Nursing and waitressing

I waited tables and bartended to pay my way through nursing school. I remember thinking, during particularly busy dinner shifts with customers who were high maintenance or angry or demanding or just determined to be unsatisfied, that things would become SO much better when I graduated from nursing school and became a real nurse. NOBODY would order me around, treat me like a servant, talk down to me, attempt to make me feel inferior or repeatedly send me back to the supply area for extra condiments. NOBODY! I would be the EXPERT! I would have POWER! (that I would wield responsibly of course…)

Surprise! Ten years later…I get ordered around, treated like a servant, talked down to, attempted to be made to feel inferior, and repeatedly sent back to the supply room for extra condiments. Except the condiments are drugs. Lots of ’em.

Family

I always find it quite sad when I get handoff on a patient and the off going says, “There’s been no family here.”  It happened yesterday.  On a patient who had been in the hospital for two months.  She had four sons, one of whom had power of attorney and refused to give his contact information to our social worker who had tried for days to contact him and finally got through via her medicaid application.  So here she sits, all tubes and drains and lines and artificial airway.  Lonely.  Probably scared.  Totally disengaged and in no way willing or able to participate in her care.

Family.  It can be my worst enemy or my best ally while I’m caring for one of its own.  I place families in three rough categories.  Up My Ass, Pleasantly Present and Nowhere To Be Found.  On any given day I may have a smattering of all three, the worst being multiple UMAs or NTBFs at the same time.  The woman above was a clear case of NTBF.

PPs are the best.  They don’t need much explaining.  They just need Nobel Peace Prizes.  They’re present, helpful, observant, stand back when they need to and step in when its appropriate.  I love PPs.  I like to think that I’d be a PP if any family of mine was hospitalized.  They get a disproportionately small paragraph in this post, but have disproportionately more respect from me.

NTBFs have a spectrum of their own.  Sometimes Dad just needs a lap chole and nobody can get the time off work to come sit and chat while he sips his broth and munches jell-o.  They show up on discharge day and Dad’s no worse for the wear.  The other end of the spectrum is like the woman above.  Often they’re incredibly complex cases with many co-morbidities and complications.  I’ll never forget a patient who was on my unit dying.  He’d been there for several days and had had no visitors or family at the bedside.  He was obtunded and unresponsive and we were withdrawing life support based on a phone call from a son who had legal DPOA.  The son lived a plane flight away and there were two local children who provided no contact.  The patient indeed needed to be allowed to pass.    As the time neared, I found myself sitting in his room while I did my charting, thinking about different family relationships and dynamics.  I realize some families must just suck.  Physical and emotional abuse, estrangement, fighting, substance abuse and mental illness would all be very difficult to deal with in a family.  I get that.   I have no idea what kind of father, brother, son, uncle or grandfather he was.  Maybe he was one of those I just described.  But as I sat watching this man take his last breaths I couldn’t help but be sad for him.  I felt strongly that he shouldn’t have to die alone.  So I held his hand and wished him peace wherever he went.  Even more sad was the phone call I had to make to that son after he passed.  We needed to know what he wanted to do with the body.  “I don’t care what you do with it” was his reply.  So the remains were sent to the county medical examiner’s office to be mass cremated with the other unclaimed, perhaps unloved bodies.

UMAs are, in my opinion, the worst.  They think of themselves as PPs, but they most definitely are not.  Quite often, the patient is very complex much like the NTBFs patients.  A typical UMA has been in the hospital for some time, is very ill, may have had some unfortunate complications and if there is an error to be made (diagnosis, medication or otherwise) it inevitably will happen on these patients.  Murphy’s Law.  This leads to distrust of all staff (somewhat understandable) and further travel UMA.  They do shifts, just like the nurses.  They have their own shift handoff too.  An update, a warning and a phone call 10 minutes after leaving the unit for an update.  I take particular offense to UMAs.  I know I shouldn’t; I’m learning not to.  But I still do a little.  It’s the trust thing.  I take pride in my excellent care.  I’m type A at work, I’m smart, I think critically, I’m personable, I’m organized, I’m observant and I get what I need from doctors and surgeons.  And when someone doesn’t have the trust in me or my staff enough to leave their family member alone in the room under our care for one single minute, I take issue with that.  And then I take that issue and I stuff it way down next to my ego.  Because experience has taught me to just go with the flow with these folks.  They micromanage, they perseverate on the things they think they understand, they control the things they can.  Like refusing to use the call light and waiting until it is answered, instead opting to trawl up and down the halls until they spot me in another patient’s room and stand waiting outside the door until I have to come out like a trapped and cornered raccoon.  UMAs usually have a rudimentary knowledge of basic medical sciences from their family member’s experience with illness.  They always want to know lab results.  “What was his blood sugar this morning? Oh, it was 205? Well you must not be giving him enough insulin because at home it’s always under 150.  I’d like to talk to the doctor right now please”  or “what was his white blood cell count? It was up? Well the doctors don’t have him on the right antibiotic then.  Call the surgeon right now because there must be some infection inside.”

Gah! It’s making my blood pressure rise just typing this!  I believe medicine and nursing are as much art as they are science.  And UMAs take some artistry.  I look at them as a challenge though, and this helps me stay neutral and calm.  Because I love a challenge.  And I think I’ll always be working to perfect my own art of nursing.  I’m sure it will never be perfect, but that’s the challenge right?

So if you find a family member in the hospital, be a PP.  It’s your duty as family to be present (author’s opinion).  Bury the hatchet if you find yourself being a NTBF, find closure or resolution, forgiveness and grace.  You’ll feel better.  Bitterness rots the bones (its actually envy, but I like to insert any negative emotion into the quote).  And don’t be an UMA.  You’ll turn everyone off, create tension and counter-productivity, and make some nurse’s day more difficult than it already is.  We want the best outcome for your loved one, and you won’t find that outcome up my ass, you’ll find it in being pleasantly present!

So here’s to family, good and bad (raising an imaginary champagne glass, beer stein, wine glass, ice water etc.)  May you never be hospitalized, and pass peacefully in your sleep at 98 years of age.

And for your viewing pleasure, here’s the third member of my family.  Don’t be jealous, but I trained him to poop and pee in the toilet.  True story.

 

Post-Mortem Care

At the risk of sounding morbid or creepy, I enjoy post-mortem care. (Spell check is making me put a hyphen in between those two words and I do not like it).  Perhaps enjoy is not the appropriate word.  Maybe what I mean is value, or meaning.  I choose to see value and meaning in post-mortem care.  What would invariably creep others out is where I often find peace and beauty. Not many people really get to experience death and dying on a routine basis, and I often find myself contemplating the honor of having that experience.  I suppose my labor & delivery nurse friends might understand a little of what I mean because they experience the magic and beauty at the other end of the continuum.  The joy of a fresh new life.  The promise.  The potential.  We often think of one end as happy, the other end as sad.

I have been present at a lot of messy, sad deaths.  The remains of a CODE 4 strewn about the room, the residual epinephrine/adrenaline running through my veins and sitting stagnant in the veins of that who we were trying to save, the family standing stunned in the doorway.  Fortunately not all deaths are like that.  Many are beautiful.  Meaningful.  Accepted.  All are mysterious.  What and who was once there a minute before is now gone.  And it begs the question, what is the essence of a person? What is a soul and what does it look like?  It’s impossible for me not to get spiritual when I’m performing post-mortem care.  One final beat of the heart that has been beating nonstop every second of every day of every year and all of a sudden the person who was “there” a second before no longer is.   I look upwards.

When exactly does death occur and life end?  The final beat of a heart as modern science tells us? What if we can keep that heart beating? Loss of consciousness or brain activity? A body with a beating heart and only a beating heart is still “alive”?  The topic has stretched ethical discussion for ages, and I don’t think it will ever cease to.  At least I hope it doesn’t anyway.  Because questions we ask about end of life are also pertinent at the start of life.  When does life start?  The same way it ends?  With a beating heart?  I remember my mom grappling with the looming death of her mother who had been suffering from progressive Alzheimer’s for several years.  The last days of her existence were spent obtunded and I remember my mom saying, “It’s just her body, her shell.  Her soul is already free and in heaven”  This helped my mom process and cope with her own beloved mother’s impending final heartbeat which would only be a final detail in a death that had been stretching for days.  My mom also firmly believes that life starts at conception, that the soul is there from the moment the sperm and egg join.  There is no “shell” stage like there is at death, and the heartbeat is just a detail.

Sometimes I feel as though I’m desensitized to death.  It lost its novelty after the first few.  Removing lines, tubes, drains & airways from a lifeless yellowing body was once disconcerting but now has become routine  But where novelty is lost, meaning is not.  I strive to find value in every death whether its holding an abandoned grandpa’s hand while he passes on without anyone to witness or care, or fighting to let a family sit with their deceased for hours rather than have them carted off to the morgue to make room for another living body.  Meaning is in the eye of the beholder.  And I behold a fair amount of death.

Reading over this post, it looks messy.  Disorganized.  It bugs me.  But I think I’ll leave it that way.  Because that’s often how I feel about these questions and situations.  I hope we never stop talking, wondering, questioning, crying, laughing and valuing death.