Fearfully and Wonderfully Made

I was driving the back roads this morning playing The Chieftains Christmas CD, "Bells of Dublin."  (Browse here to hear their fine fiddling and piping.)  "The Bells of Dublin" gladdens the heart on a dreary December day; I truly look forward to hearing it each year. By the time I reached Heart Man's house, I was in an excellent mood and whistling an Irish tune. 

Maybe you have this conversation with your patients; the one that begins, "As we age..." and concludes with trying to get the patient to make some sensible accommodations for having grown old and frail.  Heart Man is  physically frail, but his faith has never been in better health.  He sees God in almost all persons and places.  I suspect he makes daily, even hourly, contact with the spiritually numinous; the thin places where we come close to God.  His spirit is lively and faith makes him unafraid of death.  Yet, he has a hard time living with the limitations of his body.  

How soon can I plan on going one last time to Europe?  he asks.  "Can you walk upstairs without needing oxygen?" I ask gently.  Then I review the rigors of air travel.  "Do you think you could do that without getting totally exhausted?"  Of course the answer is no; but he did so hope to go just once more. 

I have another patient, recently diagnosed with elevated triglycerides, stroke, and new hypertension, whose life and diet have suddenly, radically, changed.  It was easy for Trig Lady to maintain a heart-healthy diet when it was served from Dietary three times a day, but now that she's home she wonders what to cook, because she never was much of a cook when it came to vegetables.  And, what should she do with 8 pounds of bacon and sausage she has stored in the freezer?

Do I really have hypertension now, Trig Lady asks; I've always had a low blood pressure before. So should  I really give up the bacon?  I haven't had any for a whole week...so I shouldn't worry about eating healthy anymore.  Right?

Before this begins to read like an NCLEX test question, I should  tell you the most merciful answer is the swift and terrible one, couched as a question if possible.  To Trig Lady I said,

"With your condition/on your diet/to lower your cholesterol, you have to limit saturated fats.  That means choosing foods that give you good nutrition and less fat.  Bacon has three things you don't need/want: sat fat, sodium, and nitrates.  It doesn't have much food value (protein, vitamins) beyond that.  What breakfast foods could you eat that have good nutrition and less fat than bacon?"

Of course, even after your pep talk the patient may not do as you direct; she may talk herself into that bacon after all.  Imagine how she will go about replacing that high sat-fat with something better.  Make sure she has a plan for meals and a way to get the foods you suggest.  If that fails, you can always suggest to husband/daughter/friend that a freezer raid is in order.

It turns out Heart Man had only a vague understanding of how the circulatory system works, despite a history of  major cardiac deficits.  I learned this as I was covering normal body circulation and how cardiac deficit impairs it.

"...then the left ventricle squeezes the blood out the aorta and sends it to the whole (peripheral) body," I said, wiggling my fingers and shaking a leg to demonstrate.  Seeing his wondering face, I concluded, "It really is just like the Psalmist says, we are fearfully and wonderfully made."  

The patient gazed at me and then lit up with a smile.  "Imagine all that!" he said.  "I had no idea...to think that's how God made us.  All those blood vessels.  Praise the Lord!"   I tell you, we were having church right there in the living room.

I found myself wishing someone could make travel possible for him, all the while knowing it was a forlorn hope.  On the Prayer Team at church we learn it is our place to ask for healing in body, mind, and spirit; the rest is up to God.  Whatever God chooses, I suspect Heart Man's praise will be unceasing. Let mine be, also.

Cupcake Walking?

"...and they asked her how she liked doing Home Care and she said, 'It's a cupcake walk!'"  The Super shook her head and asked me,  "Now that you've been out there for awhile, do you agree with her?  Is Home Care a 'cupcake walk'?"

I cast my mind back over dozens of visits, the parade of faces passing in review; Mr Train Wreck, Kitty Man, Lung Lady, the Edema Twins, and their kind, concerned, families and friends.  "A cupcake walk?" I said, "Not hardly!  I don't know where or how she was practicing, but is sure wasn't here and now."

Home Health is nursing for sole proprietors-at-heart, requiring a sort of entrepreneurial spirit and a love of the open road coupled with nerves of steel and a head for infinite detail.  Add to that tolerance for reams of government paperwork and scheduling.  Bring with you a fondness for human quirks and a self-assurance that you know your patients, nursing-wise, better than anyone but God.  There you have a Home Health Nurse.

Personally, Home Health Nursing puts a smile on my face that I seldom had in Hospital Nursing.  Just being able to talk with my patients, to establish a relationship with some of them, help solve their problems, figure out where their learning deficits are and teach to the gaps in medical information, nurtures me in return.  Hospital Nursing is far more high-tech and treatment oriented, because they see medically unstable patients.  No one pays for a patient to lie in hospital unless something pretty technical is being done for him.  So, hospital nurses spend their time executing orders for Medication and Treatment in a timely manner; review plan of care, meds, labs, and imaging; manage acute problems, and chart it all accurately.   Add to that at least one patient to be admitted or discharged (another blizzard of orders) per shift, and you're lucky to get a lunch.   There is less time to talk and teach in a hospital setting.  Sometimes it's difficult even to get a bathroom break.  Maybe the Hospital Nurse of the Year is able to accomplish both technical care and talking/teaching, but the rest of us are only human.

Do not imagine--for one moment--that Home Health Nursing goes at a slower, healthier pace; it does not.  Home Health Nurses do everything Hospital Nurses do, only their patients are (at least somewhat) stable and scattered across the community.  My bulky bag is the modern equivalent of the one carried by fictional character Sue Barton, who remarked on the weight of the heavy black bag on her arm marking her as a nurse among the Henry Street patients.  My car has become my supply room.  I chart with government requirements always at the back of my mind.  I set up and change the visit schedule as necessary.   Whatever the patient needs, if I don't do it/ask for it/order it, the patient goes without.

As friend Little Mary says, "God is in the details."  If you enjoy independence, glory in nature, and have a desire to walk with patients/families through difficult times, you're going to do just fine.  That's the beauty of Home Health.

Movin' On, Movin' Back

Have I ever talked to y'all about home care nursing?  

I have done a boatload of it.  AIDS patients, IV antibiotics, TPN, dressing changes; I've done them all.  The problem was, I could never make any real money at it.   Back in the day, the only ones with steady employment were the case managers.  

I finally left field work and went into education full-time, but I have always enjoyed being on the road, making creative work of patient care.  

Home care is another breed of cat, and the first thing you notice is this: the balance of authority is different when you are on the patient's turf, instead of him being on yours.   The down side of that is, you become more a partner in wellness and less a director.  Some nurses hate that aspect of it; they also hate the travel, dislike going into strange environments, and are easily frightened by anything out of the way.  

The things I dislike about hospital nursing have to do with the lack of those stimulants!  Lord knows there is plenty to stimulate you on a given hospital shift, but seldom do the stimulants have to do with pleasant surprises.  So, when I was offered a job doing regular home care I thought it was too good to be true.

Now I'm down to the last night of 11-7.  I love the people I work with on nights; they are The Best.   We've shared some truly awesome moments.  They have helped me grow and learn to be a better nurse than I ever was before.   I can only hope to find their equal over in Home Care, but I doubt if I'm going to try.  Some things are irreplaceable.  


So, to Blondie, Mr. Somber, New Kid, and all the rest, farewell but not good bye forever.  I will miss you all.

The Year of Change

Do you ever wonder when things are going to go back to "normal," whatever you conceive that to be?  Me, too.  I thought when the threat of snow was past, things would return to Normal.  Then we had the longest hottest summer in years.  That should have taught me.  We managed to put in furnace/whole house air this year, approximately one week ahead of extreme summer heat.  Talk about cutting it close!

My youngest kid got married in May.  You know what a shambles that makes of your carefully planned routine.  It was a beautiful wedding, though.  Gave me an excuse to buy one of those snazzy imported beaded blouses.  I wrote an Irish-Scottish Blessing for the occasion and had the nerve to deliver it by way of a toast at the reception.  The bride went off in a cloud of tulle and ruching and I thought, what are we going to do for excitement now?  

I assumed things would return to Normal.  (You can see this one coming, can't you?)  What are we going to do, indeed.  Three things happened almost at once; the newlywed kid packed up hubby & household for Florida, Son's wife came down pregnant, and then the Middle Kid followed suit a month later.  "It's hardly fair" Middle Kid said, "We've only been trying for a month and I only took the pregnancy test because I was going out to eat sashimi."  Evidently the savvy Mom-to-be does not eat raw fish.  I don't think I'd know enough to be pregnant these days!  So we're coming up newlyweds and babies this year.  And that's just for starters.  

Truly, it seems that everybody I know has had a crisis or undergone some sort of change since January 1.  Every month a new thing pops up.  The Sainted Rector is retiring and the parish is somewhat agog.  A few friends' family members have died, and we're all going to miss Steven Jobs.  Although I never expected to count the newlywed kid in that number, a few friends are on the move to distant cities where there is more work than one can find in the frozen upper Midwest.  More than a few got living wage jobs, which was a real surprise blessing.  

Congress gives every indication of needing its meds adjusted; and now thousands of passionate but peaceful citizens are occupying Wall Street.  I love it.

What, I wondered, could I possibly do for an encore?  Well, I finally got serious about changing departments and at long last I have a transfer to a department where I will work when it's both daylight and when most other people are awake.  That will be a novelty.  Not that I haven't enjoyed the night shift because I have, but one day recently my brain tapped me on the shoulder and said, "Yo, Mama!  This swinging from day-awake to night-awake every week has gotta stop.  You've abused the privilege."  That's how I knew it was time.  

The other thing I am doing is getting ready to go back to college for a BSN, which shouldn't be too difficult considering I have a BA already.  Don't you love the variety of RN-to-BSN programs there are now?  LPN-to-BSN, RN-to-BSN, RN-to-MSN, RN-with-a-BA-not-in-Nursing-to-BSN, the list goes on.  I'm just grateful to have found a junior college with manageable class schedules for the 4 classes I need to enter the BSN program.  From there onward it's all online, thank the Lord.

We heard last week that Son's baby will be a girl, and we're waiting for intelligence on Middle Kid's baby next month.  Although I'm knitting blankets, don't expect me to turn into a gushy Gramma in a sweatshirt adorned with baskets of kittens.  I'm the intelligence-stimulating-book-buying Grandmama. The Grandmama who wants grandchildren to reply, "yes, Ma'am."  And, I'm having no end of fun.

I hope y'all are having fun, too.

Bad Gut Weekend

We had a 3-for-one special on GI bleeders this weekend. This offer was extended to all of the unit, not just my section, so everyone could share in the fun.  All of the bleeders were morbidly obese and helpless in the face of bloody diarrhea; all of them fractious and feeling like hammered shit.  Naturally PRBC’s and fluids were running in rivers, and lab techs appeared almost hourly to draw another round of H&H. 

There was no CNA on duty of course (no CNA was to be had for love nor money) and so another RN partially filled the role.  Brainy as we are, an RN does not have the same skills as an experienced CNA.  Having an extra nurse made it possible to actually care for the people we charge the insurer for having cared for, and I was relieved that no one’s doctor chewed out the day staff because his patient’s weight or some such was not recorded.  That was nice.  However, think what replacing a CNA with an RN does to the budget then next time you hear a call for budget cuts. 

Add to that one out of control detox patient who appeared to have returned to baseline (cursing, leaping out of bed/falling down, unable to make sense of conversation) and you have the makings of a Full Moon Weekend. Except it wasn't a full moon, it was just a weekend.

Standing Up, Speaking Out

I know two things: first, we are made in God’s image and we break one another's hearts when we forget that.  Second, all that is needed for evil to succeed is for those who see it  to stand by and say nothing.

I do racial reconciliation work.  That alone classifies me as a bleeding-heart liberal.   So be it.  I do a small part of the reconciliation work by standing with brothers and sisters of color against racism and prejudice.  As a white woman, I do most of my racial reconciliation work with whites who, like me, live lives based on the many privileges we enjoy because we are white.  Not surprisingly, it's a whole lot easier to convince white people that racism hurts people of color than to lead them toward the knowledge that racism hurts whites, too.

I do another kind of work.  As a woman who lived for many years with systemic familial abuse within my marriage, I also help other women recognize abuse.   I learned that abuse happens in every level of society, even among the rich and privileged.  Many women are afraid within their most intimate relationship and unsafe in their own homes.  

That was me.  I began this work when my own situation fell apart and I was in shock.  On that day I resolved to find my way to the truth about our marriage and family that had always been covered up.  Once I found the truth I began to tell about it and I went on talking until people I knew lined up into two camps: those who believed me and wanted what was best for me, and those who wanted to shut me up and send me back to the abusive relationship.

I have a story to tell.  It doesn't matter what others think of it.   If I can help just one woman recognize an abusive situation and successfully stand against it, I will count a lifetime of work worthwhile.   

Because it turns out the kindest women among us, the empathetic ones who hold themselves responsible when they hurt the feelings of others, are often at high risk for abuse. Abused women are not always helpless women with few options in life, but they are often women who have stopped believing in themselves.  They internalize the denigrating messages they hear in their intimate relationships.   Funny how the root of the word  applies here, isn't it?  One sort of abuse is very much like another; understand one and you begin to understand them all.

As much as I would like to think otherwise, there are people who cannot see the image of God in others; who are intentionally hurtful; whose hurting intentionally goes on behind closed doors so nobody will see and call them to account.  It is easy to become an apologist for abusive people  because they are tormented souls.  It defies comprehension to learn that abusers want the comfort, but despise the comforter.  They can’t see a single thing except their own need!  Except of course when they snap out of it for a time and show something like kindness and compassion to others;  a kindness directed almost always toward someone who will be impressed by it and expect nothing in return.   

I recall the words of Mother Teresa, who said it is hardest to love those in your own family.  It’s certainly true.  But if you or someone you love simply can’t treat a spouse with kindness and empathy, if contempt is served up with your daily meals and you walk on eggs in your own marriage…it’s time for a hard look at what’s going on.  You could be participating in an abusive relationship.

Nobody belongs in that place; I don’t believe God requires it of us.  Incredible as it seems, getting out and moving on is not the worst thing that can happen.  Wasting a lifetime serving as the scapegoat for the sins and furies of a dysfunctional partner, is.  Allowing a partner to denigrate you before the children until all respect for you is gone, is.  Pretending as if your marriage and family life is normal, and expecting the children to pretend not to see what they plainly do see, is.  If you can't do another thing, at least try to stop doing that.

Whitey Tighties & Mairzy Doats

I knew it was going to be a hysterical shift when I arrived to find the supervisor at the desk, frantically phoning for a replacement day nurse.  Within minutes, the phone--which never seemed to stop--rang again.  I was asked to take an ER report on an incoming patient.  "I haven't even clocked in!" I protested mildly.  Then the call lights started in again, and they never quit, all night long.   

I caught the squeal on the new patient.  Thanks be to God, ER had done the H&P, the off-going nurse stayed long enough to get the admitting assessment, and the patient was alert. 

The rest of the night was a blur of blood vitals and on-the-fly computer charting.  At 0600 I realized we had not had a single Code Brown.  In fact, I had found three (THREE!) patients wearing clean undies.  The one patient who did move the bowels made it to the appropriate porcelain receptacle without incident.  For our unit, this was truly astonishing.

Three of them actually slept through much of the night, but wouldn't you know the other two made up for it in spades.  IV  Lasix at 2300 is not a thing designed to produce a good night's rest.  

 

The other problem with alert patients is they are difficult to distract when you have to do something unpleasant.  This morning's patient hates injections, which are ordered q12H,  but she has that all worked out.  When the needle begins to pinch, she sings "Mairzy Doats"...out loud!  She was delighted when I sang along;  my Grandmother was quite a fan of Mairzy Doats.  I know all the words.  End of Nasty Injection Time.

Don't you think we ought to adopt Mairzy Doats as the unit theme song?

Molly & Me

I'm still in the breaking-in phase of work at Li'l Old County General.  For me, that has included finding efficient ways to do patient care and chart it without running behind.  I've solved most of the task tracking and equipment issues by developing my own version of a flow sheet and carrying a basket with med administration items.  There is (almost always) a roll of my favorite adhesive tape in there.  I couldn't do nights without my trusty penlight.  People chuckle at my blue basket, but it works.  

Now I have the latest improvement; Molly the COW.  Our unit has numerous portable laptops on Stinger bases.  These allow you to wheel the computer wherever it's needed, raise it to stand and lower it to sit while typing, it has wireless computer interface, and some have an on-board barcode scanner.  It's bulky, but the Stinger has  grown on me, because I can take it with me and chart wherever I am throughout the shift.  I can look at the patient while I chart his assessment.  I don't have to log into a new computer every time I want to chart a note or pass a med.  I don't have to go back to the desk and hope my memory will recall which arm his IV was in, or what time he developed SOB.

So I've been using the Stinger and trying to work it into my nightly routine.  The offgoing nurse frequently offers me a stationary computer "so you won't have to use a laptop," an accommodation I've taken to declining.  The nurses find my behavior mystifying.  My night colleagues get a charge out of seeing me push this thing up & down the halls, while they are tied to the desk.  

One drawback developed the other night when I brought the Stinger into a patient room, and the patient said in obvious irritation, "What the hell is that thing?"  "This," I said in my most winning tone, "is Molly the COW.  She's a Computer On Wheels."  (I made up the name on the spot.)  The patient, an alert 80-something, was singularly unimpressed but the explanation seemed to settle him down, and he allowed Molly to scan his ID band for a morning med.  I'm thinking of decking her with seasonal flowers or big stickers, to see how patients respond.  Valentine hearts coming up soon?

I especially like bringing Molly into the room for admission assessments because I can face the patient while asking 1,000 personal health questions, and chart it on the spot.  Done!  I imagine that one day we'll have the same capability in a computer the size of a Blackberry, but for now I consider Molly my best girlfriend.

Wild Ride Weekend

There was no warning, really, that this weekend was going to be wild, unless you count the number of shifts that had gone smoothly and were *almost* boring of late.  Naturally, something had to give.  

It gave an hour into the shift when the patient threw me out of their room and called for a hospital administrator.   It's the first time I've been accused of giving anyone a snippy answer.  Guess they didn't like my looks.  Their behavior became so outlandish that I had no idea what they might do next.  It turned out to be nothing but a fit of pique.  So that was a ridiculous episode; a tempest in a teapot.  After half a dozen phone calls and a supervisor visit, we traded patients and things settled down.

The second night started out with a pair of undertakers wheeling out the shrouded body of a patient who had passed at the end of the previous shift.  The patient's nurse had come on at 7, so she caught the squeal* on that one, and was looking a bit subdued.  

The night was going well, despite my several ill patients.  One was comatose, with a lot of loose chest congestion and an intermittent cough.  Another's vitals deteriorated every time they dozed off.  A third, with distention and edema, had just finished 2 units PRBC's.  I rounded often and made sure equipment was at the bedside just in case.  Then I gave a few meds and talked with the nurse whose patient had died.  

"Didn't you hear?" she said.  "I must be the angel of death.  That's the second patient that's gone out on me in a week."  "Well, you know how these things run in cycles," I said.  

We haven't had any deaths, or even very sick patients,  since New Years.  Just now we have a preponderance of very ill patients.   One of the many charms of a medical unit.  

It was now near morning.  The floor was quiet, and at that hour you can hear every sound on the floor from anywhere on the unit.  Which is how I was able to clearly hear someone call out my name, in the kind of voice that tells you something is wrong.   It wasn't a medical emergency; death is not an emergency for those who anticipate it.  The patient was simply gone from this life.  

Believe it or not, as many dying patients as I've had, I had never had one die abruptly.  This was a shock to the system.  Another visit from the supervisor.  God bless my co-workers, who prepared the patient to be seen by family, and did it before I could get off the phone with everyone who needed to be called.  The ride that night went on until a second pair of undertakers, this time wearing dark suits and overcoats, wheeled the shrouded patient away.  

We consoled one another, and stories were recounted.   The oncoming nurse, one with long experience on the unit, said she had seen seen many cases of abrupt death.  Even the float nurse had a story to tell.  I came home and had a stiff drink, and slept fitfully.

I just knew the third night was going to be either a bloody bore or something else bizarre.  I put in a foley, assessed four patients, gave two meds and two prn's for pain and then we had a minor staffing crisis.  The patient we had been told was coming from the ER did not materialize, and now we were overstaffed.  You know what that does to the budget.

So I was floated to the telemetry unit, where I had never been before.  I don't do telemetry, but after meeting Frick & Frack, the Stepdown Boys, I'm ready to learn.  I took report, did a bed check, ate some lunch sitting down, and later had time for a cup of coffee before doing a nurse lab draw and am meds.  I was actually able to sit down and eat without having a chart in my lap and a keyboard in my face!  What a great night!

*British slang meaning to take the call for an emergency.

Post-Holiday Slump

I hate the Grey Days of January & February.  We've been slow at work, too; people have been placed on-call and called off every day for the past two weeks, as if the patients themselves wanted to avoid going out.  Then it began to snow and suddenly the ER filled up and we admitted three patients overnight.  I'll never understand human behavior when it comes to hospitals and snow.  Did everyone wait to have the PNA/UTI/pancreatitis so they could be in hospital while it snowed?

The last snowstorm dumped 10-12 inches on us and the county authority is complaining bitterly about the cost of scraping and sanding the roads.  It's sleeting again so here comes more road mess.


The one bright spot has been floating to Ortho, where I was welcomed.  I found someone had created a full set of patient care protocols, which made the night go more smoothly than expected.  I actually enjoyed myself, pushing a Stinger portable computer into patient rooms to pass meds and chart assessments.  Even though it got busy at 0500, it was still a manageable shift.  I gathered some ideas I will use when back on my own unit.  Comparing my Ortho experience to the other unit, I observed how much more random detail is required on medical.   It's a wonder we ever get anything done.  When I see how far medical has to go before patient care will proceed smoothly, I am daunted.