Friday, November 25, 2016

Say goodnight, Gracie.

Ladies and germs, I have worked my last shift at Sunnydale Hospital (Healthcare for the Hellmouth)(Fully-owned and operated subsidiary of Giganto Research and Education Corp., Inc., LLP).

I start a few days from now at a very posh and very private surgical center, doing pre-op and post-op stuff. It was time. It was, honestly, past time.

In the past couple of years, Kitty and Bethie and I have busted our asses to get and then maintain certification. Sunnydale just got magnet status. We've earned five stars from whatever group it is that rates patient care that way. We've earned gold medals from the folks who figure out how many patients you have die, or come back, or otherwise not do well. We have, with our coworkers, rocked it. Our unit is the highest-rated unit in the system, in terms of safety and success and patient satisfaction.

And in return, we got staff cuts. Bethie got accused by a crazy family of abusing a patient and was left to dry in the sun by Manglement; she spent two days on her own dealing with detectives and forensics teams and lawyers and so on without a peep from her bosses. And when Kitty and I went to those bosses on her behalf, we got promises and no action.

So, yeah. It was time.

In a way, my fourteen years at Sunnydale remind me a lot of my marriage: Erstwhile Hub and I had a number of really good years, but then he began a slow slide into insanity. That culminated in something so bad, so unforgivable, so weird, that I had to walk away.

I've spent the last two weeks wondering how on earth I'm going to say goodbye to all these people. The people at my work got me through a divorce and took care of me after Dr. Heron cut the roof of my mouth out and sent it to Pathology. I've been the funeral of a coworker--it was possible because nurses from all over the hospital came in on their days off and moved down the hall in a flying wedge that allowed all of us to pass on care for a couple of hours. I've been to funerals for husbands and wives and daughters and sons. I've also gotten birth announcements and wedding invitations and innumerable emails and Facebook messages from patients and coworkers, letting me share in tiny good and tiny bad things. I've cooked Thanksgiving feasts and had a couple of surprise birthday parties.

You hear a lot of businesses say, "Our employees are family," but in this case it's true. Above my immediate manager is nobody I'd piss on if they were on fire, but below that? Lidia and Carolita and Edgar and James and Lisa and all those other folks are my family.

James made the comment the other day that he and I are the longest relationship he's ever had. He was the one who looked up my NCLEX score to see if I'd passed, back on the third day of our internship together, because I was too afraid to.

I spent days and days going to every department in turn, repeatedly, and I'm sure I still missed people. I'll visit, sure, but it won't be the same. And we're all pals on Facebook, but it won't be the same. Saying goodbye was hard.

And saying goodbye to you guys won't be any easier.

I'm shutting down HN. Let's be honest: "Preop-and-PACU-Nurse" just doesn't have the ring that "Head Nurse" does. I've done brains for so long that the thought of switching to something else is a little scary. Maybe someday later I'll have more stories to tell, those about healthy people getting elective surgeries and my taking care of them for two hours. For now, though, this is a good break. It's a period at the end of a long, amazing, convoluted sentence that any Restoration author would be proud of.

Because you know what you did? You, the idiots who keep checking in on HN, did this:

You kept me sane during times that I had nothing left. You got me through working nights, through having cancer, through a nasty breakup, through periods of self-doubt that encompassed not only my work but my self.

You emailed me with questions and criticisms and reflections that made me think hard about my life and sometimes go back and edit things here.

You bought two enormously expensive therapeutic jaw-stretcher dealios for people who couldn't afford them, thus allowing any number of people (because the devices were sanitized and passed around) to be able to do things like brush their teeth and eat after cancer surgery.

You contributed a thousand dollars to the Oral Cancer Foundation, because you cared about what I'd been through.

And you all, because you were generous enough to let me siphon off money you'd donated for a friend in need, made it possible for my friends Kevin and Sarah to stay in their apartment during the last weeks of Kevin's life. You paid their rent and electricity bills, and because of that, Kevin got to watch one last episode of "Doctor Who" with Sarah before the brain tumor he had rendered him unconscious.

Most of all, though, you responded to what I wrote here and made it better. There were a lot of times I thought I was writing into a void, and you told me that wasn't the case. I've said a lot of stupid shit and been called on it, and once in a while I've said something here that seemed to resonate with people, and that's made me think that maybe the world is pretty cool after all.

The money was great, because it accomplished tangible things.

The love and support and feedback and sometimes outright rage has been infinitely more valuable.

Thank you for wasting time here. May your pumps always have full batteries and your ventriculostomies always be level.

Wednesday, November 23, 2016

Once upon a time, there was a nurse named

Carol. Or Marcie. Or Kristen. Or Justin. Or Brandon. Or John. Or Tita. Or Lidia. Or David. Or Aimee.

And that nurse taught me everything I ever needed to know about IV starts. Or dealing with difficult patients. Or dealing with difficult coworkers. Or handling death. Or handling survival. Or just surviving a shift.

Once upon a time, there was a unit secretary named Harriet. Or Girlie. Or Mary. Or Joanna. Or Marlene.

And that unit secretary taught me everything I know about finding the answers to tricky problems. Or about who to call when something breaks. Or about who to call when nobody else can fix something. Or about how to MacGyver something when nobody's around.

Once upon a time, there was a housekeeper named Shirley. Or Larry. Or Lisa. Or Gary. Or Richard. Or Daphne.

And they taught me how to put the bag into the trashcan so it didn't fall down halfway through the shift. And how to get that weird stain out of my patient's pajamas, and who to call when I needed a lightbulb, and how to fix the drain in 18 when it just would not drain.

Once upon a time there was a biomed guy, or a maintenance guy, or a woman from food service, or some person from the concierge.

And even if I didn't get their name at the time, they taught me how to avert disaster by either rebooting some monitor somewhere by doing some obscure Ancient Technology dance, or they helped me manage somebody's diet when they were about to order out for KFC, or they brought me the paper some family member was yelling for with a minute's warning.

Once upon a time there were patients: sick people, or people who only had one thing wrong with them, or people who were just plain old, or people who were far, far too young to deal with the things that they had to deal with.

And they taught me about being decent, and patient, and having humor even when you look like a goblin and things fucking suck, and loving yellow flowers and always wearing pearls, and not flipping out when you have a downturn in your diagnosis, and finally, living and dying the way you want to, with dignity and humor.

For all those people I give thanks.

Monday, October 24, 2016

What happens when. . . .

. . . .you drive hours and hours and hours and HOURS to the State Fair of Texas with four of your colleagues, one of whom is Filipina, one of whom is from Houston, one of whom is from Minnesota, and the last of whom is from the Texas valley, and you introduce them to (variously) corny dogs, fried cheese curds, and the concept of beer before noon?

You learn that it's not a touch of nature that makes the whole world kin. It's fried cheese curds. (The girl from Minnesota was practically in tears to find her native cuisine featured at the Fair.)


. . . .your coworker says, as you're giving report, "Oh, come on. It's not that hard to charge on three units at once!"

You do this:



This .gif so perfectly encompasses so many of my life situations that I feel strongly I must've been a shoebill in a past life.

. . . .you realize upon waking up that you're on the first day of three weeks' vacation?


Friday, October 07, 2016

History.

"Are you on any medications at home?" I asked. He was in for a swollen wrist--and I mean a swollen. wrist. The thing looked like he had a half a softball in there.

"Nope. Nothing."

"What about for the pain in your wrist?"

"Oh, yeah, I mean, I take Tramadol for that."

"Okay. So. . . .anything for high blood pressure, anything like that?"

"No."

Okay. On to the next question. I know this one will be fun because he's got dozens of missed follow-ups and lit up his last utox like a Christmas tree. Two weeks ago.

"Any street drugs? Heroin? Cocaine? Weed?"

"Why you motherfuckers always askin' me about street drugs? I don't do no drugs! I don't smoke weed or shoot heroin or nothin'! What the fuck are you people goin' on about drugs? I never done no drugs! (random profanity)(random tossing things around the room)(stomping)(breathing heavily)"

"So all you take at home is Tramadol for your wrist?"

"Yeah. And Suboxone."

Thursday, October 06, 2016

Lieutenant Lumpy: An Update.

Another year, another clean set of scans and a pristine checkup with Dr. Crane and his Irrepressibly Cheerful Staff. (They always seem happy to see me? I guess because I don't look like Frankenstein's Monster?)

Next year, because the lung nodule I have has not changed in six years, I can start getting annual chest x-rays rather than an annual chest CT, along with my usual head/neck/orbits MR. I'll have to get all that every year for the foreseeable future, because (as Dr. Crane said), "These stupid salivary gland tumors have a really long fuse." And they tend to recur in both the original spot and met to really weird places.

Still, I'm happy. I didn't have to have radiation, I'm functional with The Bug, and I've discovered (and am still discovering) benefits to having an obturator for a palate rather than factory equipment.

One of the most interesting side effects of having CANSUH has been my failing to give a shit about a number of things that used to be really important. I can't believe, for instance, that I worried so much about how I sounded and looked after surgery. I mean, it's understandable--the first obturator was barely better than my postsurgical mouth, and the second one, while an improvement, left a *lot* to be desired.

(If I had it to do over again, I'd go back and tell myself that 1) a year seems much longer than it actually is, and 2) to go ahead and buy a Therabite prior to surgery, rather than waiting however many weeks I waited.)

I also Don't Really Care any longer about what people think about things I might decide to do. For instance, the headliner in my car is coming down. I'm going to repair it with these little twisty screw pin things, then cover the heads of the pins with little glow-in-the-dark stars. This is a good idea. I like this idea. Other people think it's a weird idea.

And SBAR. SBAR is a communication technique developed by the Navy and figured out independently by a number of smart people in other fields, and works like this:

In oral communication, it's important to get to the gist of what you're dealing with, explain the background in a few words, give your opinion of the problem, and suggest a solution. It's what we do, by instinct, when we call doctors for (say) medication orders for nausea:

"I'm taking care of Ms. Smith in 918. She's post-angio day two and has had intractable nausea and vomiting for the last eight hours. I've given her Zofran and Tigan, but it hasn't helped. She's currently not making a lot of urine, but has no IV fluids. Can I start gentle rehydration at 75 an hour and give her a dose of Decadron?"

It works great for oral communication. It sucks for written communication.

Which is why the Powers That Be at Sunnydale have decided that the nurses will now write an SBAR summary of their shifts, every shift, and include it in the shift notes.

SBAR is meant to be a crisis communication, or give information in the case of rounding or reporting. It's not meant to sum up an entire shift. Trying to chivvy a summation of what you did into a shift into SBAR form is just. Fucking. Stupid. The suggestion from TPTB is that we focus on the problem that occupied "80% of the shift," but come on: most nurses, even those with only three patients, have multiple problems to solve that occupy about 20% of each shift per problem.

It's a bad use of a really good tool.

So I wrote my SBAR reports in limerick form this week.

Situation: Ms. S is not making much pee;
                We wonder just why that might be.
                We think that she's dry
                And the prime reason why
                Is that she's in need of IVs.

Background: She suffered a stroke yesterday
                      For which she received TPA.
                      She's had bad reactions
                      To some medications (approximate rhyme; sorry)
                      And so she is barfing today.

Assessment: Lethargic, unhappy, and sore
                     With pulse running 144,
                     And 80 systolic
                     Abdominal colic
                     And puddles of gark on the floor.

Recommendation: Hydration is our biggest worry
                             'Cause she's gotten dry in a hurry.
                             To prevent AKI,
                             We really should try
                             To top her up *fast*, Dr. Curry. [had to change the MD's name to                                        anonymize]

Next week, it'll be haiku. Nobody reads my damn notes anyhow, so I don't really care what anybody thinks of them.

Sunday, September 25, 2016

I have all the time in the world.

It was not an easy day.

We were short-staffed, and I had a patient on palliative care, whose family needed my attention much more than the patient did. Let's face it: when their urine output drops below 20 ccs an hour (those Foleys are placed for comfort care, but it's more the nurses' comfort than the patient's--we can tell how close to dying you are by how well your kidneys are working) there's not much we can do. We turn and do a partial bath every two hours and wipe their faces and clean their mouths, but it's all for the family. The person who's dying has long since ceased to care.

So I had this palliative care patient, and a patient on a titrated drip, and a walkie-talkie woman, ninety-fucking-six years old, with a tiny lacunar stroke that didn't affect her at all. The most we were doing was tuning her up; making sure her blood pressure was okay and her electrolytes were within normal limits. We weren't going to try to change her diet or stop her from smoking. At ninety-six, you're running on genetics, and who am I to say you should give up the Parliaments for an extra, horrible year of life? Keep smoking and die at 102.

So I was in a hurry that morning, making sure her breakfast was to her liking. "My husband," she said, "always liked a poached egg every morning."

She hadn't ordered poached eggs. "I can't stand them. Slimy things" she said.

She had an omelette with mushrooms and sausage and cheddar cheese. I remember this exactly because I love that particular omelette. With hash browns and pancakes.

She had toast.

Anyway, I was in a hurry. I was hungry, I wanted my own 200-calorie breakfast, I had to take vitals on the guy who wasn't on palliative care and swab the mouth of the guy who was, and this woman said, "My husband always liked a poached egg every morning."

"I used to get up," she continued, "and make him an egg and toast, and then feed the baby. I didn't have much milk, so I had to give him goat's milk and cereal."

She reached out for the omelette and I cut it up for her. Hurriedly.

I was looking toward the door, wondering why the monitor was going off, when she took a bite of toast. "It was January when we stopped having milk at all," she said, spewing crumbs everywhere. "That wasn't so unusual. You know, cows only used to give milk when they were nursing calves."

I knew that from the Little House books and nodded, distractedly, wondering if the alarm I heard actually meant something or was just artifact.

"In April, the soldiers came and kept us from going out of the neighborhood."

That sent a prickle up the back of my neck. I looked at her, ninety-six years old, two children who came to visit and then had to leave to take care of their work, six grandkids, two great-grandkids. And I did the math and realized that this might be her and my last chance to talk about this.

We are losing them every day, those people who fought a good war, and the people who were caught up in it, or who were targets of it. I will never forget the man I took care of who had crude tattoos memorializing his jumps as a Russian paratrooper on his bicep.

"What was it like?" I asked, "not having any milk?"

She said, "You have more important things to do. People are sick."

I said, "I have all the time in the world."


Wednesday, August 31, 2016

Worst day, or worst day ever?

So we have this new thing at Sunnydale: the nurses from the neurocritical care unit charge for both the NCCU and an overflow surgical/med-surg/ortho unit on a different floor.

Right now we have our usual nine beds in NCCU and eleven beds on the other floor. (I'll call it "ortho," because it's mostly post-op and pre-op orthopedic cases, but there are important exceptions, one detailed below.) Once the NCCU expands to include epilepsy patients and an epilepsy monitoring unit, we'll have a total of twenty-six rooms to charge: thirteen on each floor, with the possibility of two of those rooms on each floor being double-occupancy. That's thirty patients, give or take.

On two different floors.

Yesterday I got saddled with charging both units. Tiny Dancer and Diamond Bright were on the CCU side, and Bender and Kali were on the ortho side. Thank God for good assignments: ortho was staffed with two experienced nurses, and Tiny Dancer, though she's new, is totally unflappable. She moves through life with her head held high, her posture perfect, and her hands and feet moving at a million miles an hour, if need be.

Halfway through the day I had two critically ill patients on the ortho unit, three different patients who needed blood (no overlap there), a very sick person on the neuro floor, two interns, no nurse aides, and no prospect of lunch. Did I mention that these two units are on different floors? As in, I have to ride the damn elevator to get from one to another?

I did? Okay. Just wanted to make that clear.

At about two o'clock, just as my blood sugar was tanking, I made a major mistake.

We were about to get a patient who was in the middle of a no-kidding psychotic break. His family had found him, two nights ago, wandering naked around the neighborhood, talking about death and God and angels, and had brought him to the ED--from where he'd been discharged and sent home with instructions to present to the psych clinic the next day. The next day he was no better, and was possibly worse, talking about going home to God and taking his kids with him. He still hadn't been able to keep his pants on. This guy was badly off and getting worse.

Obviously, he hadn't taken his meds in about ten days. Part of the problem was that he had had his thyroid and parathyroids removed about a decade ago, and had been well-maintained on replacement therapy until ten days ago, when he stopped taking everything in pill form. His TSH was 15. Because he had no thyroid. And no meds.

So psychiatry, rather than admitting him to one of the medical beds in the psych unit, decided he needed a bed on a med/surg floor. . . and sent him to us.

Suicidal, on an OPC, unwilling to let anyone touch him, combative, hallucinating, unable to settle to reality, on a med/surg floor. With only two nurses, no aide, and eleven patients (I took the eleventh patient, an unstable post-op, because nobody else could).

So, anyway: the mistake. I called the psych doc on call rather than the hospitalist on call, because we didn't have an accepting hospitalist yet. I wanted to ask a couple of questions, like "Is this patient appropriate for a general med/surg floor?" and "Are you sure you don't want to admit him to the psych unit?"

I called the wrong person. I should've called the hospitalist, even though one wasn't yet assigned. This was explained to me at length and in the most insulting, condescending way I have ever encountered, by the psych doc.

Here's how you respond if somebody fucks up: "That patient is going to be admitted under Dr. X's service, so you'd best call Dr. X's on-call for that question." In that situation, I would apologize and get off the horn asap, then call Dr. X's resident.

Here's how the psych doc responded: "I don't think it's appropriate or professional for you to blah blah blah blah wasting my time blah blah blah well you know thyroid storm can cause blah blah blah blah blah blah ad infinitum ad nauseum so very unprofessional of you blah blah blah if you really knew how to care for these patients you would realize blah blah blah. . ."

I finally broke in and said, "You know what? You're right. I was totally unprofessional and inappropriate, and I am so very, very sorry for wasting your time." I then hung up the phone, gently, and will probably get written up anyhow.

All I can go by is what the admissions folks and the computer tell me. You're listed as the admitting doc; nobody's bothered to let anybody else know that you've handed off your patient to a different service. What could've been a thirty-second conversation turned into a five-minute harangue.

Maybe she was having a bad day. I know I was by that point.

My boss walked in to the break room and found me crying tears of rage. She was completely un-fazed and asked me why I was upset. I told her I missed my teenaged flattop and bicycle chain and Doc Martens; that, if I'd had them, I would've gone and curb-stomped that cunt. She didn't even blink.

I love my boss. At that point I flat-out worshipped her.

So, yeah. That was my day. My legs are screaming from running up and down stairs (elevators are slow in our building), I'm incredibly proud of Tiny Dancer and Diamond Bright for handling tricky, delicate people without incident, and I wish I'd had a quart of ice cream last night.