcoholism as a life choice, please reconsider. Massive MI is a better way to go, but the problem with that one is that in lathering up those arteries, you might just end up with the long suffering of CHF instead. Also, do NOT overdose on tylenol, as this leads to liver failure as well. Use condoms, as you do not want Hep B or Hep C. Wash your hands, as you do not want Hep A. If you use IV street drugs, (not a big recommendation for a host of other reasons), for god's sake, autoclave.
Kim from Emergiblog is an ED RN, and she rocks, as does her blog. Months ago, she did a gutwrenching post, and it's beautiful and has stuck with me since. Here it is.
Some patients seem to hit you on an emotional level, as Kim's did. Some patients interest you clinically, as this one did. Nurses do not tend to be the people in your health care world who forget ever that you're a person. I touched this woman's forehead to see her eyes, and I did so gently because this woman happened to be somebody's Mom, somebody's wife. But as a clinician, I was interested in the machine of human beings working their asses off to save her life. I was interested in what was going on with her body. I was interested in who did what, what roles functioned to do this thing to keep her alive.
This is why this is the first post I'm gonna label "learning ICU." Not because I haven't been for the past 6 weeks, but this is the first time I might have learned some vocabulary words to tell you about critical care nursing.
For non-clinical people:
You know that alcohol abuse and viral hepatitus can crash your liver. You might not know what your liver actually does for you. I mean to say that you know these things are bad, but you don't have a specific picture of why, exactly. Something to do with being yellow, probably.
* Your liver filters broken blood cells, bacteria and nitrogen out of your blood. Let us consider the example of "laughing gas", which is nitrous oxide. What happens when there's too much nitrogen (which is actually in the form of ammonia) in your blood? In small doses, you may feel silly. In toxic amounts, you're beyond crazy and you're in a coma.
* Your liver gets rid of this gunk called bilirubin out of your body. Bilirubin is what makes the skin yellow in people with hepatitis and newborn babies, whose livers learn after they're born to break down the bilirubin. Most babies are born a little jaundiced and it clears in a matter of 2 days. I had hepatitis in 1990, because the mono...a virus called Epstein-Barr, overloaded my liver. I was yellow and felt like hell for 6 months.
* Your liver metabolizes drugs, vitamins and hormones...meaning it breaks them into substances your body can use. Without that ability, your cells aren't getting fed nutrition, and drugs that your nurse gives you to do important things like regulate your blood pressure or heart rate or whatever, are not as effective.
* Your liver helps regulate blood glucose via glycogen stores...glucose = "cell food". It also metabolizes fats. A double-whammy of nutritional deficiency.
* Your liver makes certain proteins, one of which is called albumin, others relate to blood clotting called fibrinogen and prothrombin. Let's start with clotting factors...that's easy. If your plasma, the goo your red blood cells float in, does not have clotting factors, you don't clot. Ergo, you bleed. The less factor and fibrinogen in the blood, the more bleeding. You can see where this is going.
* Albumin is a happy little molecule that transports hormones around your body. It's bigger function, however, comes from the fact that it's big. I want you to go for a moment back to high school biology and chemistry and we're gonna talk about osmosis. Big molecules act like sponges and draw water to them. Wikipedia has a wonderfully egghead explanation. But what I need you to know is that big molecules suck water closer until there's stability between say, what's inside your veins and what's across the membrane of the vessel wall.
Again, with the what does this mean thing? If you don't have albumin, you leak. You leak abundantly. Your blood vessels shrivel up from losing blood volume and you lose blood pressure itself and your body swells up with fluid because all the water IN your body isn't usable to you. You swell with so many pounds of useless fluid that I can make a thumbprint an inch fucking deep into your foot. Your skin leaks clearish-yellowy fluid from any cracks of incisions made, such as IV sites, or anywhere your skin may have been broken.
You are a giGANTic sack of fluid-filled skin oozing your yellow self everywhere, beyond cognizance because of the nitrogen or ability to breathe on your own because of the metabolic acidosis. Your kidneys are dead because your kidneys require blood pressure. Then there's that other small detail of not having any blood pressure, so your heart is gasping for something to do in the time it has before your blood pH and the lack of usable potassium stops it dead. You're probably getting IV lactulose, which is a medication designed to give you constant bowel movements because that gets rid of some of the nitrogen. Oh, and there's the bleeding in addition to the oozing and the shitting. And the most likely place you'lll bleed? Your GI tract. What blood you have, since it can't go through the liver anymore, rerouts often through the veins in the bottom part of your esophagus. These are called esophageal varices. Your GI tract? Big long tube from your mouth to your ass and so you're shitting copiously, and now you're bleeding copiously out of your ass, too.
Fortunately, at this point, you are probably beyond awareness of any of this.
The unfortunate part is that your family members who love you might be watching.
love
of
god
This is a PERSON I'm talking about.
This is a PERSON.
christ.
geezusfuckingchrist
I know you're not wondering now why I had to write this to get it out.
I'm so glad I lost the belief that god/dess/GiantTurtle is responsible for anything that happens anymore. Because I'd be mad if I did.
Instead, I am staring at a gaping hole of entropic causality. I don't feel better about it than you do, probably, but I am not angry. I believe 'existential horror' covers it. There can only be two outcomes of existential horror. Sartre found it in a bullet. I think the only way out is compassion. I'm certainly not the first to draw that conclusion. Taking that complete rainbow in the mist and giving it away as fast and fully and completely as you are humanly able. And that's why there's a part two to this story.
Something I want you to know, too. Lest you are one of those assholes who think that alcoholics deserve this fate, I will tell you that this patient was not in hepatic failure because of alcohol. Nor was it viral. There was not a single lifestyle predisposing factor that caused her liver to die.
Nobody deserves what that woman got.
Liver failure is a bad way to go. Most nurses can tell you there are better ways to go than others, and liver failure is not a good one. If you're considering alcoholism as a life choice, please reconsider. Massive MI is a better way to go, but the problem with that one is that in lathering up those arteries, you might just end up with the long suffering of CHF instead. Also, do NOT overdose on tylenol, as this leads to liver failure as well. Use condoms, as you do not want Hep B or Hep C. Wash your hands, as you do not want Hep A. If you use IV street drugs, (not a big recommendation for a host of other reasons), for god's sake, autoclave.
Kim from Emergiblog is an ED RN, and she rocks, as does her blog. Months ago, she did a gutwrenching post, and it's beautiful and has stuck with me since. Here it is.
Some patients seem to hit you on an emotional level, as Kim's did. Some patients interest you clinically, as this one did. Nurses do not tend to be the people in your health care world who forget ever that you're a person. I touched this woman's forehead to see her eyes, and I did so gently because this woman happened to be somebody's Mom, somebody's wife. But as a clinician, I was interested in the machine of human beings working their asses off to save her life. I was interested in what was going on with her body. I was interested in who did what, what roles functioned to do this thing to keep her alive.
This is why this is the first post I'm gonna label "learning ICU." Not because I haven't been for the past 6 weeks, but this is the first time I might have learned some vocabulary words to tell you about critical care nursing.
For non-clinical people:
You know that alcohol abuse and viral hepatitus can crash your liver. You might not know what your liver actually does for you. I mean to say that you know these things are bad, but you don't have a specific picture of why, exactly. Something to do with being yellow, probably.
* Your liver filters broken blood cells, bacteria and nitrogen out of your blood. Let us consider the example of "laughing gas", which is nitrous oxide. What happens when there's too much nitrogen (which is actually in the form of ammonia) in your blood? In small doses, you may feel silly. In toxic amounts, you're beyond crazy and you're in a coma.
* Your liver gets rid of this gunk called bilirubin out of your body. Bilirubin is what makes the skin yellow in people with hepatitis and newborn babies, whose livers learn after they're born to break down the bilirubin. Most babies are born a little jaundiced and it clears in a matter of 2 days. I had hepatitis in 1990, because the mono...a virus called Epstein-Barr, overloaded my liver. I was yellow and felt like hell for 6 months.
* Your liver metabolizes drugs, vitamins and hormones...meaning it breaks them into substances your body can use. Without that ability, your cells aren't getting fed nutrition, and drugs that your nurse gives you to do important things like regulate your blood pressure or heart rate or whatever, are not as effective.
* Your liver helps regulate blood glucose via glycogen stores...glucose = "cell food". It also metabolizes fats. A double-whammy of nutritional deficiency.
* Your liver makes certain proteins, one of which is called albumin, others relate to blood clotting called fibrinogen and prothrombin. Let's start with clotting factors...that's easy. If your plasma, the goo your red blood cells float in, does not have clotting factors, you don't clot. Ergo, you bleed. The less factor and fibrinogen in the blood, the more bleeding. You can see where this is going.
* Albumin is a happy little molecule that transports hormones around your body. It's bigger function, however, comes from the fact that it's big. I want you to go for a moment back to high school biology and chemistry and we're gonna talk about osmosis. Big molecules act like sponges and draw water to them. Wikipedia has a wonderfully egghead explanation. But what I need you to know is that big molecules suck water closer until there's stability between say, what's inside your veins and what's across the membrane of the vessel wall.
Again, with the what does this mean thing? If you don't have albumin, you leak. You leak abundantly. Your blood vessels shrivel up from losing blood volume and you lose blood pressure itself and your body swells up with fluid because all the water IN your body isn't usable to you. You swell with so many pounds of useless fluid that I can make a thumbprint an inch fucking deep into your foot. Your skin leaks clearish-yellowy fluid from any cracks of incisions made, such as IV sites, or anywhere your skin may have been broken.
You are a giGANTic sack of fluid-filled skin oozing your yellow self everywhere, beyond cognizance because of the nitrogen or ability to breathe on your own because of the metabolic acidosis. Your kidneys are dead because your kidneys require blood pressure. Then there's that other small detail of not having any blood pressure, so your heart is gasping for something to do in the time it has before your blood pH and the lack of usable potassium stops it dead. You're probably getting IV lactulose, which is a medication designed to give you constant bowel movements because that gets rid of some of the nitrogen. Oh, and there's the bleeding in addition to the oozing and the shitting. And the most likely place you'lll bleed? Your GI tract. What blood you have, since it can't go through the liver anymore, rerouts often through the veins in the bottom part of your esophagus. These are called esophageal varices. Your GI tract? Big long tube from your mouth to your ass and so you're shitting copiously, and now you're bleeding copiously out of your ass, too.
Fortunately, at this point, you are probably beyond awareness of any of this.
The unfortunate part is that your family members who love you might be watching.
love
of
god
This is a PERSON I'm talking about.
This is a PERSON.
christ.
geezusfuckingchrist
I know you're not wondering now why I had to write this to get it out.
I'm so glad I lost the belief that god/dess/GiantTurtle is responsible for anything that happens anymore. Because I'd be mad if I did.
Instead, I am staring at a gaping hole of entropic causality. I don't feel better about it than you do, probably, but I am not angry. I believe 'existential horror' covers it. There can only be two outcomes of existential horror. Sartre found it in a bullet. I think the only way out is compassion. I'm certainly not the first to draw that conclusion. Taking that complete rainbow in the mist and giving it away as fast and fully and completely as you are humanly able. And that's why there's a part two to this story.
Something I want you to know, too. Lest you are one of those assholes who think that alcoholics deserve this fate, I will tell you that this patient was not in hepatic failure because of alcohol. Nor was it viral. There was not a single lifestyle predisposing factor that caused her liver to die.
Nobody deserves what that woman got.
Thursday, February 15, 2007
Pretend to care.
Once upon a time, there was a Dilbert computer game and the evil boss people would constantly chide you: "Pretend to care, PRETEND TO CARE."
Dilbert was funny until you lived it, and then it was humorous pain. Millions of people understand this same existential state. Sartre for Dummies. Doesn't matter what country you live in or language you speak. Absurdity is real and indomitable.
So PRETENDTOCARE was running through my head after a talk this morning with J, another NOC stepdown person. He was The New Guy until I arrived. For advanced practice school, they're having him attend Meetings. It's cruel of them, really. So he's going to QI meetings...QI means Quality I...Insects? I...I...nouns that begin with I.
(What does it mean if 'imbecile' and 'idiot' come to mind and oh, NOTHING ELSE?)
These QI people, however, are quite smart, regardless of what the ignominious (see? I can come up with adjectives with I) I nouns in their title. I faintly know two of them, and at least, they are smart. I'm gonna go with my gut and say other smart people are there, too. (My gut also tells me that at least one person at the table is somebody the rest of the people at the table want to throttle. It's a universal truth. You cannot come to a meeting without at least one village idiot.)
Improvement. I betcha it's 'improvement'. That took wayyyy too long. Sorry.
What's happening is that J is getting ensnared the way I feel like I am, too. Like a fly who touched a strand, and then another and another until I am a dry, hollow husk dangling in the breeze, discarded in a greyed and moldy cobweb.
Yeah, that really is preCISEly the image I'm living. It's corporate purgatory I fear.
J has the same problem as me. He cares. He, like me, may hate caring, but he cares. I do like going to work to do my job, leaving it there and coming home. This doesn't always happen. For anybody. But when I see something stupid, I kinda wanna fix it. MyHospital does some stupid things. And they're big stupid. It's not about my unit at all. When I hear things about how the big Meditech Rollout is er, NOT going, it irks me because it's gonna disrupt my ability to do things for my patients. When I know how rehab is kept attached to MyHospital like a gangrenous limb that nobody talks about, I kinda wanna say, "You wanna be a Magnet hospital with THAT putrefying thing dangling off 4east?" I go to these Town Hall Meetings with all the mucketymucks and they'll have FIVE new initiatives and directions for Porter. Who ARE you people?
They are MBAs.
And this is what they do.
Many wonder why they're ineffectual and the status quo is continually reconfirmed. They really do. Ask one, and many will have their insides chewed out of them wondering why their Visions don't get implemented. Many are genuinely baffled at why their efforts to improve x or y don't happen.
This is why I was a consultant. I really did read _Spiral Dynamics_. Cover to cover. (It's a sickness.)
And you know what? I just wanna be a nurse. I really love taking care of my people. I have a huge amount to learn still and I'm all elbows and scabbed kneecaps. I feel like a burden because I'm such a freshman in my new home. I'm really workin on it. I flub, and fatfinger, and I wish I were bulletproof.
And yet, some people want me to come to meetings. Somebody told J, "JustCallMeJo is just what we need at nurse practice council." For real. He told me that. He had Dead Serious Face. I was mortified. If that were true, we're doomed. Doooooooooooooom.
J's next. He is. They got him, too. He's gonna start coming to NPC, too. At least we can commiserate. Pretend to care PRETENDTOCARE.
Friday, February 9, 2007
Change of Shift is up!
...with loooooove in the air. Put on some Barry White and check out the fun at Nurse Ratched's Pad.
Thanks for including me, MJ!
/jo
p.s. Oh, and Kim @ Emergiblog does commode poetry. BWAHAHAHAHAHAHAHAHA! I'm a nurse, and therefore it's okay to laugh at potty jokes. I'm a professional.
Thanks for including me, MJ!
/jo
p.s. Oh, and Kim @ Emergiblog does commode poetry. BWAHAHAHAHAHAHAHAHA! I'm a nurse, and therefore it's okay to laugh at potty jokes. I'm a professional.
Monday, February 5, 2007
Colorado SB10
The Colorado Senate Health committee heard opinions and discussion on this bill on 2/1. The bill is found here in entirety if you click on Senate Bills.
I'm feelin funny here.
I went to Nurse Practice Council last month, and my hospital is working on its Magnet stuff. Our CNO brought the bill up at the meeting and said that she intended to testify in opposition to the bill, but she wanted to hear what MyHospital NPC had to say on it. Was she speaking for us? She wanted to know.
So I stuck my hand up.
(Me and that sticking my hand up thing.)
I wanted to know why she thought it was a bad bill. Her rationale was brief because we were short on time, unfortunately. Her main point was that staffing metrics is not the best measure of good patient care, and that to mandate that we hire someone to do staffing ratio reporting was not in nursing's best interest. Any patient that wants to know staffing ratio can call and she is happy to tell them, she says.
Okay.
I listen. Unfortunately, I had not read the bill before this discussion, knew nothing about it. So when asked if I'm on board with MyHospital Nurse Practice, I kinda had to sit back and ....say I didn't know. I hadn't read the bill. I had questions. How did it work in California, and according to whom? Is the bill truly a slippery slope to mandating staff ratios, which I do think is a bad idea for some governmental body to be deciding how many patients a nurse can take. What does the government know about health care? About my patient? No, that's a bad idea. But do we throw out a good bill because there might be another proposed bill to follow? That doesn't make sense either.
Colorado Nurses Assn supports the bill. I'm a member of CNA/ANA, too.
I don't like kneejerk reactions to something important. I don't make quick decisions when it counts. I wished I'd had more time to sit and stew on this before being asked if I was on board.
The good news is that there's a staff RN from my NPC who's gone to the senate meetings, and he's telling us what's up. No votes were taken on it yet. I think the testimonials went so long they decided to re-address another day. Most of the testimonials are coming from administrators of CO hospitals. As these are people who will have to cut the checks for the fines, I'm not sure that they should be the only people to stand up and have something to say. By all means, participate in the discussion. I'm not a fan of fining hospitals either, as that helps neither the patient nor the nurse.
But.
There are some really good ideas in that bill. Ideas that can help patients. Ideas that can help nurses. Important implications for models of care.
I've heard, through my CNO, that "it didn't work in California when they tried it...they're not happier there." Okay. Except. I had a breakfast long island iced tea on Sunday with L. And I know L. I worked nights with L for a year, and I trust her and her thoughts on things. L was, incidentally, an administrator at a California hospital before she chucked that and came back to bedside nursing here in Colorado. I trust her. And the story she told me about how that staffing ratio reporting thing worked in California was different. Yup, hospitals got fined, but the nurses were happier with the care they were able to provide.
So I don't know.
Part of me really kinda wishes I worked some days and could go sit in on these meetings; I'm sure they're open to the public. I guess I'm not just "public" either...I'm an RN, BSN, member of CNA/ANA as well as my hospital's NPC ...but I think my primary distinction is that I'm simply Not A Schmuck and I know a thing or two about what I want and need to take care of my patients.
You know, I read Suzanne Gordon. I think every nurse ought to.
I'm thinkin this is where the rubber meets the road.
I wish my way here were clearer, though. If it's a good bill, heck yeah, I'll go write my letters to congress (and have written, incidentally, within the last three months). But good/bad isn't so straightforward here. I'll go stand up for the right thing. I'd even go stand up regardless of whether or not my CNO shares my opinion. She's a smart woman. I respect her. I respect that she'll go stand up because she thinks this is a bad bill.
I haven't decided if this is the right thing or not.
I'm feelin funny here.
I went to Nurse Practice Council last month, and my hospital is working on its Magnet stuff. Our CNO brought the bill up at the meeting and said that she intended to testify in opposition to the bill, but she wanted to hear what MyHospital NPC had to say on it. Was she speaking for us? She wanted to know.
So I stuck my hand up.
(Me and that sticking my hand up thing.)
I wanted to know why she thought it was a bad bill. Her rationale was brief because we were short on time, unfortunately. Her main point was that staffing metrics is not the best measure of good patient care, and that to mandate that we hire someone to do staffing ratio reporting was not in nursing's best interest. Any patient that wants to know staffing ratio can call and she is happy to tell them, she says.
Okay.
I listen. Unfortunately, I had not read the bill before this discussion, knew nothing about it. So when asked if I'm on board with MyHospital Nurse Practice, I kinda had to sit back and ....say I didn't know. I hadn't read the bill. I had questions. How did it work in California, and according to whom? Is the bill truly a slippery slope to mandating staff ratios, which I do think is a bad idea for some governmental body to be deciding how many patients a nurse can take. What does the government know about health care? About my patient? No, that's a bad idea. But do we throw out a good bill because there might be another proposed bill to follow? That doesn't make sense either.
Colorado Nurses Assn supports the bill. I'm a member of CNA/ANA, too.
I don't like kneejerk reactions to something important. I don't make quick decisions when it counts. I wished I'd had more time to sit and stew on this before being asked if I was on board.
The good news is that there's a staff RN from my NPC who's gone to the senate meetings, and he's telling us what's up. No votes were taken on it yet. I think the testimonials went so long they decided to re-address another day. Most of the testimonials are coming from administrators of CO hospitals. As these are people who will have to cut the checks for the fines, I'm not sure that they should be the only people to stand up and have something to say. By all means, participate in the discussion. I'm not a fan of fining hospitals either, as that helps neither the patient nor the nurse.
But.
There are some really good ideas in that bill. Ideas that can help patients. Ideas that can help nurses. Important implications for models of care.
I've heard, through my CNO, that "it didn't work in California when they tried it...they're not happier there." Okay. Except. I had a breakfast long island iced tea on Sunday with L. And I know L. I worked nights with L for a year, and I trust her and her thoughts on things. L was, incidentally, an administrator at a California hospital before she chucked that and came back to bedside nursing here in Colorado. I trust her. And the story she told me about how that staffing ratio reporting thing worked in California was different. Yup, hospitals got fined, but the nurses were happier with the care they were able to provide.
So I don't know.
Part of me really kinda wishes I worked some days and could go sit in on these meetings; I'm sure they're open to the public. I guess I'm not just "public" either...I'm an RN, BSN, member of CNA/ANA as well as my hospital's NPC ...but I think my primary distinction is that I'm simply Not A Schmuck and I know a thing or two about what I want and need to take care of my patients.
You know, I read Suzanne Gordon. I think every nurse ought to.
I'm thinkin this is where the rubber meets the road.
I wish my way here were clearer, though. If it's a good bill, heck yeah, I'll go write my letters to congress (and have written, incidentally, within the last three months). But good/bad isn't so straightforward here. I'll go stand up for the right thing. I'd even go stand up regardless of whether or not my CNO shares my opinion. She's a smart woman. I respect her. I respect that she'll go stand up because she thinks this is a bad bill.
I haven't decided if this is the right thing or not.
Friday, February 2, 2007
Is it really eat the young?
Nurses talk to each other about how we eat our young and how that's shameful.
True. Reasonable.
But then, maybe it's not about age. It's about gender, perhaps, and about complex social issues of female-dominated workplaces and Empowerment and how we socialize each other to not have power and Womyn With A Y and menarche/menopause and other gagworthy propoganda. Maybe that's not fair to dismiss the latter idea with sarcasm, because I do regard it as chick schtick. The point is taken by Suzanne Gordon, and the case is reasonably made. I just don't agree.
Ninety percent of my new colleagues in ICU have been on a sliding scale from wonderful, professional, welcoming and enthusiastic at one end to indifferent, reasonably polite and reasonably professional at the other end. Who could ask for better? Nobody. (Not anybody realistic, that is.)
There's always at least one. It's a workplace, and no matter who you are, what field you're in or anything, there is always at least one. It is to my utter bliss that so far, there only has BEEN one. This one happens to be younger than me.
But now that I'm thinkin of it, this unpleasant hazing was done to me in the IT field as well. There's always a small handful in every office and on every contract. The geeks who don't help. Geeks who purposefully obfuscate. When you're a geek, it's laughably easy to blind your (non-geek, if you have them) friends and family with science. You get awe in return if you're speaking to someone who's impressed by that kind of thing.
But I've been hazed with the Blinded By Science bit; I've been hazed by the weirdly passive aggressive I'm Going to Fill Up Your Whiteboard With My Formulas And Don't You Dare Erase Them; I've been hazed by the room full of 15 men talking about the Tijuana stripclub the night before (and I'm the only woman there, and by the way, nobody invited me, which was the aspect of it that annoyed me more). This chick can code circles around me, maybe she'll take my office and the esteem and awe that every other Poindexter here has for me. Of the handful of geeks who've done that to me (and to all newcomers), the vast majority of them get over it. The ones who don't are the same ones who didn't get over it with the guy/chick hired 7 months before I was, anyway, so everybody knows That Guy's Just A Prick.
So I'm getting hazed again.
It's boring.
I mean, really. I'm not offended. It doesn't hurt my feelings. Nor am I...I dunno....what does one typically feel when one is on the ass-end of that whole Eating The Young (irrespective of age issue)/Hazing The New Girl Thing? When it happened in nursing school, which is where you see it a lot....Are you threatened? No. One doesn't feel threatened when someone else is acting as if you're a threat.
In my case at the moment, I don't know that 'threat' has anything to do with it. I don't know what the source of the malfunction is, actually. But ...I have to tell you it's weirdly liberating to not ...care.
And it's really that more than anything that has me thinking. It's about this parking my butt on a zafu to meditate business, at the root. So in circling how to write that over on Betelgeuse, I'm writing how it's affecting work here. This is my life in nursing, and to have a life in nursing, you will hit the adage, Nurses Eat Their Young, pretty much immediately. I guess....I'm not feelin readily digestible. That's not an analogy I'm willing to take further, mind you. But it's got nothing to do with age. Or gender. Maybe it's just people. And maybe you can ...step outside of that stupid little dance altogether.
/jo
True. Reasonable.
But then, maybe it's not about age. It's about gender, perhaps, and about complex social issues of female-dominated workplaces and Empowerment and how we socialize each other to not have power and Womyn With A Y and menarche/menopause and other gagworthy propoganda. Maybe that's not fair to dismiss the latter idea with sarcasm, because I do regard it as chick schtick. The point is taken by Suzanne Gordon, and the case is reasonably made. I just don't agree.
Ninety percent of my new colleagues in ICU have been on a sliding scale from wonderful, professional, welcoming and enthusiastic at one end to indifferent, reasonably polite and reasonably professional at the other end. Who could ask for better? Nobody. (Not anybody realistic, that is.)
There's always at least one. It's a workplace, and no matter who you are, what field you're in or anything, there is always at least one. It is to my utter bliss that so far, there only has BEEN one. This one happens to be younger than me.
But now that I'm thinkin of it, this unpleasant hazing was done to me in the IT field as well. There's always a small handful in every office and on every contract. The geeks who don't help. Geeks who purposefully obfuscate. When you're a geek, it's laughably easy to blind your (non-geek, if you have them) friends and family with science. You get awe in return if you're speaking to someone who's impressed by that kind of thing.
But I've been hazed with the Blinded By Science bit; I've been hazed by the weirdly passive aggressive I'm Going to Fill Up Your Whiteboard With My Formulas And Don't You Dare Erase Them; I've been hazed by the room full of 15 men talking about the Tijuana stripclub the night before (and I'm the only woman there, and by the way, nobody invited me, which was the aspect of it that annoyed me more). This chick can code circles around me, maybe she'll take my office and the esteem and awe that every other Poindexter here has for me. Of the handful of geeks who've done that to me (and to all newcomers), the vast majority of them get over it. The ones who don't are the same ones who didn't get over it with the guy/chick hired 7 months before I was, anyway, so everybody knows That Guy's Just A Prick.
So I'm getting hazed again.
It's boring.
I mean, really. I'm not offended. It doesn't hurt my feelings. Nor am I...I dunno....what does one typically feel when one is on the ass-end of that whole Eating The Young (irrespective of age issue)/Hazing The New Girl Thing? When it happened in nursing school, which is where you see it a lot....Are you threatened? No. One doesn't feel threatened when someone else is acting as if you're a threat.
In my case at the moment, I don't know that 'threat' has anything to do with it. I don't know what the source of the malfunction is, actually. But ...I have to tell you it's weirdly liberating to not ...care.
And it's really that more than anything that has me thinking. It's about this parking my butt on a zafu to meditate business, at the root. So in circling how to write that over on Betelgeuse, I'm writing how it's affecting work here. This is my life in nursing, and to have a life in nursing, you will hit the adage, Nurses Eat Their Young, pretty much immediately. I guess....I'm not feelin readily digestible. That's not an analogy I'm willing to take further, mind you. But it's got nothing to do with age. Or gender. Maybe it's just people. And maybe you can ...step outside of that stupid little dance altogether.
/jo
Thursday, February 1, 2007
Love of god, eat some vegetables
You ever have one of those patients who come in, and you read their history and physical and you think: LOVE OF GOD, MAN/WOMAN! DID YOU EVER IN YOUR LIFE EVER EAT A VEGETABLE?!
Maybe that's just me.
When at least three coronary arteries are over 70% stenosed, and your ejection fraction is in the toilet and you're having syncopal episodes cos, GOLLY, no blood gets to your head when you stand up....
(Translation for the non-medical person: your heart sucks)
I mean, I'm seeing these postop hearts night after night and what keeps boggling me is how proFOUNDly preventable all this sturm and drang is. All the pain. All the...did they mention the bit where they saw into your sternum? That leg that has blood running down it all the time cos I can't change the dressing fast enough and you're too set in your ways to elevate your legs in bed cos you've got 2+ edema and you've been sleeping in your recliner for the past 15 years of your life and want to do it here...?
This is why millions of Americans can't afford insurance.
Because people with insurance don't eat their gd vegetables, they get sternum-cracking-open sick, and it costs tens of thousands of dollars to slap veins onto where arteries are and/or put pig valves in where your old valves have worn out and/or just roto-rooter your carotids ....
And are we teaching these people in the hospital how vital it is to stop eating eggs and sausage for breakfast every morning?
No. We are not.
We see them a year later for pulmonary edema or kidney failure.
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