Saturday, March 29, 2008

How to have a good stay in the hospital, or:

Driving your nurse crazy, in three hundred eighty four thousand, six hundred forty-two easy steps.*

Adopt a lofty tone. Nobody here will remember how important you are. Therefore, it's crucial that you remind them at every possible opportunity. Condescend as often as possible. Refer to your nurse as "The Girl". Refer to every female doctor as "Nurse"--they love that. If you can, work in a shadow of doubt about your nurse's or doctor's competence. Ask repeatedly if they've "ever done this before."

Don't forget to bring your four-page, single-spaced list of demands. Make certain that you've listed all of your drug allergies, even if they're not actually allergies, on the first page in bold type. List all of your previous surgeries on the second page, with editorial comments such as "spent six weeks in hospital--doctor's fault". On the third page, specify that you be transferred to the "VIP floor" only. The fourth page will have plenty of room for you to note your food preferences, the fact that you don't want to be served on plasticware, and that, regardless of your latest test results, you refuse to be put in isolation.

Refuse to have an IV placed in a spot where it is least painful and most convenient for all involved. If necessary, lie about previous surgeries to that extremity in order to manage this. Nobody reads your history, right?

Be noncompliant with treatments. If you can't turn off or change the settings on the IV pump because it's locked, the next best thing is to unplug it and leave it unplugged until the battery runs down. If you've been ordered to remain on flat bedrest because of a cerebrospinal fluid leak, by all means sit up as often as possible. Conversely, if you've been ordered to walk at least three times a day, make as dramatic a production as you can of getting out of bed. Moaning and groaning is required; sagging to the floor whimpering is optional but effective, especially when done in front of your family.

One very important note about treatment noncompliance: If you are diabetic, ensure that your family brings you huge amounts of sugary food. Hide it in your room. Hide it in your bed. Hide it on your person. The Girl needs exercise, which she will certainly get when your blood sugar comes back at 1300 mg/dl.

Work the occasional old-fashioned derogatory term for racial minorities into your conversation. Those People have to be reminded where they stand, after all. The Girl and the other nurses will be glad you're reinforcing the social order, even if they don't act like they are.

Invite all your friends, fellow gang members, remote family connections, and strangers on the street to come visit at all hours. Instruct them to talk loudly on cell phones in the hallways. Send whatever small children they bring into other patients' rooms. The pre-teens should be told to ask for ice cream and sodas, repeatedly, at the nurses' station.

If you can't get what you want, call your doctor at home. This is particularly effective if done at 3 am, and if your doctor doesn't have admitting privileges at the hospital where you are. Bonus points if you have a doctor who'll call the nurses' station and bluster.

Speaking of bluster, if you have a family member who's a doctor, use that person the way God intended: To attempt to bully the staff of the hospital into changing treatment protocols.

(Special note for those with medical family members: Be sure that if your son-in-law is a staff physician at the hospital, he is the primary physician on your case. It's been too long since the last ethics course refresher; the staff could use the training.)

Remember that medical people, nurses in particular and neuroscience nurses in especial particular, are too dumb to know if you're faking a seizure. A well-timed fake seizure will get you two extra days of Ativan and Dilaudid.

Instruct each and every one of your family members to call the nurses' station every sixteen minutes throughout the day for updates on your condition. Phone trees are for the hoi polloi. Extra points if you can arrange to have several family members call at once during shift change.

If all else fails, barrage the director of nursing, chief medical officer, and police with phone calls. People in management will have a better idea of your treatment needs and activity restrictions, your diet orders and medication regimen, your physical therapy schedule and dressing changes, than your nurse or doctor. 

*I wish I were capable of making this shit up. 

Thursday, March 27, 2008

Things they don't tell you in nursing school

There are plenty of books and articles out there about how to survive your first year or two as a nurse. Most of 'em are pretty useful; they cover things like confidence and time management and self-examination, all of which are important. There's always a "transitions" class in nursing school that attempts to cover the same things.

Nobody, though, gives you the real dirt on being a nurse. Here, then, are ten things you didn't learn in school and which will become obvious soon:

1. Constipation: Your own, not the patient's.

Everybody poops, yes, but some of us have to learn to poop less often. If you're working three or four days in a row, your first day off will be spent pooping and sleeping. Accept this and do not attempt to buck the trend. The downside to not getting to poop when you'd like is hemorrhoids. The upside is stronger sphincters and the ability to work through a case of food poisoning.

2. Did something die, or did you just take off your shoes?

If you wear decent shoes (ie, supportive closed-toe-and-heel shoes made of leather), your feet will stink. If you work a full shift in them, your feet will stink to high heaven. Again, acceptance of your plight is key. Soap and water before bed do a lot to prevent both athlete's foot and the death of your bed partner.

3. Bleach is your friend.

The likelihood of getting something nasty splashed on your scrubs is directly proportional to the amount of white you wear. If, like me, you *have* to wear a white coat as part of your uniform, you should buy stock in bleach companies now. It'll subsidize your retirement.

4. You will become more cynical than you ever thought possible.

Look: It's impossible for a human being with a heart to do what nurses do on a daily basis and not become cynical, both about other people and about the universe we live in. Cynical doesn't mean evil; it just means that you're coping with the stresses of your job. I used to feel bad about the sort of whistling in the dark we do until I realized that it's the only way to keep from crying in the face of three patients dropping dead unexpectedly in one day.

5. You will become capable of both more tenderness and toughness than you ever thought possible.

Nurses soothe people. We ease their fears. The number-one thing that we do is educate our patients about what's going on, and knowledge is power. The number-two thing we do is stop pain. Those two things, taken together, will make you more tender and gentle than you ever imagined. Even turning a comatose patient can be done with gentleness, and you'll find yourself doing it. 

Nurses also have to hurt people. It's part of the job. Shots hurt. Dressing changes hurt. (Cue "Cruel To Be Kind", please.) When you're changing the dressing on a deep, awful wound that hurts, you'll find yourself wincing in sympathy--the first few times. Later on, you'll get tougher, but never to the point of cruelty. Change the dressing, get it over, and go on. This is not a bad thing.

6. Coping mechanisms can be good or bad.

I'm not talking about the people who sneak narcotics out of locked drawers. I'm talking about what I've heard other nurses say: "I never drank this much before I was a nurse."

There are good ways and not-so-good ways of dealing with the stress of the job. If you're coming home and pouring six shots of tequila down your throat, either you need a new coping mechanism or a new job. One glass of wine/liquor/beer, though, done properly and with ritual, can ease the transition from Nurse to Real Person. Do not be ashamed. 

If you *are* ashamed, then get a different way to cope. Buy a treadmill and go for a run after work. Get a puppy. Buy some Mister Bubble and use it. Adopt a new ritual.

7. Doctors are (mostly) people, too.

There are some doctors who came here from Planet Asshole. The same can be said of some chefs, some office bosses, and some bowling-alley customers. The majority of doctors, though, are nice, normal people with nice, normal needs and reactions to things. The same doctor who writes insane orders and demands that crazy things be charted does the in-car butt-dance every time she hears "Girlfriend" come on the radio. Remember that.

8. Dating somebody from the same facility is always, ALWAYS a bad idea.

No matter how discreet you think you're being, somebody's figured it out. 

9. Nurses are nice, normal (mostly) people, too.

All but two of my nursing instructors in school went on and on and on about how dysfunctional and co-dependent nurses are. I figured out pretty quickly that the instructors who were down on nurses were no longer working as nurses because they hated the job and couldn't cut it on the floor of even a moderately busy facility. The two instructors who still worked full-time as nurses had a much better, more realistic attitude. 

Yes, there are bitches and bastards. Yes, you'll run into the occasional young-munching nurse. But they're as rare in this field as they are in others, and you'll learn to avoid them the same way everybody else does. For the most part, nurses become smarter/faster/less inclined to bullshit the longer they work. This makes them good people to work and relax with, both.

If one or more of your instructors is pathological about hating nursing and nurses, ignore them.

10. If you hate it, you can always do something else.

Nursing school has a weird vibe: like this is the be-all, end-all, most important and worthy thing you've ever done. It's incredibly, indescribably stressful--more so than medical school, according to several people I know who've done both. It's also wrapped 'round with the whole Ethos Of Nurse. That makes it hard to admit that you've chosen wrong or that maybe you hate being a nurse.

Let me make this totally clear: If you don't feel like you're a fish finally dropped into water, you don't need to be doing this for a living. It's too hard, and the money's not *that* good. At any point in school or in your career, you are certainly allowed to back out and go be a banker. You haven't wasted your own or anybody else's time; remember all that great stuff you learned?

Don't let one bad day or one bad month or semester or year (whatever) make your decision for you, though. If you have a gut feeling you shouldn't be doing this, then for God's sake back out as soon as you can. If your gut is happy, though, and it's your brain or ego that's bruised, keep on. Things will improve.

Thursday, March 20, 2008

Change of Shift!

It's here.

Wednesday, March 19, 2008

(Clever Title)

If you have to get one bizarre disease in your life, one that defies diagnosis and makes doctors scratch their heads, one that'd land you on a not-happy ending episode of "Medical Mysteries", one that would make Hugh Laurie sit outside your room with his chin resting on his cane, don't pick the one bizarre disease with the word "encephalopathy" in the name, okay?

'Cause it would suck. Hard.

"Encephalopathy" means "brain disease". It can be caused by a number of things: everything from kidney failure to liver failure to mitochondrial failure to viruses, bacteria, and fungi have been implicated in the different forms of encephalopathy. "Encephalopathy" is also used as a catch-all term for the "God Only Knows" diseases--the things we can't diagnose except on autopsy.

This has been Encephalopathy Fest Month. Every third person and his brother has some form of brain swelling, sterile meningitis, or GOK disease. What that means for us, practically, is that there are a lot of people with balance and cognition problems getting lumbar taps and having to be babysat so they don't wander naked down the halls.

Taking care of people is a weird business to be in. It's never weirder than when you're split in two (so to speak)--watching somebody go down the drain with astonishing speed and feeling bad about that, while at the same time being pissed off because their drain-circling is accompanied by annoying, time-consuming symptoms and problems. 

Taking care of people on a neuroscience ward is particularly pissing. There's so much that we do in hospitals that's routine--like giving pain medicine or various electrolyte solutions--that can cause symptoms that mimic the progression of disease. I've spent a lot of time over the last three weeks trying to figure out if the person who can't remember her own first name is suffering from a narcotic overdose or simply losing neurons at an ever-increasing pace.

I had a patient go down in a big, scary way. Not in a heart-stopped, start-compressions sort of way, but in a neuroscience nurse scary way: she forgot who her brother was. She forgot her name. She forgot what year it was. She couldn't repeat a phrase I said to her, and kept word-salading everything. She stopped making sense and started making trouble over the course of a shift.

So we stopped her drugs. I reversed the narcotics and benzos. We started one thing after another, tried to get an MRI (no go; as she got mentally less with-it, she became physically more active), tried to get a CT (ditto, even with me in a lead dress holding her hand), got an EEG, did neuro checks every hour, managed a lumbar tap somehow...I finally cracked in a quiet, professional way, after I'd spent two hours dodging punches and kicks while trying to keep her down after the lumbar tap.

And you know what? Every. Damn. Test. Came back negative. There's *something* wrong; there's *something* in her brain that's making it light up like Christmas in New York on an MRI film. But we don't know what it is. Meanwhile, her family is flipping out because she's obviously not right, I'm flipping out because she's a danger to herself and others, and the docs are flipping out because they don't know what's going on.

I've worked with one of our neurology residents now for better than six years. I've never had reason to doubt his competence or his intelligence. I've also never heard him say what he said that evening: "I don't know. I've never seen anything like this before."

So. Don't get a generic encephalopathy, okay? At least get something diagnosable. You'll save everybody, including yourself, a lot of trouble.

Friday, March 14, 2008

Fun Medical Words for the Non-Medical Type: A game the whole family can play!

Ever wish you had a really good excuse for not going to work? Ever wish you had a hellacious conversation starter for that cocktail party? Ever want to drop random words into conversation?

Well this, my friend, is your post.

Observe the wonders of medical terminology and pharmaceutical brand names! To wit:

Mucomyst: No, it's not a faerie land where everyone has bad sinus problems. It's the brand name of a drug (acetylcysteine) that thins and loosens inspissated phlegm. It's also used in cases of Tylenol overdose.

Inspissated: What a lovely word. It means to be hardened due to lack of moisture. Why say your hands are chapped, when you can say they're inspissated?

Whipple procedure: About the furthest thing from squeezing the Charmin you can imagine. In a Whipple procedure, the head (thick part) of the pancreas, the bile ducts, the gallbladder, and the duodenum are all taken out, along with (sometimes) a bit of the stomach. It's not something you necessarily want to undergo. It should be differentiated from...

Whipple's disease: Caused by bacteria, its signs and symptoms include joint pain, diarrhea, and malabsorption. 

Duodenum: Go ahead. Say it over and over: doo-WAH-duh-num. Doo-WAH-duh-num. Your duodenum connects your stomach to your....

Jejunum: That's the central part of your small intestine. The Doo-WAH-duh-num is the first bit and the ileum (which sounds like a town in Greece) is the last.

Zyvox: I wish, I wish this were the name of a Galactic Emperor. Unfortunately, it's not: it's the name of an IV antibiotic. Oh, well.

Melanoma: Sounds like a pretty girl's name, but is actually a nasty, invasive, scarily common form of skin cancer. Do. Not. Want.

Glioblastoma: Another pretty word for an ugly thing: in this case, it's invasive, incurable brain cancer. 

Frenulum: I love this word. It's the name of that little bit of tissue under your tongue (there's another under your upper lip, and several more here and there) that connects your tongue (etcetera) to the bottom of your mouth (and so on). 

Cachexia: Pronounced with a hard "K" sound rather than a "ch" sound. It means "starvation."

Stapes: AKA the "stirrup" bone in your ear. Technically, this bone is an...

Ossicle: a bonelet. No, I'm not making that last term up. "Ossicle" equals "small bone". If you have icicles on your ossicles, you're in deep trouble.

Buboe: Save this one for when you really need it: a buboe is the swollen lymph gland that accompanies bubonic plague.

Tuesday, March 04, 2008

The laws of Nature have been temporarily suspended. Please do not adjust your set.

It snowed yesterday.

March in central Texas is not a time when you'd expect snow, but sure enough, there it was. As I passed through the little nothing towns betweeen work and home, the snow fell harder and thicker and wetter, making for a bad case of CSS (Can't See Shit).

Max was outside when I got home. He hates rain and goes all Sarah Bernhardt on me when it thunders ("I can has snuggles? KTHNX.") but loves the snow. He was zipping (well, as much as a 100+-pound dog can zip) around the yard, making like a snowplow with his schnozz. If it hadn't been so dark, I would've gotten a picture.

In other news, I can hurt myself creatively. I know this will come as no surprise to those of you who are regular readers.

I fell the other day at work. I mean dropped to the floor without warning, without the chance to even *try* to catch myself, without even the barest hint of grace. 

It was a clean, non-slippery floor. I found the one thing within sixty square feet that would've caused me to fall over, and promptly stepped on it. And fell over. Like a short tree made out of sandbags, I toppled.

If the bruise on my leg weren't enough, I now have a nasty sneezy head cold. I don't feel bad, exactly; just disinclined to move fast. I'm sneezing, did I mention? And did you know that it is entirely possible--I have just proved this to myself--to bruise your own soft palate by sneezing convulsively several times in a row? I think I might've bruised my right tonsil as well, strange as that sounds. It didn't hurt, I sneezed a bunch, and now it hurts.

Then there's the bruise on my shoulder. I got that one in an interesting way, by lifting a patient who can't use her legs. We'd tried to get her back to bed with a two-person lift, but whatever bizarre thing she has going on in her brain (not my patient, so I don't know details) has taken both her legs and her sense of balance, so the two-person lift was a no-go. She swayed and buckled and the gait belt wasn't doing the job. Being safety-minded, I did a squat-lift to pivot her from her chair to the bed.

I didn't realize that her neck was as weak as her legs. Her forehead hit my left shoulder with an audible thud. Now I have a nice egg-shaped-and-sized bruise there, right above my collarbone. The patient is fine.

Finally, this news flash: Some Doctors Can Be Assholes. 

I don't know what it is about this particular guy, but every time I deal with him, things go from being normal to being a total clusterfuck in about five seconds. I'm not the only one with this problem, so I figure if the only common denominator is him, it's him. We'd had a run-in about a year ago involving his inability to follow directions in order to reach another physician and then being insulting about it, so I was primed.

What he wanted this time was a series of genetic tests so obscure that it took our lab manager the better part of a day just to figure out where to send the blood. I mean, when *Mayo* doesn't do a test, you know you're looking at something weird. Specialty Lab Of Fredsville faxed us the proper requisition, which contained lots of numbers and capital letters in strings next to check boxes somebody was supposed to tick off. The resident didn't know what to make of it, and I was totally flummoxed, never having heard of the genetic condition the attending wanted to test for, let alone the test for it.

So, when Attending With An Attitude showed up on the floor, I (waited until he wasn't busy and then) asked him to (pretty please) fill out this form so I could send it to Specialty Lab.

Whereupon he threw up his hands, sighed heavily, and made a comment about nurses being stupid. I stood there like a bump on a lump while he ticked boxes and scribbled his name at the bottom of the requisition, considering whether beating him to death with a chair was something I had the energy for. I decided against assault and battery and for simply ignoring his comment.

And you know what? With inveterate assholes, ignoring their comments is the best way to piss 'em off. He got a few more jabs in before he left the floor, some of them personal and not related to any clinical situation, and I just...pretended not to hear. At all. He was both annoyed and deflated when he left. I don't think we'll have any more trouble from him for a while.

God, that was fun.

Sunday, March 02, 2008

An apology.

Dear Nursing Students Who Were On Our Floor Two Weeks Ago:

I'm really sorry about your last rotation with us. If I'd known my coworker Peevie McGripersons would be there, I would've taken each and every last one of you on, like a string of ducklings, to save you from McGripersons.

I probably should've realized there would be problems when I heard McGripersons berating a student about how Medication Sheets Are A Legal Document, Like Charts Are. I mean, yeah, you copy down all the meds your patient has and you learn all about 'em before you come in the next day, right? It's probably still not a good idea to go with your hand-copied notes when you start to pull meds, because something might've changed--but there's no reason for you to get excoriated about Legality and License and So On because you're inexperienced. 

It would've been better if McGripersons had said something like, "Oh, you copied everything? Damn, you're dedicated. Snag the med sheet out of the chart, willya, and let's go yank some pills out of the machine, eh?"

I *knew* there were problems when I watched one of you pull up a couple of different meds into the same syringe--something we do all the time--and watched your face change when it became obvious that the meds weren't compatible. Not one of us hasn't cursed inwardly when we've seen incompatible solutions crystallize in a syringe. Not one of us hasn't grumbled our way back to the med cart to grab two more syringes and re-up the meds. It happens all the time. We just don't give the crystallized solution, y'know?

But to hear McGripersons, you'd've thought the world came to an end. 

Seems to me that a better way to have done it would've either been to have warned you that Solution A isn't compatible with Solution B *before* you pulled 'em up, or to have sympathized and explained after it turned out they weren't. I don't see that you needed to be subjected to a pharmacological lesson *after* you'd screwed up, which does nothing to help you figure out what the hell is going on and a lot to make you feel an inch tall.

And, finally, I apologize for not stuffing Peevie's limp body down the laundry chute after he told one of you that you weren't to do *anything* without him there, because A Chart Is A Legal Document.

Yeah, Peevie, we know. There are better reasons, though, both to follow a nursing student pretty closely and to chart completely and correctly. Legality is a very minor concern.

First of all, your average student is scared to death of your average patients. They're not people to the nursing student; they're huge bundles of foreign problems who are likely to die suddenly while gasping out that it was all the student's fault. Having an experienced nurse at your side makes you a much less scared student (unless the nurse is Peevie McGripersons, that is).

Second of all, other nurses--and the occasional doctor, alors!-- read your charting every day. They do so to figure out what's been going on with the patient and to make sure they don't reinvent the wheel. Charting completely and correctly is about *safety* and *information* more than it is about legality. Yes, good charting will save your license in the event you're sued--but it's much more likely that it'll save your patient some trouble. Other people need to be able to read an informative, intelligent chart to decide if that numbness warrants reassurance or a call to the doc.

Guys, on behalf of my other coworkers and decent, humane nurses everywhere, I apologize for Peevie and his ilk. Please don't be scared away by one jerky nurse. I promise that I'll steer you away from him in the future if you'll just come back. 

And I promise, too, that you are not the idiot McGripersons made you out to be. You're inexperienced, yes, but that does not in any way equal stupid. You've gotta be smart and hardworking to have made it this far, okay? What remains is more hard work and a little more time with sick people and their pills, and you'll have it made. You may not feel confident until you've been a nurse for a couple of years (I didn't, and I don't know many people who did), but it'll come. Just avoid the McGripersons of the world in the meantime. 

Sorry, guys. I really am. Come find Auntie Jo next week and she will set you up, okay?