Tuesday, December 28, 2010

December 28, 2010

Last year on this day, Sweetie and I were shopping at a popular variety store in my old hometown when I got a call from the director of my Nurse Refresher program.   I had sent her an email just before Christmas, abandoning pride and throwing myself on her mercy.   

Find me a unit--anywhere--willing to take me for clinical experience, I begged.   My husband's company has been idle more than half this year and there are no projects on schedule for 2010.   I need to work!

She was not the person in charge of nurse placement, but she read my email and went to work trying to place me.   Now she was calling to tell me she had found a place for me at Li'l Old County General, 12 minutes from home; I should report the second week of January.   That phone call made my Christmas.  

A few of you may understand the chagrin I felt on visiting relatives, most of whom were healthy, happy, and well-paid while we were unemployed, broke, and putting on a good front.   I was glad for my family's success, but for me the hometown visit was too cruel a reminder of the years when we all had new clothes at Christmas, an obscene overabundance of gifts, and I was the Perfect Christmas Fairy.

2010 proved to be a year of adjustments and (Thanks be to God!) easing of financial worries.   We are in process of closing husband's company, a business into which we both put many hours of time and creative energy.   His client base has been demolished by the economy and work is so sporadic now that it doesn't make good sense to keep going.   Still, it is difficult to agree to label it DNR while there is any life left in the company.   I think at last we've agreed that "quality of life" for our company in this economy is impossible.   Pull the plug.  (sigh.)

Nursing work has made it possible for us to survive and prosper.   I didn't get a paying position until June, but Li'l Old County General has turned out to be a golden employer.  Along with decent working conditions, decent pay, and shift differential I got health insurance, sick leave, and chance for advancement.   These things are not (like husband's business) dependent on the whims of the wealthy.   Being a nurse makes it possible for me to stand on my own and provide for us while doing some earthly good.

Nobody is more surprised than I that nursing finally worked out.   Since I began in 1973, nursing seemed  an albatross of a job to me; I never felt fast enough or smart enough, and the shift work was a constant trial.   I left nursing three times, but fortunately I never lost my hard-won nurse sensibility.   The RN refresher course gave me a chance to demonstrate that my skills were not too rusted for use; forty years of varied life experience had made me a better nurse, too.

In the upcoming year I will grapple with my future in nursing; what direction will I take?  Informatics?  Chemotherapy certification?  RN to BSN to MSN?  Watch this space.

Gone to La-La Land

Apologies for months of no blog entries; Nurse Philosopher has been working a second job with Sweetie Husband which took a whole lot longer than anyone anticipated. 

We were elated when the project at La-La Land Care Center came through, failing to appreciate how it was strategically timed to fall athwart of every other plan we had for the next 60 days.  A few lessons learned: first, I'm not too old to burn the candle at both ends, but the flame meets in the middle a lot faster than it used to.  Second, I don't ever want to work in an Alzheimer's unit!  Just shoot me and send me to a place where patients don't pull on your leg while you're 4 feet up on a scaffold.  Third, when a worker doesn't show, you can call him and yell, but when you get the flu yourself, you're just SOL.  Last, I can personally attest to the reason-destroying properties of Christmas Muzak.  Work beneath a speaker pouring out Christmas drivel should be regulated by OSHA..  Heavily. 

Anyway, we send best wishes of the season to all the folks at La-La Land Care Center.  We're certain you can figure out where the gift deodorizers go.  Those small Christmas bags for the nurses contain earplugs; we hope they'll save the sanity of a nurse or two and help them cope with the continual din at La-La.  

Peace on Earth at last!

Friday, October 22, 2010

A Cast of Characters

No doubt you've noticed that patients are characters.  I have my favorites from over the years, like Hank,  an inpatient who went on to home care through an agency I worked for.  Patients are memorable for a variety of reasons, and are more likely to be remembered if they were somehow difficult to care for.  Hank was a head injury victim with altered mental status (AMS) and a persistent flat affect that made him very difficult to read.  Bunny, his devoted but high-strung wife, had depended on him for everything and tended to swoon every time it appeared he might not come home. 

In the months it took for Hank to recover from the head injury and subsequent surgeries, he progressed from being wildly confused through an episode of PE, to discharge home.  On the day we began to strongly suspect PE, Bunny demanded to know why Hank was having a new series of tests.  My simple but clinically correct answer sent her immediately over the edge.  The dismaying idea that Hank was suddenly sicker  burned like wildfire across her mind toward the thought Hank Might Not Make It Now!  She immediately got on the phone to his doctor with a thousand queries and demands, and Doc  pretty promptly got back to the floor wanting to know what idiot told her Hank's actual condition! 

Bunny was an over-imaginative hysteric, incapable of remembering the simplest directions.    Hank under optimal conditions was no prize.  After being reprimanded for informing the patient's family as I had been taught to do in nursing school, I came to dread caring for the both of them.  One night I brought Hank's hs meds and found him in bed watching tv.  As usual, he glanced at me with utter disinterest and said, "The w'm'n w'n."  Hmm?  "The woman won," he repeated.  (What woman?  What now?  Good heavens; was he experiencing dementia?  Elevated ICP?  This would just be frosting on the medical cake.)  Suddenly and to my great relief I saw that he had been watching Billie Jean King beat Bobby Riggs 3 out of 3.  Saved.

Despite all, Hank did go home.  I never cared for him at home, but the nurse who did reported great success in implementing Hank's post-hospital regimen.  She convinced Bunny that really effective home care begins with a martini before getting started.  Once the wife was calm, Hank made excellent progress.

AMS is a condition a person has to get a feel for.  I once cared for a petite, elderly lady with terminal cancer during her long, final, hospital stay.  Her one pleasure was smoking, and back in the day we allowed patients to smoke in their rooms as long as no O2 was going; the right to keep & use smoking materials was one of the last privileges to be withdrawn, and as I recall a doctor's order was necessary to do it.  One evening she asked me if I knew what "they" were planning to do with her, but when I questioned her she clammed up.  I was concerned, but later her disorientation seemed to have dissipated and I took no further action.

Her roommate was a pleasant, alert woman who had just come back from knee surgery and was bedbound  with a hemovac in place.  That night was to be my last on the unit--my transfer to another floor had come through--and when I heard screams from far down the hall after lights out I first thought it to be a farewell prank of the night staff.  Nevertheless, on approach I found eerie shadows of firelight flickering in the doorway of a patient room.  I rushed in to find the terrified knee surgery patient screaming for rescue and the elderly woman watching as if observing from a balcony while a blanket blazed nearby on her overbed table.   I called a Code Red, and floor staff appeared with looks of astonishment.  We unlocked bed wheels and pulled the nearly frantic knee patient quickly out into the hall, where she reported her roommate had intentionally lit the blanket with a cigarette lighter. 

The rest was a blur.  I recall pulling the old lady's bed away from the fire, leaving the blazing blanket for fire responders, who were pounding up the stairwell.  I checked her bedding for sparks and then pulled her bed out into the hall.  I burned my hand on the metal side rail, although it was 45 minutes before I actually felt the pain. 

Fortunately it was a small fire, despite the great mass of responders present from all over the hospital.  The hospital was run by Grey Nuns and one of the sisters who responded had psychiatric experience.  It was she who learned that the patient who started the blaze did so because she believed the hospital was to be auctioned off  tomorrow and her along with it.  The source of her AMS was found to be metastases to the brain.  I never took the things patients say quite so lightly after that...

Thursday, September 30, 2010

What Do You Do With a Day Off?

What do I do on my day off?  Well, since I live at 1927 House, my day off is spent working on something.  If you visit me, you'll get an hour of being fussed over, the dog will kiss you as long as you'll tolerate it, and there will be tea in the good china at the dining room table...but if you stay longer than that, the dog will go back to sleep and you'll be put to work.  You can start anywhere, and do anything you like; this place is a handyman's dream. Like to drywall or plaster?  How do you feel about tile?  Come by next week and I'll have plumbing for the Inner Plumber in you.  I promise, the sound of a sawzall does not disturb the dog at all, so have at it!

After ridding ourselves of the Great Striped Wasp Migration of 2010, (highly recommend the Rigid contractor's vac) we went to Homely Despot and loaded the van with materials to finish our countertops.  We're covering them in Weathered Stone ("The World's First Bendable Stone" www.weathered-stone.com.) The malleable plaster and vinyl "stone" is perfect for jobs like ours because I can wrap a bullnose counter edge and I don't have to spend a month cutting tile to fit.  We'll grout, coat the whole thing with clear epoxy floor finish, and it's a wrap.  My husband, Mr. Geometry, is laying the product out on-point.  Weathered Stone is made in Fairhope AL, and is the brainchild of Sean Howard, a former paperhanger who is a friend of ours. We like to give him a plug when we can.

As I'm standing at the wall taping drywall joints, I am thinking of my favorite squirrelly patients.  Hospitals spin off their own sort of humor, the best of which is the recent "There is a fracture" cartoon.   Patients tell me all sorts of things, mostly because I haven't yet learned to flee when they start to speak.  A 90-yr-old struggled to speak after a long convalescence; I wondered about his LOC and orientation when he said tenuously, "I know the man who invented the hospital gown..."  I stopped what I was doing and looked at him.  "His name was Seymour Butts."   I blinked; then laughed.  He got me on that one!  One could also never forget the garrulous patient with lower leg cellulitis who nevertheless stumped out to the station to ask, "What is it that the more you take away from it, the bigger it gets?"  Hmmm.  You got me there, pal; what is it?  "A hole.  Gotcha!" he chortled with glee.  So glad I could make his day. 

After the patient humor, I just couldn't let a good giggle opportunity pass, so I went to the internet.
Q: How many nurses does  it take to change a light bulb?
A: Twelve: One to do it. One to chart it. Ten to write the policy and procedure. http://www.jokes.com/funny/health/doctors--nurses--lightbulbs

Vintage Nurse out.

Thursday, September 16, 2010

Time On Your Hands

First of all, after several months of utter mayhem q shift, it was an unexpected surprise to find two nights in a row where I was not hideously busy.  I was busy, mind you, but not ridiculously so.  In other words, I was able to think ahead rather than react to a series of crises.  This was nice.

I even had time to do the sorts of things I do to occupy myself when things are slow, like restocking syringes and changing IV tubing.  Sure, restocking is done once a week by Central Supply, but that's small comfort if you've ever been ultra-busy and needed a saline flush STAT only to find the box empty and had to hunt for backup supply.  Restocking is a good way to get to know where supplies are, before you need them in a hurry.  I like to tidy things up, because having the med room in a shambles is to me like visual "noise" which I find very distracting.  And I contemplate pressing philosophical questions such as, why do two med rooms have a full supply of Day-of-the-Week tags, but the 3rd never does?  Night Shift Nurse remains baffled.

At about 0200 the floor went quiet; not an infusion pump beeped, no bed alarm split the silence.  Aaaah.  There is something to be said for any job that takes you away from the clamor to be endured on days and 3-11.  I made a bed check just to be sure the patients weren't getting away from me.  They were all snug in their beds; Lung Lady, the Moaner,  Mrs.NPO, BatLady, and Smiley; all snoring, the IV's infusing beautifully.  "IVF, O2, and patient safety maintained." You have to be careful with moments like these; they make you  think you've become Wonder Nurse and created the present serenity, when in fact it's pure dumb luck.

Down the hall, the staff were beguiling the time in conversation.  "Do you all follow nurse blogs?" I asked.  They looked at me blankly.  "Noooo..." they responded, after a moment to figure out what I meant by Nurse Blogs.  I wanted to tell them about Head Nurse's surgery, and how proud we all are of Crazed Nurse, and the latest ER story from Storyteller Doc, but I didn't think they'd get it.  Instead, I heard gardening and canning tips, we discussed the whereabouts of the last 3 heavy-work patients who had left, and Blondie told us an amusing story of an elderly woman so reticent that she could never bring herself to speak of her genitalia as anything but "my kittycat."  (I'm not a native; it was a new one on me.)

We looked at one another.  Our hardworking CNA heaved a sigh.  "Well, who wants to help me turn patients?"  Several of us volunteered and wandered off to the next Code Brown.  The rest returned to charting.  And so it goes...

Wednesday, September 8, 2010

Commodores - Nightshift

Night Shift

I'll have to tell the story on myself:

Now I find, after all the aversion I experienced over the prospect of work on the 11-7 shift, I actually like it.  Really.  For many years I dreaded working the Night Shift, but it's far from an  unworkable situation now.  I have no trouble staying awake, little difficulty sleeping during the daytime, and I enjoy being the quiet voice of reassurance in the dark hours of the night.  Of course, I no longer have little ones depending on me for three squares and program direction.  My Darling Dog sleeps when I do, regardless; although she is puzzled about my going out late at night to work.   It's just as well that Dog Daddy sleeps nights and consoles her with biscuits.

What happened to the Night Shift Effect I recall?  The post-shift feeling of being among the walking dead, the days misspent lying in bed, and still feeling foggy with fatigue on arising?  What happened to the feeling of missing everything that was important in life?  I never could see how others did it.  For decades I swore I'd sooner be hanged than work the Night Shift. 

I promised myself the one thing I will NEVER, EVER do is work the Night Shift, yet here I am.  I offer you the next 10 minutes to laugh--gloat if you must--over my former silliness ( I really had worked myself into a froth over this) but your privileges expire in...9.6 minutes.  I'm counting.

County General is a well-run tertiary care hospital.  Our medical unit is a magnet for high-acuity patients who also have concomitent physical, psychological, and social challenges.  We see more than our share of non-compliant diabetics and COPD'ers, plenty of elders with UTI's and altered mental status, more people with clostridium difficile and MRSA than I ever thought existed, and the odd rara avis.  More on the Bird of the Day later.

The true beauty of the Night Shift at County General is not rank or privilege, but teamwork.  At the moment, we manage to work together through the most difficult nights, without calamity or expecting fanfare.  A sense of humor is indispensable.  For example:

At the start of shift, our census had been low; we knew it was too good to last.  At 0300 our capable CNA stopped me in the hall to chat; "Do you believe this," she asked me, looking not at all incredulous. "This is the--what?--fourth admit tonight?" Here she smiled ruefully. I had been wondering myself how many more new admissions the supervisor was going to send us.  My hands were full already with high-acuity patients when ER called to announce the impending arrival of yet another new patient. The one that would cost me two hours of work and more.

"Do you work tomorrow?" she asked solicitously.

"No, I'm off one day and then I'm back Tuesday night. Are you on Tuesday, too?" She nodded, continuing, "It seems like I never get time off.  I'm here all the time." 

I replied, "Well, after Tuesday I'm off for a week...but (noting her shocked expression) remember I only work part-time."

She blinked. "I'm not speaking to you," she said firmly. "A whole week off!  I'm not talking to you," and she strode off in the direction of our latest admit shaking her head, but smiling.

"I'm going to spend my day off hanging wallpaper, if it makes you feel any better," I called after her, still laughing.

Friday, August 27, 2010

Return to Nursing 1988

I left nursing to become a full-time mother, and by 1988 I had three children, a son age 9, and two daughters, ages 7 and 3. I loved motherhood; we spent long hours at the park and library, and made ceremony of bedtimes and snowy days. The children caught insects and had the usual lineup of pets; rats, toads, & an ill-tempered box turtle named Mort. I was a big fan of finding new things for the children to try, especially during the interminable summer breaks. This year was radically different, though; my then-husband had been laid off for several months and after a month or two of dithering I decided I'd better take the nurse refresher course in case I might need to work as a nurse until he found another job.

A nurse refresher course was readily available through my old college nursing department, and with very little ceremony I found myself sitting among 24 peers, listening to day-long lectures on body systems. I did surprisingly well on the tests. I had not wanted to go beyond nursing school in college; this experience made clear that I could do the work. After a month of study, we were required to do 2 weeks of clinical experience, which I also passed, and then I had to do the thing I least wanted to do in life; leave my children and go out to work. Because I was sure I would not stay at any job for long, I didn't apply at a hospital, but chose to work for two agencies. They sent me out to do whatever was available; staff relief, nursing homes, private duty, and home care.

The paycheck was about the only good part of the experience. Despite taking any work offered to me, I didn't make enough to pay all our bills, a fact my husband reminded of every time a bill came in. Rotating shifts was bad enough, but leaving the children in the hands of their father who might--or might not--maintain their daily routine was very difficult. I would call home and ask, what are the kids doing? "I don't know; they're outside." "Where outside, what are they doing?" I don't know," he'd say, "I'm working on the porch."

The children hated the whole idea of me working, and their natural energy demanded a response I couldn't give. It seemed to me that they were all lined up with their hands out; one wanting to play, or tell me a story, or show me a picture, or ask me when is payday. I remember coming home from work one night so tired and depressed all I wanted to do was have a shot of whiskey (make that several shots) and go to bed, to find we had drunk all but the last three drops. There was no money to buy more. I broke down and cried.

I worked 3-11 so I could spend part of the day with the children, but found it hard to get up in the mornings with any enthusiasm. I worked 11-7 when it was all I could get, and even did a few 12's, which I found utterly draining. Oddly, I didn't have the energy then that I have now. I also worked staff relief in a hospital gynecology/oncology unit, which was the first place I ever used an automatic BP cuff and O2 saturation monitor. The patients tended to be frequent fliers, and many of them had perfectly horrific fistulas, obstructions, and non-healing infections.

I recall one of my favorite patients returning with a possible bowel obstruction. I got the order to put in an NG tube. I laid out the equipment, explained things to the patient, handed her an emesis basin, and began to pass the tube--whereupon she hosed us both with about 500ml of stomach contents! I managed to get her a wash basin for the second round of emesis, and between heaves the patient apologized profusely. "No apology needed," I said, managing a smile, "Looks like you really needed that tube!"

I also worked the general surgical floor, which was a nightmare of heavy patient assignments. One end of the floor held oncology patients who were admitted for chemotherapy, which was administered with much cautious preparation by a harrowed RN named Stella. Many of her patients had nausea and were generally miserable, which kept Stella running. I did a number of shifts in orthopedics, which I liked. It took no more than a few overwhelming evenings on the GU floor to understand why they had a chronic staffing problem; the patient load was heavy and the patients' conditions subject to rapid change. Oddly, it was there that I met my first Cystic Fibrosis patient. On most units where I floated the staff was happy to see me arrive because I was filling in, but no unit seemed like a place where I would spend one shift longer than necessary.

Home care was a bit better. I found my natural empathy went a long way toward calming patients and most of them liked me. I remember heart patients and chronic kidney patients, and a bowel-obstructed oncology patient whom I connected to TPN every night. I once arrived to start an IV infusion for a troubled young woman and I needed to take vitals first. Damn; that day I had left my nurse bag containing the BP cuff etc., at home. I knew I was in trouble when I phoned then-husband and asked him to bring me my nurse bag, and got the truculent reply, "What do you need it for?" I was on the patient's phone--which was in her room--trying to maintain a calm, professional, demeanor while I wrangled with him and the minutes ticked by. Finally convinced of the importance of having my equipment, he consented to bring me the bag. As always, his attitude was that his work, whatever that was, was "important" but whatever I was doing was not.

In home care I met Luke, my first AIDS patient, who was being cared for at home. Luke had a Hickman catheter, and I recall spoiling more than one Tegaderm trying to stick it to Luke's chest and not itself. After awhile, we became something like friends, as much as could be expected considering neither of us was where he wanted to be. I often thought I did more for his family than for the patient, for I was able to provide them emotional support during that difficult time. I had cared for Luke for several months when I stuck my finger trying to close a sharps box in his room. I went to the bathroom, poured bleach over the finger, and forced it to bleed. I forced myself to breathe slowly, remembering a prayer someone once prayed in extreme circumstances; I prayed, "Jesus."

The needle had been on a saline flush syringe, which greatly reduced the chances of me coming in contact with an HIV virus. I couldn't go back to Luke's after that. Everything was a haze of HIV testing and months of gut-wrenching worry. Luke's family was devastated. That was when the irritable bowel syndrome began in earnest. "All I wanted was to earn enough to feed my children; I can't believe I could die for it!" I said to myself, although it never came to that.

Catastrophe always goes in threes. At the same time I thought I might be pregnant, and not long after, our Aspen wagon caught fire in the parking garage. Fortunately, a security guard saw it and called the fire department. The catalytic converter had burned itself out which only happens once, so don't worry, our auto mechanic said cheerfully. Two weeks later, in the same parking garage, the Aspen caught fire again and this time it burned out the entire auto interior; no one noticed.

There was a steady stream of chronically ill home care patients, including two children under the age of 3. Both had been born prematurely; one was expected to live, and I spent long nights caring for her. The family living room was overflowing with the baby's crib and equipment which included apnea monitor, continuous humidified O2 to her tracheostomy, and G-tube feedings. She was an irritable child who would not suck or feed or do much else except grasp occasionally and stare at tv; she never smiled and had an eerie noiseless cry when displeased, which was often. Some nights I looked at her and wondered whether the parents, who had gone so far to save her life, had not saved her for a life of abject misery.

My other patient had obvious developmental deficits incompatible with living to school age. Obvious, that is, to everyone except his mother, who had given up everything including her marriage to "save" her baby. I stood in this child's room where he was surrounded with soft colors and beautiful plush animals, listening to Mom explain his care. Her unresponsive son was an edematous respirator baby, about the size and consistency of an oversized doll. His world revolved not around his furry menagerie but the tubes forcing air into his unwilling lungs. Despite Mom's chipper narrative and affectionate attentions, his response never advanced beyond blank, open eyes. Through experiences like these, I came to understand that medical science has a long way to go and while it knows how to prevent death with devices that can perfuse the body's tissues almost indefinitely, that is not at all the same thing as living.

The year 1988 ground on as I redeveloped nursing senses & saw all sorts of patients. It was my personal opinion that I still lacked some element of knowledge or attitude that would have made me a good-enough nurse. Add to that the fact things were going no better at home, I was chronically exhausted, and I was just holding on until my then-husband got a new job so I could go back to motherhood. Over the few next years, I enjoyed some aspects of nursing, but had an abiding animus against nursing as a career; it took me a very long time to understand that nursing was not really the problem.

Wednesday, August 25, 2010

"Camp Nursie Here"

If each area a nurse works leaves its mark on the nurse identity, then I have amassed a dozen identities over the years; my favorite was Camp Nurse. You haven't lived until you've managed health care for 125 Girl Scouts and a score of adult staff for a full week. I agreed to my first week of camp nursing because I could bring my girls for free, and I was promised the only cabin in camp with air conditioning. (I’m a real wuss when it comes to camping out.) What a week it was! Homesick campers, asthmatics, international staffers with allergies, hyperventilating adolescents, dehydration, and Camper's Complaint (constipation-induced stomach ache) filled my camp nurse days with drama.

As I recall, this is an outline of camp nurse duty: the week begins with Sunday afternoon intake, an event that fills my Infirmary wall-to-wall with excited campers and nervous parents. I and a helper wade among them, taking temps, checking medical forms, and examining for head lice. I organize camper medications and write out MAR’s before supper and prepare for the week's routine. Medicine call begins with before breakfast ac meds (which the sensible nurse administers clad in bathrobe and slippers) and ends after evening meds at bed time...if the campers show up on time. Be aware that the camper with the heaviest hs meds always signs up for Night Owl Stargazing.

A camp nurse learns to say things and make them stick. "No, you can't have a nurse excuse to avoid diving practice." Not even if you pretend to have the following: the 45-minute flu, excruciating pain related to a microscopic cut, unnatural dread of horseflies/menstrual cramps/garter snakes, or you think you might have poison ivy. Homesick campers are gently but firmly denied a tearful phone call home to be picked up . The remedy for most homesickness is getting involved in activities; campers are encouraged to pair with a counselor "buddy" for moral support, write distraught notes to the camp mascot if they like, and check in with the nurse twice a day. The goal is to stick it out for three days, after which the director will phone home, but by Wednesday it seldom comes to that.

Campers at risk of dehydration and heat prostration must be taken seriously. "You may spend 60 minutes in the air-conditioned nurse's office; I want you to drink a glass of Gatorade and then plain water, and sit quietly. After that, you'll (almost always) return to your unit," (not lie here in a bunk and quiz the nurse.) “Counselor, while it's this hot, make sure you have extra fluids for campers to drink, and watch everybody drink a glassful every 2 hours.”

The change to a new diet is enough to throw some campers’ digestive tracts off. Remember root dietary causes when dealing with "homesick stomachache" which is constipation that manifests as generalized stomachache and homesick feeling. During assessment the nurse should ask, "Did you poop today? Yesterday? Not sure?” and after ruling out something more serious, “Eat this apple and drink a glass of water. Counselor, remind her to eat fruit at lunch and drink fluid every time it's offered. Feeling a bit better? No, lying in the nurse's office will not help, but exercise will. Come tell me how you're feeling at lunch. Bye!"

There are serious issues in camp, as I learned when an intractably homesick camper was picked up by her (at least verbally) abusive father. In the absence of abuse evidence we had to let her go with him and her totally cowed mother, but I regretted having to do it. I watched racial conflict play out before my eyes, between a white camp staffer and the family of a black camper who had acted out and was going to be sent home. As camp nurse it was my job to second the director in cases of campers or staff who needed to be disciplined; many discussions took place with me as observer. I was the second line of emotional support for staff as well. One quiet afternoon I was working at the Infirmary, Rimsky-Korsakov's "Scheherezade" on the stereo when the director came in, shut the door, and blurted, "Take my blood pressure; and turn down that music, it sounds way too much like my life right now."

Then there are the things you will learn nowhere else. Camp nurses learn to announce at the weekly dance, "Campers who insist on head-banging to 'Bohemian Rhapsody' will NOT receive Tylenol for headache after the dance!" then make a show of watching the campers dance for awhile. This should be continued at least until the first emergency sprain draws you away. In anticipation of minor emergencies, I found that a military surplus medic's pack makes a fine nurse kit, if stocked with band-aids, thermometer, adhesive tape, ace wrap, bandage scissors, and so on. I also figured out how to sweet-talk the grounds keeper into handing out replacement shower curtains, a thing he was inexplicably reluctant to do.

The camp nurse is relied on for advice on all things medical. Utter annoyance compelled me to tell staff at a week's end meeting not to hover over the girls so much. The campers in question, aged 11-13, had been doing glass art all week and a few of them had suffered minor cuts. Staff was concerned that the activity was too risky; should staff handle the glass for campers to prevent future lacerations? Having observed activity in the craft house, it seemed a controlled risk to me and I said so. "When DO we let the girls take risks, if not here under supervision? Let's empower them to get cut occasionally, if that's what it takes to help them explore new things."

Bear in mind that camp life is not quite real compared with everyday standards and those who survive it get a sense of proportion and humor right quick. I didn't have a sense of humor when I started out, but I began to develop one after my friend Maureen insisted I participate in Costume Night. She fixed me up with an over-sized, deflated, mylar fish balloon (in shocking pink) which she affixed to dangle from my bandaged forearm...and called me a shark bite victim.

Camp life can also be a grind—long stretches of wet weather or heat bring on health problems and snappish tempers. Even in good weather, mental health among campers and staff can go awry, and since our reason for being there is all about girls under the age of 18, staffers need a firm grip on themselves. Everyday camp survival for me involved carrying a travel mug, learning the hours at which dining hall coffee would be fresh, and cultivating what I considered a MASH-casual look. T-shirt, shorts, stethoscope, and a pink name badge. Regardless of the badge, someone jestingly called me "Nursie" and it stuck like super glue. In the end I resigned myself to being called Nursie and gamely answered the phone in my cabin, "Infirmary, Nursie here." Whatever you’re doing at camp, you just can’t be too careful; one morning I entered the bathroom to find gigantic cockroaches climbing the mirror. They were no less horrific for being plastic! Another morning I was arrested by the Fashion Police and cited for passing meds in my unfashionable bedroom slippers. So much for the dignity of the adult.

Somehow, I enjoyed the unpredictable quirkiness of camp nursing. Girls who started out as strangers and argued over caper duties all week became the closest of friends by the end of Friday night campfire. Over time I watched girls grow into young ladies; I was amused at their squabbles, and touched by the way they'd come to the Infirmary in a noisy, untidy flock, bringing an injured or ailing friend and watch over my shoulder with terrible concern as I went about the examination. I wasn't so much treating a camper as treating the lot of them and educating them as I went. We had many daft-but-serious talks at evening meds and treatment time. Life is never so glorious or so crisis-filled as it is for teen aged girls who feel they are among friends. For obvious reasons, camp nursing is not for the faint of heart, but in many ways it’s the opportunity of a lifetime.

Tuesday, August 24, 2010

Encore Nurse - September 2009

Trust me, you don't want to know how long ago I left nursing, or how little I have missed it since then...

I had grown to despise the shifts and rotation, the post night-shift dead feeling, and never knowing whether my relief would come in at the end of my shift.  I was not unhappy to bid acute care nursing farewell and enter home health care, and then toss the whole thing over when the children came along. 

Mostly the problem was about me; I had a lively family of three children and an overgrown toddler at home, a husband who was also frequently out of town on short notice, and no reliable babysitter.  On going back to nursing at the height of the AIDS epidemic in 1988, I found things changed but essentially the same; more IVACs, higher patient acuities, more responsibility, and little support for nursing.  I had plenty of that back at home!  My then-husband *loved* the idea of a two-income family and made a case for me staying in nursing.  However, he did not make himself useful in family management, so his grand vision for me, in practice, meant I’d have two full-time jobs: nursing and family management.  This was often reflected in his attitudes about work; his work was Serious Business and nothing took priority over it; my job was Just A Little Pin Money and was something to be disparaged when my shift fell at an inconvenient time.  Seeing all this, I was determined to work for awhile and then get out again, and I did. 

Some things are worth waiting for, I guess.  I was surprised to find I have interests and experience that are of value in the world of nursing after all this time.  Of course I'm going on the word of a BSN and an MSN, but I'm taking their opinions as authoritative. 

At the center where regional nurses go for continuing education, their interview centered around my past experience as an RN and my current computer savvy, which I had thought pretty marginal until I told them about my experience.  No, I'm not afraid of computers, I can do email, have a Facebook account, and in general can run the Microsoft Office suite.  How did I learn this?  Try running a small business without them!  I completed a course on Computers for Educators as part of my Education degree.  Did I mention having lived in a house where we had 1.2 computers per person?  Computer literacy, check.

I've always considered my lack of BSN a liability; I never especially wanted to study for one, but I did want to explore areas of practice beyond patient care in a hospital or nursing home, and back in the day nurses needed a BSN to do that.  I explored motherhood instead, then small business, then college; the next thing I knew I'd been out of nursing school for 30 years and in my absence they'd moved all the furniture.  Today I see things like holistic approaches to nursing, healing touch, magnet hospitals, a “culture of safety,” and spiritual dimensions of care, that remind me of why I went into nursing to begin with.  Maybe there's a place for me here after all, I mused.

The re-entry process for RN's is not simple.  We are required to study and pass exams on 24 modules of material involving all aspects of nursing.  Then we have a choice of independent study or classes on physical assessment, IV therapy, central venous lines, and delegating patient care.  In addition, we need a physical exam, criminal background check,  updated immunizations, and malpractice insurance, all before we can begin 160 hours of clinical practice.  A person couldn't do all that in a hurry if she wanted to; so I've entered the process.  I'm going to let it flow and go with it to its end.

Five years ago I was afraid I was too old to re-enter nursing, but now I'm returning to a workforce composed of a significant number of "gray-hairs", the experienced people like me with gray hair.  The average age among RN's in my state is 46.4 years, which means returning to work ought to be like a nursing school reunion.  I remember it all, right down to the glass IV bottles and metal bedpans; when discharge planning meant calling a cab to take the patient home with extra dressings, 10 days post-cholecystectomy; and our "gray-hairs" then could tell you how (and why!) to administer a turpentine stupe.  I hope this leg of the journey proves as interesting.

Tuesday, August 10, 2010

Graduate Nurse, 1973

Thinking back...

There was no shortage of graduate nurse positions when I graduated. I was hired without fanfare to work in the rehabilitation unit at a large teaching hospital at the munificent rate of $4.11/hr. Orientation, such as it was, lasted two weeks and centered around hospital issues such as how to charge a patient for use of equipment. The white nurse's cap with its black-velvet ribbon declared you an RN to one and all. Add to this a crisp white uniform and a four-color ballpoint pen, and you were ready for duty.

All nurses wore dress uniforms (no pantsuits allowed) with white hose and shoes; if we weren't clean and tidy, we heard about it immediately from the supervisor. One thing every nurse had in her work locker was hairpins; no nurse could go onto the floor to work without her cap pinned snugly in place. I was taught to pin a folded kleenex to the top of my head with crossed bobby pins to anchor the heavy cap, which was then also pinned behind.

Graduate nurses wore caps with a school-designated ribbon (not black), and were required to sign themselves Jane Doe, GN, and were supervised by an RN until they passed state boards. We spoke in a hush about what might happen to one who failed state boards, but as I recall all my cohort passed on the first try. The board exam prep we got must have been good; I ranked in the 99th percentile on the boards and still use their test-taking techniques today.

After passing the state board I dribbled a narrow bead of KY jelly along the back of my new black velvet band and affixed it to my nurse's cap with cap-tacks. I think my pay went to $4.23/hr. Eventually I transferred to a medical-surgical floor. The work was difficult, repetitive, and there was little nurse autonomy. We did team nursing, with the RN as med-passer and overseer for LPN's and Aides who gave care to a group of 8-12 patients. In practice it was a difficult juggling act to pass meds on time, keep the IV's running on time, check patients for critical changes, call doctors for orders, and take care of smaller details. Sometimes patients waited for hours for a meal tray or equipment.

IV fluids came in glass bottles with a straw inside to vent; venous access was made via metal needle with two wings called a butterfly. More often than not the patient's movements spoiled the site by puncturing the vein or producing a localized phlebitis. There were several kinds of IV tubing, with three different drop rates, which we calculated by hands. The Buretrol, a rigid plastic chamber which one could use to infuse a controlled dose of meds/fluids, slowly moved from pediatrics to the med-surg floors where it was considered high tech. IV's were regulated by roller clamp and counting drops timed with your wristwatch. Not a shift went by when all the IV's infused according to Dr's orders.

All medical equipment came from Central Supply. Most of it was reusable stainless steel, thus the reputation for cold bedpans. A bedpan thrown to the floor had served as an emergency signal for help in the era immediately preceding mine. Those high, bulky, bedpans were hard to get onto and off of, and the very devil if your patient was helpless or had back/hip pain. They could be emptied in the patient's toilet but had to be taken down the hall to be cleaned in the bedpan washer; thus the necessity for a small linen bedpan cover. A lower, scoop-shaped fracture pan was standard issue only on the orthopedic ward. Like everything else, you could requisition one via pneumatic tube to Central Supply and after a time it would be sent up on the dumb-waiter.

Most pliable medical equipment was made of rubber; gloves (sterile only), suction catheters, and tubing (except IV). Kits for procedures, such as lumbar puncture and chest tube insertion, were made of durable equipment wrapped, sterilized, and sent to us from CS. The only things we didn't return to be re-sterilized were needles, which were all disposable. No sharps boxes in patient rooms, though. No Hazardous Waste bags, either; anything especially nasty was double-bagged and went with the usual trash.

Kardexes were done by hand in pencil, and changed as orders or patient needs changed. A long-term patient could be identified by his grey-smudged Kardex. There was no such thing as "nursing orders" so literally anything you wanted to do for the patient, for whatever reason, required a Dr's order. Standing orders were few; we called the docs for just about everything.

Narcotics were counted...endlessly counted...dozens of sleeping pills, pain pills, and injectables had to be counted at the start and finish of every shift. The outgoing nurse couldn't go home until the count was right, or the discrepancy reported and written up. We carried the keys to the narcotics cabinet (another sign of a full RN) and occasionally were called back to work for having carried them home in a pocket.

Each and every medication had its own 2"x3" med card, listing patient name, start/stop date, drug name, dose, and time of administration. Usually they were legible. We were required to check med cards against the Kardex at the start of every shift for accuracy and order changes, which meant we began every shift behind time. Nurses with strong visual perceptual skills were deemed "good" nurses because they were quick to identify transcription errors and they worked fast. Fast was good.

Meds were supplied as patient bulk, floor stock, and emergency types. It was a rare shift when all the med cards were accurate and the patient's meds were in his box; calls to docs to clarify orders, and to pharmacy for missing meds were frequent. There was no med administration record, and much was left to hopeful memory. With all the "holes" in this system, med errors were all too frequent.

Patient charts were all paper, bulky, and the purview of doctors, except for the Nurses' Notes section. We were expected to note all the features of a patient's day in ink, without spelling error or time discrepancy. Day shift wrote in blue ink, 3-11 in green, nights in red. If an error was made, we lined through it just once and wrote above it "error" and a signature. About this time, lawyers popularized a way to impeach the testimony of a nurse under litigation, out of which was born the phrase, "If you didn't chart it, you didn't do it." We did our work under terrible constraints of time and staffing...and prayed. After a year on the job, I developed a case of irritable bowel syndrome that still flares up occasionally today. After six years in nursing, I was downright grateful to stay at home with my firstborn, and I never really wanted to go back to it after that.

Monday, August 9, 2010

Future Nurse 1965

Nursing seems to be one of the strongest threads of  my life.  As a child growing up in the 1960's, I can't recall a time when I didn't tell people, "I'm going to be a nurse when I grow up."

I had a great curiosity about all animals and medicine.  The library held a fascinating training manual for Practical Nurses with graphic pictures of equipment and describing the proper procedure for such things as the Harris Flush, which I tried on my dolls. My favorite reading at the time involved stories of children with cerebral palsy and leukemia (Mine for Keeps, Karen, The Blood of the Lamb)  It never occurred to me, as it did to my squeamish friend Liz, that I might one day be afflicted so I kept on reading.

I found that adults were a good source of ersatz medical equipment, but a poor source of information on things medical.  Mother counted among the ultra-squeamish and except for the Family Home Medical Adviser she kept, which had beautiful color plates of internal organs, she was not helpful.  I once asked my grandmother, as she explained that the neighbor had died by heart attack, "What happens when you have a heart attack?"  "You clutch your chest and fall down," she answered. I put the question in another way; no luck.  In other words, I thought, you don't know what happens inside the body when a person has a heart attack.  I thought this a great loss of what promised to be some thrilling information.

Like most children, I bandaged the dog and had a doll hospital.  I read every student nurse book series available; Sue Barton was my favorite.  One solitary afternoon I occupied myself by fashioning a pair of leg braces and crutches for my doll, Mary Van Heusen.  My fascination spread to the other neighborhood girls, who joined me in reading the PN manual and setting up an isolation room for another of my hapless dolls.  For a time I thought we would all go to nursing school but I was the only one who actually did.

I was a dedicated candy striper, a creature rarely seen now, in a large teaching hospital run by Grey Nuns. Wearing a carefully ironed pinafore and blouse and shod in white nurse shoes, I felt ready for anything.  I had a history with this hospital, having been born there and back again at age 5 to have my tonsils out.  Each unit had its own atmosphere, and some like the Burn Unit and the Newborn Nursery had a distinct smell. I stocked whistle-tip rubber suction catheters for the Burn Unit, made identification cards (the size of old-fashioned charge cards) in Admitting, pushed dozens of wheelchair patients, and sorted computer keypunch cards in the Lab.  I explored every bit of the hospital's eight floors, including the tunnel to the nursing school and the chapel.  I loved that the sisters created beauty (albeit with religious theme) in every corner of the hospital.  Those experiences allowed me to see a wider world, but I also saw how woefully inexperienced and prepared I was--for anything.

Nothing else seemed to hold my interest, or feel like a real career the way nursing did.  Still, it was my mother who found a nursing school for me.  Ever a "C" student, I assumed that my grades were too poor to get me into the nursing school of my choice.  After high school graduation, decades of clerking at the department store yawned before me; I slept late and made no moves.  Mother awoke me one morning with the announcement that she'd had a lovely conversation with the dean of nursing at a local community college.  You know what it means when your mother says that; the adults are in league against you.  Their ADN program was still taking students for its first class starting in the fall, she enthused.  At that point I wasn't sure I wanted to go to nursing school; I was scared and lacked confidence.  Without so much as a cup of coffee under me, Mother propelled me toward the phone; before I could protest I had an appointment to meet with the dean and take the ACT.  After I passed the ACT, there sat a brand-new nurses' cap on the sideboard in the dining room, and it looked like I was going to be joining the ranks of Sue Barton after all.