Worth a click...

I don't know who this guy is, but I loved this post. Erica at Blissful Entropy bounced me there.

Some planets are aligned against me.

I don't know which ones. I try to make this blog less personal, but my week was just partially stupid.

Predominantly because bad things happened to my patients.

On Tuesday, my patient's left lung had been gradually filling up with fluid until he wasn't getting enough oxygen even with thirty liters of it blowing into his face. He was transferred back into ICU, less than 24h after he got out of it. Today, he came back to me on 15 liters, satting fine. (I bet it was the whole MD Decision To Move Him Down To A Room Down The Hall To Receive The Extra Lasix that did fixed him up....meow.)

On Wednesday, a patient got phenergran on dayshift for mystery reasons. (i.e. wasn't nauseated) It made him loopy and he wandered out to the nurses station looking for his wife. I took a hold of him because he was pale and diaphoretic and had C go get a wheelchair. He blanked out and needed to be helped into it. A very long twenty seconds later, he came back to us, AOx3. Stroke assessment negative. Is now fine, oriented, and understandably wary of all prn meds.

Tonight, I had a patient complain of some foot pain. He's 87, has not received pain meds of any sort in days as he has said he had no pain. I gave tylenol. My other choice was dilaudid. An hour later, it still hurt. So I could give a nuclear warhead or I could send in a tank, i.e. Restoril 15 for sleep. Yes, a benzo, not a 'painkiller'. An hour and a half later, I hear a crash and he's on the floor, AOx2. Bonked head. Pupils equal, moves all extremeties, abrasions to RLE (shin) and head. Mediastinal incision scant bleeding, which stopped.

...

I had no control over 2 of those things, little control over the last one. For Crappy Thing #3, I coulda given dilaudid 1mg IVP to an almost 90 year old narc-naive kidney-compromised gentleman whose NOC respirs were 12. Or I coulda said, "Stay hurting for 3 more hours." I did do a foot massage, which didn't fully cut it. I had few choices. Calling MDs for medium-strength narcotic of choice for "foot pain" isn't done in SDU.

*****

I'm irritable over Crappy Thing #3 and I'm getting over it by writing it down. It's just same shit, different post. Both in Crappy Thing #2 and #3, I got shoved aside as another nurse jumped in and took over my neuro assessment. They are used to jumping in and doing it after a patient loops out or falls. Great. However, er, so am I. I spent all last year with dementia and strokes. Got crazy and Fall Down Go Boom (fdgb) down pat. I will check for moving body parts and equal strength. I am looking for abrasions and bruises. If you would please move down and let me get to the head of the bed, I will look at his pupils.

It's likely a trust issue and it doesn't matter except when I'm tired and it's happened twice in two days. It's also that I'm really only a pushy person when there's a vacuum. In ICU/SDU, there's no vacuum of strong people. During a crisis of whatever degree, ego is a waste of time. So when somebody steps up and is doing a good job, I just let them. I'm not greedy. It didn't really yank my chain until I realized I was walking out of the room for a bloody flashlight for good neuro-check and saline to wash the scrapes when two RNs who don't know my patient are still at the bedside.

This tendency to not-push-first might have....outcomes....for me, in ICU.

Then, a different RN said, "You have to call the doc, you know." I turned and barked. "Yeah, I KNOW I have to call the doctor and I will DO it when I'm done assessing my patient." (I apologized shortly after for barking at her.)

I didn't bark at either RN who helped my patient and me because they were helping my patient and me and doing their jobs. Am I annoyed at them? Of course not. I am grateful for the fact that I work on a unit where people help each other, and I have people so willing to help me.

I'm not always enjoying being the New Kid. When, with some things, I'm not new. I really can take charge of fdgb just fine.

In retrospect, one thing is making it okay for me to feel like I took a backseat with my patient. So, I didn't feel calm during this episode. I was remembering Mrs. W, who fdwb on Patricia. Patricia, the RN who refused to call the MD, despite my loud protests and patient-worst-case-scenarios and even the license-defense arguments. Mrs. W had a slow SDH and two days later, lost her scintillating, wonderful Bette Davis personality. So my patient fell and I clearly see his face and his pupils and I also see Mrs W and my brain is screaming FSCK! FSCKITY FSCK FSCK!

However. The benzo wore off and my patient got his marbles back. I was taking my leave after another set of vitals and fluff and buff. I shut the lights off. "Jo?" Yeah? "Thank you for everything tonight." No problem. "It really helps that you were calm through that whole thing." (I was calm through that?) I'm glad you felt that way. "It really helped a lot because this whole surgery and everything has been really stressful." I'm sure it has. But everything is gonna be fine, now, okay? I called the doc, and he'll check you out in the morning, get some tests to make sure. Get some sleep now. "Okay. Good night, honey."

Or maybe he was just headbonked.

*******

This is all related to other things from this week. The week was sometimes stupid and some cans of worms got opened. To be continued...

If I ran the world...

...people wouldn't hurt so much. Don't like pain, generally speaking. I think it's bad. That's my professional opinion.

If I ran the world, surgery wouldn't hurt. Actually, if I ran the world, coronary artery bypass surgery wouldn't be necessary because everybody would eat a lot more broccoli. Less cow, which has cholesterol and higher in fat. My point is that sawing open your sternum and ripping out busted plumbing by replacing it with plumbing elsewhere in your body would be a kinder, gentler process...kinda like in Star Trek where there are whirring lights and funny noises and no blood does brain surgery plus recovery time in 25 seconds. I vote for that.

Smoking? Think that's bad, too. I'm even an ex-smoker, and not one of those rabid ex-smokers who purged themselves and now wishes to purge the world of this evil. When I drink, I want a cigarrette. Or two. And on occasion I just want one, anyway. Even though I think smoking is bad, a thought grounded in mountains of scientific evidence. A sixty pack-year habit? That's bad.

Also, if I ran the world, people wouldn't drink a quart of whiskey per day. Generally against that, too. Think it's not good, just not healthy. If I ran the world, we'd all deal with our realities in much more productive and happy ways.

These are my opinions. Thing is, I do not run the world. I do not make other people's decisions. I do not *want* to make other people's decisions. It would be a debacle if I ran the world...for one, there'd be too few accountants in it. And a lot less math. Um. And beetles! I'd get rid of all beetles, especially box elder bugs I HATE those.

But I'm on board with the idea that math is probably necessary for stuff. Accountants do things that have (dead dull) use. I am not on board that beetles serve any function, as they do not till earth, do not pollinate, do not actually appear to do anything useful in the ecosystem. However, I am not an entymolygist and I could easily be wrong on this point. (And why does anything NEED six legs!?!)

....I had a point.

If he hurts, give him the fscking medication. Do not give one tablet of Vicodin for 10/10 pain ("because he always says 10/10.") Give him fscking Dilaudid. Because when I get to him, his respirs are 32, his face is grimaced and his hands are balled around wads of sheets. How are you seeing, "A tab of Vicodin" here?

The world is not as we fashion it to be. The world is never as we would fashion it to be. It is only what it is. People only are who and what they are, and they come to us who and what they are. Can we quit trying to change them to think as we think, do as we do, and feel as we feel?

He hurts. Your feeeeeeeelings about his pain level and his habits and decisions are a complete nonsequitur. If you feeeeeel like a drug-pusher, fine, vent it in the medroom because we all do it, we all need to do it. But push the fscking med. You don't run this place. Relax, that's a good thing.

The Nurse Practice Sticker Club

When I was 12, we had clubs. For stuff. Sticker club. Or, dancing club or roller skating club or bike-riding club. We'd take turns being president, and vice-president, secretary and treasurer and everybody got a job. Somebody would take attendance in a spiral notebook with a pink or purple pen. And we would have meetings. I don't remember what happened in these meetings. But we'd have our club for a week, and then we'd have a different club next week and somebody different would be the attendance-taker. I remember lots of meetings on the grass in my back yard. Or Jenny's. Or Melanie's. After while the meetings got held more at Melanie's house, because there were boys in the neighborhood playing basketball. And eventually, we lost interest in clubs.

NPC is having a lot of meetings lately. They're scheduling them for four hours in the middle of the day. Eight p.m. to midnight my time...after having woken at 4 a.m. to do a 12 hour, 7a to 7p for me. NPC wants to organize unit-based practice councils.

The trouble with this is....NPC doesn't do anything yet. It is a sticker club right now, and we listen to a consultant hired to help us attain Magnet status. And we do what she says. She says we need sticker clubs on each unit, so that there's communication between Big Sticker Club (us) and the little sticker clubs.

I ask around on my unit if anybody has opinions about NPC, and nobody does. Because we don't have a function. We don't have bylaws. We do not have action items (other than spawning more clubs). We don't know what we DO.

I joined because at another hospital I worked at, the NPC did stuff. They made charting consistent hospital-wide. They made practices about IV and tubing changes consistent. They do research. They provide continuing ed to the nurses on the units. They bring gripes from the units to the NPC table. Everybody knew who was on NPC. RNs were elected to council and expected to be accountable to their units.

So I inserted myself on NPC in the hopes of doing some of this stuff. I'm finding some frustration. I send suggestions to our council chair. Could we add this to the agenda? Would you like me to take the preliminary steps to do x?

No.

The other ICU rep (a sensible woman and incidentally, the only other NOC shifter at the table) and I were charged with finding more poor slobs who want to go to meetings of ill-defined purpose.

Trade you my extra sparkle roller-skates with hearts sticker for your round unicorn with rainbow sticker.

I am not her big sister....

I am not her big sister.

I am not her big sister.

Even if I was her big sister, it wouldn't be my place.

Taiwan.

In May, i.e. in six weeks.

Do you know where I can get my shots? Will they take my insurance?

*boggle as I'm doing math in my head and a flood of microbiology comes to mind*

I give her a clinic name. Knew the nurses a little. You, er....
have....some...SOME...shots right?

Tetanus.

That's good for 10 years. How about Hep A?

No.

....I don't even go through the remaining litany. The look shows it, though.

But Fiancee's Brother and Sister-in-Law went without them.

(If you're curious as to what I think of the collective brain power of this family, you can go here. The cliffnotes version is that somehow the laws of natural selection managed to miss them.)

She sees that I'm thinking this, as you can pretty much read everything I think on my face. Oddly, I don't think she sees the memory of when she was in Peru and told me she jumped in a river and golly, had diarrhea for a week. 'Could it be cholera?' 'I don't know, Fiance has given me some antibiotics. Really...? I forget what cholera does....' (Fiance is a pharmacist. Yes, Fiance doesn't have shots, either. Ask me what I think of Fiance.)

I guess my description of cholera wasn't graphic enough.

I am not her big sister. I am not her big sister. I am not her big sister.

Do not tell a crazy ba$tard to "not mess with you because it's not funny."

Yes, there are patients who will stool themselves if you tell them this.

Yes, it is gross.

No, some people do not have normal shame inherent in successful resolution of Erikson's Initiative v. Guilt, completed by age 6 by most of us with a pulse. Some people really do want to piss you off to prove an inane point more than you think possible.

You'd think I wouldn't have to SAY that to a nurse.

Fortunately, I don't have to. I can gripe about it here, in my happy little outlet. In the real world right now, I'm working on expressing compassion, not on telling the world what's wrong with itself.

Besides, poop kinda speaks for itself.

..........

My patient last night is just completing his volcanic alcohol withdrawal last night. Off the benzo drip. CIWA score almost where the rest of us are on any given bad day. Diminishing number of restraints. 2mg of Benzodiazepene last night, down from 12+ the night before and 7 plus 2 of Antipsychotic on days. I feel good about a night when I didn't just medicate the mentation out of a patient.

He thanked me this morning, which oddly....hurt. I had this man tied down last night, all night, and didn't give him his phone or his car keys like he asked for (you're welcome to anyone driving a car anywhere in the city last night and to everybody in this guy's phone list) and he THANKED me this morning.

just odd.

Sometimes I'm a very analytical clinician. Sometimes, I'm still just empathic me. Right-brained, artsy, intuitive and (ex-)pagan me. Good nurses are empathetic. Few of us call ourselves 'empathic' but a large number of us are. To function, all of us put it aside 90% of the time. Each of us can tell you patient name, diagnosis and the minutest details about that other 10%.

This guy...? He's just some drunk whose life is imploding. He doesn't constitute that 10% for me, even. But the yawning, hungry maw of hell this guy is living in was a little to ...bloody for me to not....notice...ignore...avoid.

Again, I'm reminded that physical suffering is horrible. Awful. I mean, I am mentally revisiting my angst about liver failure if I need proof of it.

Emotional and existential angst, the stuff of the psych nurses....really and truly just as horrible. I looked into those (hubcap sized, I mean) huge pupils just for a split second, but all the fire and screaming and darkness and clawing at slimy walls like the sides of a well from which there is no escape...was in it.

So strange. I really. LOOKED. at this guy. It was suffering the size of Everest, though, and I saw it and he knew I saw it. ...Strangest damn thing.

bloody. howling. sinking. light fading to a pinpoint and shoulders covered in slime from the cold rocks that scrape as he falls...

Meet a patient like that. And I'm just. Wrong about everything some days.

The organized mind.

I am an absolute snob at certain things. Oil paint. Sesame tofu. Godzilla movies.

I'm also a snob about receiving report at change of shift. I may meander when I write, but when doing patient report at shift change, get to the point. Economy of words. Do not tell me they fell down went boom in 2nd grade. Chief complaint, pertinent history, review of systems, last prns, outstanding issues. Bang. Done.

I would be delighted to socialize in our spare moments. Really. I like the new people. But before we do that, can we get the basic job done first please? If we do it faster, I'll have even more time to ask you about your househunt/husband/children/hobbies/etc.

There are two dayshift RNs who I like very much personally, and I respect. And they drive me wild. Report with them can be like listening to Wagner. (Not every day, but many, and always on day 1.) The Bugs Bunny version of Wagner, mind you. It is a saga that never ends. (Insert swelling music with images of valkryies here....kill the wabbit!...kill the WAAAABBITTT!) For one nurse, there is no thread that I can follow other than "this happened today and this happened today, and oh, this morning this happened, too."



She starts well: "This is a 67 year old gentleman in for a CABG times three, done on the 12th..." and then we talk about how he felt about ambulating the fourth time today.

Don't care. Unless he an epic meltdown about his fourth walk around the nursing station and you had to call a code green.

"He's voiding okay (define "okay"), and I've dumped the urinal 6 times."

Don't care. Just UOP = x mL, please. If it's not clear yellow, you can tell me amber/sediment/hematuria... otherwise, move on.

Do NOT give me seven full minutes on the psychodynamics of this patient and his relationship with his wife and forget to tell me he has a goddamned pacer and AICD. When I start seeing cardiac pauses and pacer spikes at 0130, I am thinking: "Did you LOOK at his strip or were you too wrapped up in kill the WAAAAAABBBITT!"

(Oh, and I am A NIGHT SHIFTER. I care about my patients and I don't give a damn how their appetite was today. You're a day shifter, and you don't give a damn how their sleep was, either. We make each other crazy by thinking the other shift cares about these things. Don't waste my time with ad nauseum about what was left on his plate unless we're into albumin-bolus and TPN/TF territory and... I won't waste your time unless he's a) less than 4h sleep or b) becoming so psychotic you should expect to restrain him.)

Most RNs at my hospital do review of systems, which makes the most sense to me. But if you want to do head to toe (or toe to head), that's okay, too.

Nurses are organized people. Most nurses are scientific people. I find it easy to talk to other RNs about nerdy code things and coding life, I find it very difficult to talk to them about my life as an artist, or my meditation practice, or, come to think of it, anything on the equally-developed intuitive right side of my brain. The exceptions to that rule become actual friends. Generally, these people were good at algebra. How I managed to slip in among them I do not know.

Taking 45 minutes to tell me about 3 patients is pathology. Is the product of a disorganized mind. Is fugue, in both senses of the word.

I would love to tell you that my sitting on my zafu every day has made me a more patient person...and that I sit in equanimity as the clock ticks and my off-going RN travels the stars to glean the occasional pertinent detail about my damnpatientforthenight.....

But if you've guessed that I stand there bug-eyed, teeth-clenching and finally bark questions after we're 11 minutes in and I still don't know whether the patient is in sinus rhythm or not, you would be correct.

It is a personality flaw. This intolerant impatience and unwillingness to let the disorganized mind to keep putting her damn paws on my patients after 1915, givemethatfsckingclipboard!

I know this. I will work on it. Aum mani padme hum. Aum mani padme hum, dammit, aum mani padme hum how the hell did you get to ICU with a brain like thaummanipadme hum. Aum mani padme hum.

Who the heck would sue me when I'm trying to help?

Check out Angry Medic's story.

I don't know any MDs well. I work nights, and the few that I see tend to be bleary-eyed and wearing clothes they'd donned 22 hours previously. This is unfortunate, as I'm sure a great many of them are worth knowing. (Not all, but probably most. Kind of like most plumbers and accountants are probably worth knowing, too.)

So when I read Angry Medic, I'm sometimes struck with how different the world of learning medicine is different from the world of nursing, and of learning nursing. It shouldn't be, as we're actually in the same world. But if the same situation he describes happened to a pharm class in nursing school, the story would have been very different. I doubt any person present would have been thinking 'lawsuit'. (You probably would have had several think, "Neat! I can practice CPR!")

It's a travesty that so many commenters to AM told him he was right to fear lawsuit. This is awful. These posters can, no doubt, make a solid case for being right to fear lawsuit. And I'll bet you most of them hate the state of a world in which this interrupts good intentions, good help, good care to people. I'm sure most MDs wanted to be MDs because of good intentions to provide service to others.

This fear of lawsuit doesn't exist so much like that in nursing. I certainly know RNs who have been to court, none that have been censured. We are all human, and we've all made mistakes. I've made mistakes. I'd tell you what they were (because I remember each) if this wasn't a blog out on the internet. Nurses who've been on the stand tend to be sticklers with documentation, and I can learn from them. (One charts like Charles Dickens, and I don't want to learn from her, but that's beside the point.)

But fear of a lawsuit wouldn't stop me from helping somebody who falls down, goes boom. Fear of HIV/Hep C or other infectious disease gives me pause. Give me a decent barrier, and I'd be fine. I'd make do with a rag or a shirt in a crisis fine.

Fear of a crazy bastard who bites or will suddenly grab me in a headlock gives me pause. But that only causes me to consider my position when I'm approaching this person, and that takes split seconds. Fear of being hit by projectile vomiting and ruining a shirt and the hours of showering and scrubbing it would require later...same thing.

But 'lawsuit' wouldn't cross my mind in those critical seconds. In the U.S., we have a Good Samaritan law that protects us. (Sad that one is necessary.) Based on the comments AM's gotten, this lawsuit fear seems to be something that a sane MD has to think about in a crisis. Just like my thinking about biting, HIV and projectile vomiting are kneejerk thoughts. 'What if this poor bastard sues?' I had no idea. I find it fascinating.

It also makes me wonder what the hell medical school is *teaching* these basically good people? What are the NHS and the American and Australian hospital systems teaching to people out there trying to give care to their communities?

*gah*

This is messed up.

I get called an angel at least once a week. This week, it was on Thursday. A patient's husband was expressing gratitude, and it was best-intentioned. I thanked him, laughed it off and told him he could ask my mom if I was an angel and she'd give him an earful. (This is one of my ways to get the idea across that nursing is a profession and not a vocation.) Sometimes patients mean this 'angel' thing in a way that is so saccharine or manipualtive it gets on my nerves. I'm not an angel, I'm a clinician. I'm a nice clinician and I like to help people. The only wings I have were tattooed on in a neon-lights parlor on Colfax a few years ago. Tequila was involved.

(Pointless segue: I had a patient last night tell me he will be putting me on his Christmas list. Had to say, that was a first and cute as hell. Ex-IV drug user, ETOH, slowly dying while waiting for an organ to be transplanted. His words are sweet and this is a man who probably has in the back of his mind something a little more airbrushed and Playboy with bows in indecent places, but I didn't actually care. It was still cute.)

Maybe it's this reason that people don't tend to sue nurses. For one, I don't think they know they can. (And I'm not gonna tell.) For another, I think there's that idea about nursing that we're all sweet and cute and female and helpful that actually ends up protecting us. That some of us are men, some of us are fugly and some of us are profoundly ill-tempered and that ALL of us are multidimensional people and flawed, seems to not be the point.

I don't want to be a doc. I'm glad there are good people who want it. I'm sorry for them that they have to hesitate for fear of lawsuit. I hope nursing never gets there.

No.

I don't get it.

Had a friend almost-crying on my shoulder today. This is perfectly okay; I've offered a shoulder before. She's a good person. She's a good nurse.

She's got some health stuff goin on. Big stuff. Medical leave stuff. It's not new, it's several years that she's been dealing with this stuff. She wants to scale back to two days a week instead of three a week and she needs to do this. It's not up for discussion that she needs to do it. She has stunningly obvious medical reasons that require her to take it easy.

I mean. This is not optional.

She applied for a job at SomeOtherHospital. Got the job, turned the offer down on the promise from her supervisor that "Oh, yeah, we can scale you back to two shifts a week." This morning, said supervisor backpedalled. "Well, that would be part time, and I don't really have a part-time position available."

I hear the tail end of this conversation, and Supervisor goes to office, and Friend looks like she's about to crack, but says nothing. Friend takes me walking, tells me.

My words of advice: "Well. You can say to Supervisor that if she can't make it work, you'll be taking a leave of absence." Friend: "I don't want to threaten." Me: "Who said 'threaten'? You need time off. This isn't a choice for Supervisor to make, this has nothing to do with her. If she can't 'create a part-time position', okay, that's fine. She cannot create a new position for you to be. You can therefore leave for three months and she's required to keep your full-time job open for you. You get your time off. She gets the logical consequence for making an asinine management decision. Meanwhile, you can look for a part-time job for a nurse of your caliber and have a line of people wanting to hire you for two days a week."

Friend wrings hands. Friend is still thinking she's going to "threaten" and nice nurses don't threaten.

No threaten. Do. (Like Yoda says.)

How is this up for discussion?

In what cockamamie universe is this not a JOB, people? With FMLA rights the same as those given to every other working, taxpaying citizen of the United States? And where is it not okay to vote with your feet when you're working for someone unreasonable? When is your health optional? Why should a nurse feel guilty when some person with deplorable management skills is managing-by-taking-advantage-of-you?

I can't say this doesn't happen in the business world because it does. But most not-nurse people know that the sacrifices and the blood and guts these people put out ...are not rewarded. They do not have a saintly home. They have lives of missed soccer games and dance recitals and missed weddings and missed deaths and a whole lot of things that Could Have Been.

This is why I walked away from my $75/hr gig in Tijuana, Mexico, to be with my grandfather when he died. I do not regret it. A woman that was my friend told me at the time, "I don't understand this...I don't know anybody that close to their grandfather....You should have cleared this trip with me first" ("Ask the cancer eating his body alive if it can come back another time, M. Because I'd really it rather not kill him now, either.")

My point of this little anecdote is to point out that I am astonished to see how people cannot fathom that a job is just a job. It isn't your life. It is more than okay to regard it as just a job. It's important to have goals at work, professional goals, but it's not okay to put that first when it's your health, or your family's.

Duh.

According to some book I read, part of this is generational. That a job is just a job. People of Generation X, this doofy tome says, have learned that it's important to balance work and life, and not live to work as previous generations have done.

My friend is older than me. But not so not-my-generation that she doesn't hear me. That she doesn't hear the sense of what I say to her. Just enough older to feel guilty that I might be right. Just enough older that, I'm afraid, she may accept the terms she's been given and let her health get worse.

That guilt is not okay.

No.

It's an easy word. It really is.

You are not a hero for picking up 17 shifts in a row because "they can't find anybody." Guess what? They really won't find anybody if you're willing to be the beast of burden. You will never go down in the history book of What A Fabulous Person because you took it all on yourself. You are not Abandoning Your Patients. You are not a bad nurse for needing to take care of your health.

You became a nurse to help people, and you do.

The world is an endless spiral of suffering that increases exponentially. With each birth, by 2050, there will be 11 billion of us on this planet and each one of them will suffer horribly. Each withers, sickens, debilitates and will die. You do not stand alone to stop the deluge. You are not the arbiter of the cure.

You need to get a grip. What a nurse does is of immense value. But a broken nurse stops the suffering of no one. Even the physicians say to heal thyself. Why don't nurses do that?

No.

Just. No.

Say it with me now.

The big fish in the petri dish

I picked up an extra shift. After eight weeks of luxuriating in Only Full Time Hours, I decided it was time. They didn't need me tonight on SDU, so I called Rehab and they were a little too happy to have me back on a Saturday night.

So I'm charge on rehab. It is 11:45 p.m. All five of my patients are happy, medicated, sleeping, dressings changed, thoroughly charted, crash cart checked, chores done. I've made sparkling conversation with family members, and reviewed medications for home, and talked about mechanism of action of select laxatives with a bowel-perseverating woman who wants me to call Dr. Franny at 9:00pm on a Saturday night to ask for Metamucil. (Gotta love those people.) I've confirmed NIVA results and altered anticoag orders to return to proper weight/mg.

I can't think of a single thing more to do with these people.

Oh, and T's (the float RN who's with me tonight) six patients? I've bedchecked them and charge-checked her med admin stuff. And met three of her patients cos I'm helping her with her call lights too.

I got my CNA and me some coffee.

I got eight hours left.

Actually it feels good to be here. Really good. I own it. I am bulletproof. Remember me telling you about the nerd who was blinded by my 'mad unix skills'? I'm 'damn' here and I feel it. I forgot how good it is to be in your skin when you own it like that. To rehab, I am now a bigger fish and I walk in and the people here smile and say, "JustCallMeJo! We're so glad to have you back tonight!" And they mean it. They really do. It's kind of neat.

This pond is the size of a petri dish, and I don't care. I'm gonna wallow in my "mad (rehab, anyway) nursing skills" tonight. It's a nice little petit four in my eight weeks of feeling dumb and nervous that I'll screw up horribly...of not knowing everybody well and tripping over invisible rules and general learning-to-fit-in-ness and all that normal stuff that just takes time. I love my new unit. It's becoming home, really enjoy the new people, really love the challenge and that I'm stimulating some neurons. And....the smaller town home is also nice, too.

I am thinking all this, then around 21, the chimes sounded. Code blue (COR 0) in room 8214 (not a room that exists at MyHospital, duh). T and I both hop into the computer to look at 8214. She knew the patient from three days ago when she'd worked on 8west. Chimes again. Code green (out of control person) to the same room. (Person's dead, then they're out of control? ...how does this work?)

So I'm itching to know what happened and missing being on my unit, where I'd get a chance to help and be in the thick of things. It's another liver failure. And hey, recall that I know a few things about that. I am itching and everything is ridiculously under control here...so go downstairs at 2230ish, after the patient's been shipped over. To stepdown side, where there are two SDU RNs, an ICU RN and the tele monitor and that is it.

The first thought goin through my mind (from the moment the chimes rang) is that R and C are havin all the fun. And they are. C's talking about somebody's pacer spikes to the charge nurse, I wave. A's pulling off orders, I wave. J (ICU) is charting, I backscratch. (This is my sign of distracted, idle affection, not something weird.) The place is buzzing, but it's cheerful buzz... meaning whatever happened, it happened well. I poke my head into the patient's room and notice that there's a pulse. Nice. And R's in there, running a 12 lead.

Bastard. :D

He even had a big grin on his face, too. I bet I thought "Bastard" loud enough that he heard it. Thus the grin. I missed out on this one, being in the beyond-the-burbs. ...

They're busy. I go away. Upstairs to the town where I grew up that had a cornfield across the street until I was in high school, when they paved it.

Up where the crickets are chirping.

It's all good. It's a nice little visit. I'm getting paid 68% more tonight just cos it's overtime, a Saturday, and I'm charge.

...chirp, chirp, chirp....

p.s. Something else I'd forgotten about rehab is that a rather large number of nurses here are perimenopausal. It's two freakin degrees in here. I'm in my lavendar polar fleece, two warm blankets, sucking down hot coffee (which I'd be doing anyway), and my fingers are still icicles.

"Someday, you'll grow up and be a dayshifter, too."

The dayshifter who said this to me today means well. He meant, "I know you're new here, and you seem like you're sharp enough to, once you get used to things, come play with the Big Kids in the daytime."

He means well, but he got a withering look and "I do not want to be a day shift nurse."

Reasons I Do Not Like 12h Day Shift

* Every time you turn around you're feeding people. I felt like a waitress, not an RN.

* Every time I turned around, I'm looking for my clipboard. Unilaterally, it was in the hands of some MD who didn't have the courtesy to tell me who s/he is and what they would like done for my patient. I would find out 2 hours later after I saw the "new orders" printout, and I'd end up wasting my time paging somebody to ask for clarification on it. (Also wasting the MD's, and unit secretary's time, too.)

* Utter chaos. Too many people, too much wailing and gnashing, people pushing others aside in a struggle to make themselves seen, heard, or have their orders put in first. There are no more medical crisis on days than on nights. People crash 24 hours a day.

* This fight for survival leads to a certain unwillingness to pitch in and help others with their own patients. On my unit, teamwork is the rule at night, and sometimes happens on a good day.

* Family members are here by day. This is terrible to list this in the negatives. Large families who love the patient are a positive when the patient feels loved and supported. They are a negative when the patient is in INTENSIVE CARE because they need rest and quiet. They are a negative when the family is dysfunctional and doesn't trust one primary family member to disseminate information and I, the RN, has to go through a complex plan of care and med review for each of say, 5 siblings. If I have to do that for your family, you've taken 2.5 hours away from my ability to care for your loved one. Families are a problem when each family member is asking for pain meds for the patient (patient alone knows their pain level, families tend to want to super-medicate because it shows "love"), or they're trying to feed them a fruit smoothie when they're in diabetic ketoacidosis. Families are great. Except that sometimes they are not. In ICU, they go home in the evenings. :D

Reasons I Like NOCs.

* I read my charts. Dayshift doesn't have time. They're swamped with things like calling the kitchen because, "She said she wanted turkey and you brought her bologna." I'm not suggesting that this is unimportant because maybe bologna gives you hives. And the patient's comfort and well-being is why we are here. I became a nurse to do nursing, and I feel like I get to do that at night. I read my history and physicals on my patients. I read physician notes. I read previous shift nursing notes. I read lab values. I notice trends in vital signs. I have more time to do this than your day shift nurse has. Your night shift nurse might know you and your story WAY better than you think s/he does.

* Nighttime physicians. I tend to love the docs at night. They tend to be polite. They tend to talk to me about what the master plan is for this patient, what tests they want and what they anticipate finding in those tests, why we're switching this med or that. I'm not one of those annoying nurses who wants to be a doctor or wants to tell the doc what to do with the patient. I want to do nursing. Nursing works best when the nurse can put her/his energies in the same place the MD's energies are placed. Don't you think?

* Again, with nighttime physicians. I had a WONDERFUL ED doc in the other night whose specialty was toxicology. Patient with an overdose came in, worsening cardiac issues in an otherwise healthy heart. This MD, after the patient was stabilized, explained to the RNs present certain EKG changes due to the specific drug the patient had OD'ed on. Treatment for these EKG changes would not be what we RNs would expect (atropine), but the MD explained that when we saw these changes again for this clinical picture, a different drug should be given (more propofol). It was great to learn from this doc, who clearly knew this clinical picture exceptionally well. And bonus: was polite, professional, and happy to share her knowledge.

Nighttime docs. Fabulous people.

It's that kind of stuff that makes nights a better place to work. Dayshift does not have time, and I mean both RNs and MDs. Why would you care that a bunch of RNs spent 20 minutes to learn this specialized cardiac pathophys stuff from an ED specialist? Instead of say, fetching your turkey sandwich? You aren't really asking that question, are you? When your kid inhales 60 tablets of an antidepressant, you are gonna be so happy I know how to keep your kid alive.

* I have time to broaden my brain a bit in other ways. It's called professional development, and MDs and attorneys and IT nerds do it. Probably dentists, too, but I don't know any dentists. When I was an IT nerd, I did this and gave it no thought. People seem to think this is somehow not appropriate or necessary for nurses. Not being on dayshift, I'm not there for the frequent procedures that happen during the day. I don't get to yank chest tubes much. Or assist with the odd thoracentesis, or bronch. This is a bummer. But at night, I get to actually look up what a MUGA scan is, instead of take the snatched "it's like an echo," response to the MD who's ordered it and running down the hall.

* The quiet. I am softspoken. I have a big laugh sometimes, but people are otherwise always telling me to speak up. It's not because I'm afraid to speak or mousy. I did not grow up in a house that had shouting (at least until I was a teenager). I grew up in a house that turned the tv down or off when someone was talking. I like pauses in storytelling in which one thinks and rolls words around in one's head. There are daytime nurses who are like this, too, and they've learned to be more aggressive to get their patient's needs met. I don't want to learn this aggression.

There are other things true of night shift. Nights does draw certain...personalities, or proclivities.

* We tend to have a rated-R sense of humor at night. Days keeps it PG-13. There's good and bad with this. If nights seems less professional than days, this is why. If I feel like I know nightshifters better, this is why. Only the NC-17ers work at night. They're rare, and they stick out, and there is no way you'd find them in sunlight.

* A lot of normal people work at night. Mostly, that's what we have. But often, the oddballs are found less on dayshift.

Yeah, I miss sunlight. I try to stagger shifts so that I can see it sometimes. Yeah, it's a major ordeal to get a dentist appointment. There are entire weeks where sleep is optional and entire weeks where my life is built around sleeptimes. Denver is not a 24h town, and this sucks.

But there's a 24 hour diner not far off. And four o'clock in the morning is an underrated time of day, good for being awake and driving up to a state park to look at stars on a random Tuesday. And for this brief time left where I have a roommate who wanted cable, all the really great (horrible) science fiction movies and old Star Trek are on at 0300ish. Night of the Lepus. Invasion of the Body Snatchers. Starship Troopers. You know the ones. I consider this a bonus. Your mileage may vary there.

Nope. You couldn't get me on days for all the coffee in Columbia.