Wednesday, July 16, 2008

Sedate my Dad, please...

Vented patient coming off a day of significant hypotensive problems secondary to sedation medication. Patient now awake, alert, calm, cooperative and self-reports pain-free. VSS, trend with sbp low 100s, pulse high 90s to low ST.

Daughter at bedside and has been at bedside for the entire day. Pt appears entirely comfortable and a million bucks better than the day before. It is 9p.m. She says: "Can't you sedate him more? It's only at.... (she reads a number off a pump) 12."

I ask patient, "Mr. Smith, are you comfortable?"

He nods, ET tube in his mouth. "Pain level okay?" He nods again. I say to his daughter, "I'm all about letting your Dad get sleep tonight, but I'm all about keeping a blood pressure for him, too."

"But his blood pressure says (she reads another number) 115 over 40."

"Yup. He's also wide awake now. People have a lower blood pressure when they sleep. He'll probably drop another 20 points once you guys head out for the night and he drifts off to sleep. If he doesn't get to sleep, I'll up the sedation. One of my goals for tonight is that he get some good rest, since he had so little last night." I speak to her and the patient, and as I say the last I smile at him and nod. He smiles and nods back. He understands our plan.

She also wanted to argue vent settings with me, arguing that he DID turn and move today, and that obviously it was enough. (As I listened to rales and rhonchi throughout that were not there yesterday.) Argued that he didn't need more oxygen, argued that He Was Weaning Fine A Few Minutes Ago And Didn't Need It.

You know... I know you're worried. I know you're freaked out. I know you're hangin onto your father's hand all day like he's a dyin man. Lucky for you, he isn't a dying man. His prognosis is good.

And you appear to be the kind of person who needs somebody to boss around so you feel like you're in control. Even though you have no idea what you're talking about and you don't seem to want to listen to me or anybody else.

I know that you don't mean to be such an a$$hole to the closest target, i.e. me. I know I'm part of the solution that your dad's gettin better and what's nice is that your dad appears to know, too. I can see your father mouth 'thank you' and smiles and nods with a thumbs up. I like your Dad; he's a nice guy.

Tonight, I was too tired to find polite and kind and unobtrusive nursey ways to say that to you. Because some days I actually am too tired to find compassion for someone who insists on arguing with me nonstop before I've had my first fscking cup of coffee. Over completely retarded shit like My Dad Doesn't Need More Oxygen that are so dumb I'm amazed that a seemingly normal intelligent person like yourself doesn't realize how bratty you sound when you spit that out at me.

The right way to deal with you is talk to you as if you are already know everything and are totally in control of the situation while I explain every miniscule part of what I'm doing and how it contributes to the pathophysiology of your father's case. I'm a woman and I've been married. Even if I weren't a nurse, I already have useful skills in dealing with this situation. You are being simultaneously petulant, stubborn, and just plain stupid.

But I don't have it in me today and you're being a real b!tch while I try to do what your father needs me to do. I am a long way from being a bodhisattva, much as I'd like to be that person. I'm human, and some days I get tired of that bullshit that a nurse isn't allowed to have a bad day.

(Thank you, Johnson and Johnson campaign, for reinforcing the ridiculous myth that nurses are martyred saints instead of professional clinicians:)

I'm not even havin a bad day. You're just bein a b!tch. Your father is a genuine pleasure to take care of. He shall have superb nursing care tonight. I will sit outside his room ALL NIGHT and make sure he's stable and comfortable. Even if you're dad wasn't a sweet man (and he is), he'd STILL get superb nursing care tonight.

Now get the hell out of my room.

Monday, July 14, 2008

Then AFTER the sentinel event....

A patient COR'ed under... well... a horrible set of unfortunate circumstances two months ago. I'd been involved with the case and had blogged about it, but I've since removed that post. Seemed like a good idea, what with all The State Inspectors coming through and forcing some policy changes.

Steps were taken fairly immediately to change some staff roles. The State told us to do it, and for once, a governmental body stepped in and said the right things. The changes were good steps, to the RNs view. Essentially, we added staff in ancillary roles to increase patient monitoring. Yay for the patients! Yay for us!

In the short term, nurses filled those roles. Nurses were more than willing to accept the inconvenience for patient safety. The state inspectors were apparently satisfied with our change. We were glad for the role change/addition. We were thinking that more ancillary staff would be hired to fill the ancillary roles, and then we could get back to the bedside.

Exit state inspectors.

Then, we hear that there are more changes under discussion. First, the number of patients for each ancillary staff to monitor doubled. Then the ancillary roles were physically moved away from one of the units. Then discussion was underway on whether to add more patients from two entirely different floors for the staff to watch.

I had a hissy fit.

I sent a scalding email to my manager and the CNO. I talked about the patient that died. I mentioned her name, I talked about her family, and the tone of my email implied that SOME of us had forgotten and we didn't care that she was dead.

I talked about the logistics of the proposed changes being dangerous. I talked about what is GOOD on our unit, what WORKS on our unit, and the difficulty of these proposed changes being feasible. I hammered at how unsafe these changes appeared to be for patients, and how unsafe I would feel leaving my license to this system.

I was pretty hot.

So my manager pulled me into her office days later. She was upset and hurt. Why did I write an email criticizing instead of coming up with positive solutions? Because it sounds like the decision's done, and you never solicited suggestions at any point.

How can you suggest I didn't lose sleep over that woman's death? I'm sorry, I was angry and honestly, this looks like a decision made with a bottom line in mind, not patient safety....Of course you lost sleep over it....everyone involved in the case lost sleep over it. However, I said, I don't like this decision. I don't think it's safe for patients. I'm sorry you are hurt by my tone, but I feel very strongly about this one.

Hopefully, the meeting at least allowed her to get what she needed to off her chest. I apologized for implying she didn't care. I didn't apologize for finding the new policy changes flawed and dangerous.

I was requested to meet with my manager's boss, Director. (This woman reports to the CNO, so technically I guess I went over her head.) So I went. The director doesn't like my way of communicating. O....kay. (And?)

I broke chain of command. Yes. I've known CNO for a long time and feel comfortable going to her....I just met you two months ago....CNO has always said she has an open door. Director said, Of course CNO has an open door, she's a very caring person, but if you have issues with this unit, you can come to me before you go running to CNO. (Direct quote, that one.)

I told her I didn't like the proposed policy changes. She said the state made her do it. I said: I liked the changes that happened after the state went's this new stuff I don't like. She asked if I'd worked in other ICUs, where things worked differently. I haven't and she knows that. Director said that in her x number of years of experience that she'd never seen nurses be so lazy and rely so much on ancillary staff.

Wow. ....I was struck so stupid by that I don't remember if I even responded to it.

She outlined her ultimate plan for the unit, and parts of this plan do appear to have some positive things about it. I still don't like the fact that the ancillary staff will be monitoring 40 patients apiece, including both ICU pods, and a new ER chest pain center.

She said I could come to the meetings "with concerned staff members" and take part and be "part of the solution." The qualifying factor is that I was chair of ICU's nurse practice council, and was part of the hospital's unit practice council for 18 months....being "part of the solution". I quit two months ago because nothing had changed in that 18 months.

I'm also wondering how she concluded from my angry email that I was promoting RN laziness by asking for adequate ancillary staff. (This picture of yet another lazy RN to the right.)

I promised her I wouldn't go "over her head" again. I will keep my promise.


I called another company the very next day and left the message that, You know, I'd told your recruiter I was only interested in prn at this time...and I think I've changed my mind and I'd like to talk about a full time position. Could you have her call me back please?