Abdominal pain & nausea = a burger and coke?

Seems like that sentence is backwards right? It should be “a burger & coke = abdominal pain.” Except last shift it wasn’t. Patient with long standing abdominal pain & nausea of unclear etiology (read: there’s no organic or radiological evidence to suggest a reason for the abdominal pain) with multiple ER and hospital admissions for IV pain control and GI rest. So we throw the bus at her: nasogastric tube for GI decompression/rest (refused), nothing by mouth (complained), IV Dilaudid for pain (Yay!), encouraged mobility, because believe it or not, your gut likes you to walk (refused). Flash forward three days when she finally wakes up out of her stupor when docs decrease her narc dose and lengthen the amount of time in between doses (irate!) and liberalize her food options (your food sucks!). This is generally how these stories play out. And yet I surprise myself because I still get surprised when the first thing they order after DAYS and DAYS OF PAIN AND NAUSEA is a cheeseburger and coke. Two cokes and “put this one in the fridge!”

It’s like a hip replacement wanting to do yoga or a triple bypass itching for some cross fit the day after surgery. Doesn’t happen like that. So if this sounds like you…at least try and fake it, for my sake. Order some jell-o first.

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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.

Pronunciation & slang

One pet peeve of mine is mispronunciation of medication names.  And unnecessary slang usage.  From both patient and provider.

As a provider, I think it is essential that we be able to pronounce medications properly.  Yes, there are a lot of medications with tongue twisting names, but every medication reference book has some sort of dummy instructions (pro-pee-sha, vie-ah-gruh).  Besides…how confidence inspiring is it to have your nurse butchering the names of the medications he/she is giving you? Not at all.

I mean, if my barista called out my caramel macchiato as “care-mall match-ee-ay-tow”  as opposed to “car-mul mach-ee-ah-toe” I’m pretty sure I’d think they were on their second day of barista training and that if they can’t pronounce it, how can they possibly create it?  And that’s okay really, because caramel macchiatos can’t kill you.  But carvedilol maybe can, or digoxin, or lorazepam.

And slang.  Oh slang.  Just as I don’t walk up to my barista and order a “cuppa joe” or “jet fuel” or “mommy’s milk”, I refuse to be asked for “oxy”.  We’re not on the streets here.  I’m not selling it to you.  I’m administering it.  So call it by its proper name, thank you.

The Devil Wears…Danskos?

The devil doesn’t wear Prada on my unit….he wears old worn out brown Danskos.  Danskos that I wish he would replace, STAT.  He’s our bigwig surgeon.  Dr. X.  He’s arrogant, he’s charming with the lady patients, he’s published like a gazillion papers in peer reviewed journals, he has impeccable outcome statistics and he has expectations of perfection that only Mother Theresa could meet.  But his Danskos? He’s had to have had those things since residency, which must have been ages ago.  They probably smell horrid, like a combination of dog anal glands and epoisses on a hot day.   A lot of surgeons have their “thing”.  A little superstition.  A certain surgical cap, a Mont Blanc fountain pen they’ve used for every paper order and progress note since the 70’s, their alma mater pin etc.

This guy? His ratty brown Danskos.  Now, don’t get me wrong.  I have a love/hate relationship with my Danskos.  I fought the good fight to avoid buying a pair until my aching feet protested after a year of 12 hour shifts.  I caved.  I bought.  I hate.  They’re so ugly!  But they’re SO comfortable.  And the 1 3/4″ heel comes in mighty handy when you have to walk to work in the rain.

When Dr. X breezes onto the floor for rounds, you can see him coming down the hall with his entourage of 4-5 residents, a few interns and perhaps a terrified medical student trailing 4 feet behind.  They flank him like a flock of geese migrating south in  V formation.  And every time I find myself humming “My Posse’s on Broadway” when they walk by.  Usually we’ve had about 23 seconds of lead time before he arrives to round on his patients because his Danskos have a certain recognizable squeak.

You know the scene from The Devil Wears Prada where Meryl Streep’s character is making her way into the building for work?  Scenes of her getting out of her town car, entering the building, getting in the elevators and opening the big glass doors to the fashion magazine headquarters are interspersed with scenes of frantic fashion magazine employees racing around making sure everything is perfect in the office before she arrives.  Cleaning up clutter, touching up their makeup, changing out of comfortable shoes into high stilettos, hiding carbs, taking off functional clothes and putting on haute couture, setting her coffee in its exact proper location on her desk.

That’s what its like when Dr. X comes on the floor.  We race around making sure all his patients are awake, out of bed (“get up now! get in the chair!”), medicated, working on their pulmonary hygiene (“If anyone asks you’ve been doing this incentive spirometry all morning!”)* or…jackpot…just happen to be walking in the hall when he arrives (which he loves).  If they’re asleep and shaking them awake wouldn’t be appropriate, we just shove the incentive spirometer into their limp hands. **

And he buys it every time.

* We normally do all these important post operative nursing interventions anyway.  Many times a day. We’re good nurses.  He just rounds so early in the morning before we’ve had a chance to get everyone going.

** I’ve totally done that before

Put down the chicken strip…

If you had a paper cut, would you ask for a slice of lemon to rub on it?

If you had just burned your mouth on scalding pizza cheese, would you quickly grab a swig of hot coffee?

If you had a fresh blister from a new pair of heels, would you put them back on right after it popped and exposed the raw skin?

If your butt smells like something crawled up there and died, would you fart on an elevator?

No?

Then why would you order chicken strips right after you’ve just asked me for a dose of phenergan to take away your ‘nausea’?

Oh yeah…because you’re not really nauseated. And because phenergan makes you feel good. And I must look like I graduated from nursing school this morning before shift change.

Let’s just put this back up…

Yesterday my assignment included two tracheostomies.  There are no hard and fast “rules” on our unit about assignment limitations.  Mostly we just divvy up the isolations, the total cares, the trachs, the chest tubes and the needy as fairly as possible among the nurses.  Usually a nurse will only have one trach.  3 isolations at the most.  A couple of chest tubes is no big deal.  One total care is plenty.  Usually it works out, sometimes you get screwed.

Some nurses complain more than others about their assignments.  Some nurses don’t even bother to put their things down when they come in to work in the morning but rather head straight over the the assignment sheet with their purse/bag, lunch, coffee and phone in hand to make sure they didn’t get an unsavory assignment that day.  Some nurses bitch and grumble if their assignment isn’t perfect, like with 5 walkie-talkies.  I tend to figure, eh, what goes around, comes around.

Yesterday was a “come around” day for me.  Two tracheostomies, one with a deep oral flap that required frequent checking but that I could barely see because she couldn’t open her mouth farther than a finger’s width.  A total care with diarrhea (jackpot!) and an 80 pounder with a stage III.  If given the choice between that assignment and a root canal yesterday, I would have strongly considered the latter.

My second one wasn’t a technically difficult trach.  His secretions were thin and manageable and he didn’t need frequent deep suctioning like my other one did  Which is probably why I got the two and everybody else only got one.  Nurses are like the opposite of greedy kids at Christmas.  “How come I got two and Johnny only got one!?…I only want one!”.

The Easy Trach, we’ll call him, was progressing nicely towards decannulation (taking the trach out and taping up the hole in their neck and letting them breathe through their upper airways again).  Yesterday was time for cuff deflation and speech trials.  Without getting into the anatomy & physiology of your airways and vocal folds just remember the following easy equation.  Cuff up = no talk.  Cuff down + Passey Muir speaking valve = talk.

I had been having difficulty with Easy Trach that morning while his cuff was up because in addition to being the worst lip speak enunciator, he had horrendous handwriting/spelling/grammar.  He lip spoke too fast and when I couldn’t decipher I asked him to write down what he was trying to say.  So he’d write down one word (“medasin”) and then continue to rapid fire lip speak the rest while pointing a the clock.  After about 5 minutes I finally was able to figure out that he wanted his pain medicine precisely at 8am and not a second later.  The morning went on like this with him lip speaking too fast, me asking him to write it down, him writing one or two “words” down and then lip speaking the rest.  I was desperate to deflate his cuff so we could communicate better.

When it finally did happen, everything made sense to me.  He was a talker.  A fast talker.  And he wouldn’t shut up. I wanted to immediately re-inflate his cuff.  “Let’s just put this cuff back up, shall we hmm?”

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.