No News is Good News

I have been absent for more than a year while the office was under construction, but I have not forgotten my BlogFriends!  It is good to be back. 

I am now in a new phase of nursing, having attained the exquisitely harrowing position of RN Case Manager.  I manage up to 30 patients at a time, usually working with a Bluetooth and WiFi from the front seat of our trusty Dodge.  So far the only drawback has been occasional loneliness, but then the patient mix changes and suddenly there are more in-town patients.  Who has a chance to get lonely when there are only 10 road minutes between visits?  I have Mr Prattle this month, too, and my ears are bent flat to my head when I come out of there.  (I didn't think anyone could babble nonstop for an hour like that.)  Meanwhile, back at the office we have new students, which I love. 

The summer so far has been hot, humid, and very wet; I count myself fortunate that I have not yet driven into a sinkhole or been covered by a landslide.  The rain has been good for the garden, but on the other side of the house we are growing a crop of kamikaze bamboo which threatens to grow thick and wide enough to enshroud the entire house. On my days off I am losing the Bamboo Battle...or perhaps I am just bamboozled.

O Brother, Where Goest Thou?

Have you ever assessed a patient, weighing in your mind the number of  co-morbidities present and their severity, and realized with a jolt that if things don't change right sharpish, your patient will be a former patient?

On a Christmas weekend many years ago, I stood by  Eric's hospital bed.  He liked his room dark, lit with only a nightlight after 11pm so I did not snap on the overhead light.  That night the room was suffused with a glow from a miniature Christmas tree hung with tiny packages and ribbons.  From beneath a plaid blanket brought from home, Eric watched me approach with several syringes and alcohol wipes.  Where once we had joked and talked about his tv programs, tonight he managed only a wan smile of recognition.  

Eric was no older than 30; he had once had a profession but gave it up as the illness made simply getting out of bed an ordeal.  He had an intestinal condition...nausea & vomiting...weight loss...inability to gain a meaningful amount of weight...intractable pain...and insomnia.  His diagnosis didn't seem (to me or anyone else) sufficiently grave to cause a young person to waste away before our eyes.   

This condition waxed and waned over the course of five years.  He was hospitalized when the pain became too much to bear or he was unable to keep down any food.  Once he came in with a brisk GI bleed and passed frank blood for days.  Each time he was discharged he recovered, but never fully; then would come a relapse.  

He was not a favorite Frequent Flier.  Some of the staff disliked his continual demands for narcotic pain meds, coupled with whatever anti-nausea drug and sedative the doctors ordered, as often as he could get it.  He was a timekeeper, knew exactly when the stuff was due.  It was seldom enough to allow him a full night's sleep or full relief from pain and nausea. 

As my eyes adjusted to the low light this Christmas night, he threw back the coverlet, revealing a shockingly emaciated body.  I came to an abrupt and horrifying reality; he was back again, no improvement, back on mega narcotics, still insomniac, no definitive diagnosis.  Where are you going with this? I asked myself.  I have learned since to be wary of the question.  
 
To be privy to the end of human life, whenever it presents itself, is a burden and an honor. Most of the patients know their time is short.  Yet some people go along with the flow of their disease process without understanding what is going on or how serious their illness has become.  Think of COPD patients who leave the hospital and continue smoking, or diabetics with every -opathy possible who will not control their diets, check blood glucose only "when they think of it", and take their meds the same way. 

Silly of me to talk as if attention to regimen is the whole answer.  No one gets out of here alive, someone observed.  So it's true we are all on the same road to what we hope will be a good death in the end.  It is my hope for those I care for that they will become co-creators in their good death, not one day stunned to find themselves in line at the pearly gates.  

The discussion that follows the question, "Where are you going with this?" is not a comfortable one, which is why there are palliative care teams and hospices to guide the process.  Understanding that recovery is not possible allows room for other kinds of care just as important as vigorous treatment.  We got a note of thanks from the family of a patient who had gone to hospice.  The family had difficulty facing The Discussion, which they had to do in their parent's stead; dementia had left the parent sweetly senile.  The parent is at home under hospice care now, with less medical intervention (fewer needle sticks) and surrounded by loving family & staff.  Sometimes the hardest thing to do is the best for the patient.

We are not always talking about the end of life; we often need to teach cause-and-effect of a patient's condition and encourage him to take positive measures to keep whatever function he still has.  Some patients will take your information as gospel and they will recite it back to you with full compliance by the third visit.  Some only get it when they have had another  exacerbation...or three...or six.  
 
As a nurse develops a "spidey-sense" when things are not right, I hope the other sense is also allowed growing room, so that when a nurse sees signs of denial or end-of-life they are not afraid to begin the conversation.   I wish I had understood enough to sit down and talk with Eric that Christmas, for he was dead by the end of January.  "Where are you going with this?" may be one of the most important conversations your patient will ever have.

 

Thank you, Helen

I was at breakfast recently with Big Sweetie who was going on about people at the soup kitchen whose behavior is utterly annoying, and one in particular whose tolerance level is somewhere in the negative digits.  Sweetie was working himself up into a proper fit of indignation.  I fixed him with a critical stare and said, "Sounds like somebody needs to learn when to say 'Thank you, Helen.'"  Big Sweetie paused, then swiped half of my biscuit, lathered it with blackberry jam, and bit.  

While his mouth was full, I launched into a story.

Several millennia ago I was in nursing school.  We were the first graduating class in this particular school, and for our second year they added new instructors to the faculty, including Mrs. Willis who was to teach us psychiatric nursing.  She was an odd duck from the start; everyone agreed to this.  She was short and skinny with a pointy nose, cropped dark hair, and black-framed glasses that today would spell "geek".  She genuinely liked psych nursing.  She also had a way of evading questions that put the Gotta-Have-an-A students in a panic.  

Our class was nothing if not diverse.  There were among us women who were grandmothers, mothers, young marrieds, one just-out-of-high-school, and four men.  Adult students take college more seriously than do young people; add to that faculty who were learning to work together and an untried curriculum and you have more variables than an established nursing school presents.  It proved to be a learning experience for all.  

In those pre-NCLEX days, my adult classmates developed the habit of arguing every ambiguous answer.  One memorable test question involved a patient with hyponatremia, a term our instructors had not used, speaking instead of "low blood sodium."  I read the question, thought Na = sodium, so natremia must mean sodium in the blood, and answered the question accordingly.  (I think I answered wrong.)  The more vocal students ate up a good deal of class time protesting the test question because it used a term we had not been taught.  Ambiguous test questions like that one were thrown out with startling regularity.  

By the second year the faculty were not so easily argued down.

We waded through OB, successfully as it turned out, but we still had to pass psych in order to graduate.  Few of us looked forward to psych rotation, and the mental hospital where we were to be students looked like the set of One Flew Over the Cuckoo's Nest, which put us all on edge.  

In the classroom, Mrs Willis' lectures on psychiatric nursing further horrified us with talk of electroconvulsive therapy, masturbating patients, and four-point leather restraints.  Her peculiar sense of humor and often cryptic answers should have warned us.  I was not the only one counting the minutes until we could escape the whole psych nursing experience.  Mrs Willis finally finished lecturing; she grinned fiendishly when the A's asked her what to study for the test.  And then there was a memorable test.

38.  "Helen, a patient on the psychiatric unit, approaches you and hands you a shoe; the shoe is filled with feces.  Your response should be:

A. There is poop in this shoe, and it's unsanitary.  Did you wash your hands?

B. Tell me what this means, Helen.  Why are you giving this to me?

C. I am going to report you to the doctor.  Maybe you need a change of medication.

D. Thank you, Helen.

Imagine the furor in class as we corrected those questions!  Few of us answered correctly; I think I went for answer A.  The correct answer, Mrs Willis insisted, was D. Thank you, Helen.  Several A students gasped; the class all but collectively fainted.  We were still talking about it at year's end.  During the faculty roast we wished her a hearty handshake from a masturbating patient, and a shoe filled with shit.  She seemed pleased by our tribute.

Big Sweetie put down a rasher of bacon.  "You mean to tell me the correct answer really was supposed to be, Thank you, Helen?"  I assured him it was so. He shook his head.  

I continued, "You know, the more I work with people who are crazy or addicted or half-dead the more I learn about people who are not on the same leg of the journey as I am.  It seems to me the only thing we can say to some people is a simple acknowledgement that we don't get each other, but we're still cool. Thanks, Mrs Willis, for the insight.

In memoriam Mrs. Willis, wherever you are.  May your shoe be always full.

Lunchtime

It was past noon and I was driving like a native; that is, more or less down the middle of  a two-lane road, in a hurry to get down the mountain and on to my next patient.   I was also hungry; the hot tea and banana I'd had upon leaving the office had completely worn off.  After several unsuccessful attempts to fetch my lunch box, I lost patience with it.  "For heaven's sake!" I snarled as I pulled over and snared the insulated box from the passenger side floor.  

I was pleased to see Big Sweetie had packed me a piece of leftover pizza, some apricot-pecan cake, a yogurt cup, and cold water in a non-BPA bottle.  With no traffic in sight, I was free to savor this little meal by the roadside.  Nearby ox-eye daisies nodded in the breeze and I could see the jacaranda flowers were just about spent.  A bluegrass tune floated out of my CD player, ancient as the place where I stood.  

At the end of nursing school I was voted "Best at Carrying Her Lunch" which, being poor but always hungry, I did with some regularity.  This amused my wealthier classmates no end and I let them have their little joke because I wasn't about to go hungry just to impress them.  I had no idea it would prove good training for the future.  

Then I poured myself another cup of tea, checked my GPS, and pushed on, still chewing on remains of the cake.  Time and tide...and patients...wait for no man.

Peace and Quiet

Sunday is my favorite day to work.  Sunday is usually a quiet day with a lighter patient load.  I enjoy meeting visiting family members and everyone seems more relaxed.  The radio plays hours of Celtic-Blue Grass music as I drive back roads mercifully free of excess traffic.  In general, patients scheduled for a Sunday really have a need to be seen and it's always nice to be needed.    Today even the weather cooperated to put me in a cheery frame of mind.

Often clients ask me about my weekend work, as if it might be a terrible burden or something.  One recent client  remarked at length how pleased she was that a nurse had been able to visit on a Sunday.  "You don't have to work every Sunday, do you?" she asked.  "I work the weekend," I replied, "unless I'm on vacation.".  Her eyes flew open and she exclaimed, "Oh my!  Why do you do that?"  I smiled.

"You remember the old Star Trek movies?  The one where Commander Uhura says," (I put on my best no-nonsense Uhura look and continued)  'Peace and  quiet appeals to me, Lieutenant.'"

http://www.youtube.com/watch?v=_k9Ukm9LaWg

watch for it at 1:38  Happy Sunday!

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.