The hospital has a weekly lecture series that covers a variety of medical issues, from new technology to trends in patient advocacy. I started going when I was a student because many of their topics touched on bioethics (an acute interest of mine).
Last week the topic was on medical writings and literary criticisms of it. I know my viewpoint is skewed because I'm in medicine... so when I see medical-themed books at Barnes & Noble, on a prominent table with lots of other "big name" books, they especially stand out to me. So I can't really tell if I'm just seeing more medical books because I'm more aware of them (and have started reading more and more of them), or if there are more being published.
Turns out, more are being published! More people are writing about their experiences as a patient, a family member of a suffering patient, or a medical professional. ... And by medical professional, I just mean doctors. No nurses. Just like in movies and TV shows, doctors get all the attention and nurses have the supporting role. (Yes, I am aware that Jada Smith has a whole show about her role as a nurse... but it's an absurd show and paints the nurse's role in a totally unrealistic light. There's enough drama and emotion without having an "us vs them" attitude portrayed. End rant.) I want to read a nurse's memoir. I want some thoughtful nurses to write. That's why I'm blogging... because it's how I process my experiences. I want to hear how other nurses process their's.
Anyway, about the talk. The speaker was a New York Times book critic. She is also a physician. She reads and critiques many books in the medical world, and she was giving us her opinion on medical writings. Something she pointed out that was very interesting is that the whole perspective on disease has changed in America in the last 50 years... disease used to be private. Now, there are breast cancer awareness bagels at Panera and comedians discussing their heart surgeries on HBO. There are loads of books about various diseases... from Alzheimer's to polio. One of my favorite books ever is a memoir written by a recovering alcoholic, explaining the way her mind thought about alcohol, how she experienced being buzzed, and how she felt without it. It made me 200% more sympathetic to my patients going through alcohol withdrawal in the hospital. I've read various short stories and seen a documentary on eating disorders that showed the true mental disorder behind the behavior... these aren't people making bad decisions, they're people suffering from an illness (not that ownership isn't part of the issue, but that's another blog post).
So the NY Times Critic posed the question of whether or not we should be evaluating these books at all. Should be treat them as true literature and critique their use of metaphors and character development, or should be excuse them from those standards? Many people write because they want to share their experience; an experience they either feel is so unique that it should be proclaimed or is so universal that others could find comfort by relating to it. This is for both the patients/families and the physicians... enduring the culture shock of being a resident and slowly taking on more and more responsibility for people's lives is definitely something worth writing about! And seeing a loved one slowly succumb to end stage Alzheimer's is something people will experience more and more (it is the 6th leading cause of death in America, according to the CDC). These experiences should be captured, but should we criticize how we capture them? How we present them to the public?
The Critic pointed out that it should sorta depend on their motivation for writing and publishing it. Is it because they just want to process it, and it happened to get published along the way? Is it to help illuminate the situation for others, an "this is life in the trenches" sorta story?
I don't think that it should matter why they decided to write and get published. I'm writing a blog to work through my own emotions on matters, and to help document my emotions to reference later. ("See how far you've come, Jenn!") I'm not seeking editors to work through these experiences and polish them for audience appeal. You can choose to read this or not... but you sharing in this experience with me isn't a big investment for me. However, if I choose to go down that road someday, writing my own nurse memoir, I hope to get my literary critique. I can't step into someone else's profession and ask not to be held to their standard. That's absurd. If you choose to write and then go through the effort to get published, you choose to open yourself up to THAT WORLD and all it involves.
One reason I feel that way is because a writer can do real damage to a story if they write poorly. You know it's true: give two people 3 talking points, and one will create a beautifully worded speech and deliver it with equal eloquence, and the other will give a dry lecture. Same info, two presentations... and two very different effects. One audience will walk away energized with knowledge, maybe contemplating these issues on their own, investing their own time and energy and money into that selling point so wonderfully presented. The other audience may almost feel contempt for the talking points because of the limp presentation, avoiding other opportunities to learn more about it, and internally labelling that topic "boring" or "irrelevant". A somewhat controversial example would be Al Gore's "An Inconvinient Truth"... information that has been presented by science magazines and environmentalists for years, but finally brought forward in an appealing (well, sometimes assaulting) way, and within 2 years there was new legislation about green house gases and tax breaks for "green" home improvements.
So what damage can be done from poor medical writings? I've read several physician memoirs, and all have been great. They've done a terrific job of showing the very human emotions and physical limitations of their jobs without appearing to shrug their shoulders about it. They aren't heroes and they aren't assholes: they're just people working in a strange world. They show the limitless advances of healthcare wrapped in a wet blanket of politics and emotions and conflicting opinions. As someone "in the trenches", I appreciate this raw view that highlights both the sacrifices we make and the failures we endure.
But speak to one patient with a negative experience with a nurse or physician and you'll be overwhelmed by the impact it made on their universal perspective of healthcare providers. One doctor talking about them to their family as if they weren't in the room or had already died. One nurse forgetting to draw the curtain before undressing a patient for a bath, or rolling his/her eyes at the complaint that the pain medicine isn't working. In short, one experience of feeling so entirely vulnerable and being met with an utter lack of awareness of their humanity, their HUMANNESS, and they are forever scarred. Being denied their significance and value when feeling the most insecure will burn and distort and sensitize that person for years.
Can a book do damage like that? I haven't read one that has, but from discussions with coworkers and "tell me how you really feel" moments, I can see how it could. And I think a solid critique should scare away those writers, or at least come to defend the offended audience.
Wednesday, November 17, 2010
Friday, September 24, 2010
My First Code
I found something I'd written back when my first patient ever coded. It's from November 2008, written the night after this patient had coded and died. I went home from work exhausted, crashed into my bed, but was awakened by nightmares of the situation. I had this "fullness" feeling, like I was carrying something in me that shoved every other thing out-- rest, peace, or feeling connected to anyone else's reality. I decided to get it out the same way I get most of my other emotions out-- by writing about it. I usually journal or pray through my other emotions, but for this, I needed to share it with a nurse who wasn't there: someone who could hear my story and how I experienced it and why it was, now, haunting me. So I wrote to one of my nursing instructors. This is what I wrote to her:
I coded the first patient I ever admitted today, Ms. G. She came about a week after I started orientation on the unit. My preceptor and I cared for her steadily for about 3-4 weeks. After that, I needed to get new experiences, so I had to accept other patients, but I visited her almost daily. I spent a lot of time with her mother, also a nurse, and even when I wasn't Ms.G's nurse, her mother would come over and hug me and tell me how her daughter was doing and ask how I was doing.
My preceptor and I would go to Ms. G's room and have "spa days". We'd tell her family to bring in her favorite shampoo and conditioner, and we'd pull out the green bin and wash her hair FOR REAL (not just with one of those warmed shower caps). Then my preceptor would braid her hair while I got the room in order. Ms. G had very particular and orderly taste... she could be downright persnickety at times! The unit started referring to her as the CCU Princess because my preceptor and I gave her such special treatment. We'd lotion her with her favorite Ann Taylor lotion, and organize her bedside table exactly to her liking. When she started getting better, but also lazier, we created a daily schedule for her that incorporated specific times for her to get out of bed to the chair, times when she would be on pressure support rather than a breathing rate on the breathing machine, times for physical and occupational therapy to come, and even times for the massage therapist to come at the end of the day. (We'd jokingly made a deal that she had to earn her massage by doing her homework and sticking to the schedule). It was a great experience in interdisciplinary collaboration and individualized care that allowed us to plan to give her pain meds before physical therapy, time for a nap before her pressure support trials, etc.
I knew she was getting worse, but I didn't expect her to die today. I walked out of my patient's room and heard her nurse yell, "Get the code cart!" and I couldn't believe she was standing in front of Ms. G's room. My preceptor knew I needed experience in Code 12 situations, so she told me to get over there. Initially, I was the "med pusher", where I stood at the head of the bed and pushed meds through her central line while yelling out their dosages to the person charting the whole event. As we started doing CPR, one of the nurses asked the doctor to let me do the compressions for the experience. I did my first set of CPR ever today. It was surreal. I was doing what I'd always seen on TV and prepared for in school, but I wasn't scared or nervous... it felt very natural. I started feeling proud of myself for handling the whole event so well!
A doctor took over compressions when I got tired, and then we stopped for a moment to see her heart rhythm. Pulseless Electrical Activity... PEA. Nothing was there. The doctors pronounced her dead.
Somewhere between being pulled into the code and pronouncing her dead, I forgot who the patient was. I was totally task-oriented, completely immersed in what was happening rather than to whom it was happening. When they pronounced her dead, it all came stampeding back to me. I saw her mother approach her crying, kissing her forehead. I lost it. I had to get out of that room as quickly as possible, but the world moves in slow motion when a death takes place. I held my breath as I waited for doctors and nurses to file out of the room. I was suffocating. I ripped off my isolation gown and quickly walked to the bathroom where it all came out. I couldn't believe she had just really died. I couldn't believe I had just felt proud of myself! I felt guilty and overwhelmed and very isolated. I knew that none of my friends had just felt a woman die. They were all in offices or in graduate school, reading and going to meetings and complaining about their bosses. I just physically sustained a non-beating heart, and watched the decision to stop it all. I just watched a mother lose her daughter. I've worked it the hospital for 3 years now and today was the first day I've cried there.
I will interrupt at this point. This is how my morning felt that day. Even after the code and crying, I felt like I couldn't catch my breath-- like when you are trying to get your ears to *pop* and just want to take in a good deep breath. I couldn't breathe in deep enough. I felt heavy. I felt like you feel in an air plane when the cabin pressure isn't quite normal... I literally felt the atmosphere around me.
But that didn't last all day.
What happened next was amazing. My whole unit was very supportive of me, encouraging me on the "good job" I did in the code, asking me if I needed to take a break, etc. When things settled down, a few of us found ourselves in the lounge drinking coffee and mulling over the event. As the conversation progressed, we started telling our favorite "Ms. G stories", of her sassiness and strength, her family and her resoluteness. I said that I felt like she would stay with me for my entire career as the first patient I'd really grown attached to... and then, one by one, every nurse told me about their own "Ms. G". Many of them were patients from the CCU, so other nurses could join in on talking about those patients and their personalities. Everyone had their own version of my Ms. G.
I told her mother what an impact her daughter will make on my career as a nurse. Because she was a nurse, she knew what I meant by that, and she was very thankful for it.
I feel like I've really experienced the heavy privilege of being a nurse; daring to care for people and risking the potential for grief. And each of those more-experienced nurses had stories just like my Ms. G, but they told them with laughs and contented smiles and a gentle attitude of thankfulness for the experience; the privilege of caring.
I've shared my feelings about being a nurse on this blog before, and to many of my friends and family. I know that, for all of its lifestyle difficulties and absurd personalities, I'm incredibly blessed to be in a job I feel called to do... in a job I feel God created me to do (for now, at least). There's a movie, Chariots of Fire, about an Olympic runner who is a Christian, and at some point in the movie he describes why he loves running: "I believe God made me for a purpose, but he also made me fast. And when I run I feel His pleasure." I don't always feel God's pleasure when I'm at work, but I do feel it sometimes. And in that moment after Ms. G died, when I felt alien to the atmosphere around me, I think I vaguely felt what God was feeling then, too. Not pleasure, but grief, like when Jesus wept after Lazarus died. He knew he was on his way to bring him back from the dead, but he experienced the grief of human loss all the same.
And after the code, sitting among others who had lived through their own heavy days on the unit, I think I felt His pleasure. And now after 2 years of heavy days and joyful days, I see the arch of His emotions even better. His pleasure isn't always there, but it doesn't leave me for long.
I coded the first patient I ever admitted today, Ms. G. She came about a week after I started orientation on the unit. My preceptor and I cared for her steadily for about 3-4 weeks. After that, I needed to get new experiences, so I had to accept other patients, but I visited her almost daily. I spent a lot of time with her mother, also a nurse, and even when I wasn't Ms.G's nurse, her mother would come over and hug me and tell me how her daughter was doing and ask how I was doing.
My preceptor and I would go to Ms. G's room and have "spa days". We'd tell her family to bring in her favorite shampoo and conditioner, and we'd pull out the green bin and wash her hair FOR REAL (not just with one of those warmed shower caps). Then my preceptor would braid her hair while I got the room in order. Ms. G had very particular and orderly taste... she could be downright persnickety at times! The unit started referring to her as the CCU Princess because my preceptor and I gave her such special treatment. We'd lotion her with her favorite Ann Taylor lotion, and organize her bedside table exactly to her liking. When she started getting better, but also lazier, we created a daily schedule for her that incorporated specific times for her to get out of bed to the chair, times when she would be on pressure support rather than a breathing rate on the breathing machine, times for physical and occupational therapy to come, and even times for the massage therapist to come at the end of the day. (We'd jokingly made a deal that she had to earn her massage by doing her homework and sticking to the schedule). It was a great experience in interdisciplinary collaboration and individualized care that allowed us to plan to give her pain meds before physical therapy, time for a nap before her pressure support trials, etc.
I knew she was getting worse, but I didn't expect her to die today. I walked out of my patient's room and heard her nurse yell, "Get the code cart!" and I couldn't believe she was standing in front of Ms. G's room. My preceptor knew I needed experience in Code 12 situations, so she told me to get over there. Initially, I was the "med pusher", where I stood at the head of the bed and pushed meds through her central line while yelling out their dosages to the person charting the whole event. As we started doing CPR, one of the nurses asked the doctor to let me do the compressions for the experience. I did my first set of CPR ever today. It was surreal. I was doing what I'd always seen on TV and prepared for in school, but I wasn't scared or nervous... it felt very natural. I started feeling proud of myself for handling the whole event so well!
A doctor took over compressions when I got tired, and then we stopped for a moment to see her heart rhythm. Pulseless Electrical Activity... PEA. Nothing was there. The doctors pronounced her dead.
Somewhere between being pulled into the code and pronouncing her dead, I forgot who the patient was. I was totally task-oriented, completely immersed in what was happening rather than to whom it was happening. When they pronounced her dead, it all came stampeding back to me. I saw her mother approach her crying, kissing her forehead. I lost it. I had to get out of that room as quickly as possible, but the world moves in slow motion when a death takes place. I held my breath as I waited for doctors and nurses to file out of the room. I was suffocating. I ripped off my isolation gown and quickly walked to the bathroom where it all came out. I couldn't believe she had just really died. I couldn't believe I had just felt proud of myself! I felt guilty and overwhelmed and very isolated. I knew that none of my friends had just felt a woman die. They were all in offices or in graduate school, reading and going to meetings and complaining about their bosses. I just physically sustained a non-beating heart, and watched the decision to stop it all. I just watched a mother lose her daughter. I've worked it the hospital for 3 years now and today was the first day I've cried there.
I will interrupt at this point. This is how my morning felt that day. Even after the code and crying, I felt like I couldn't catch my breath-- like when you are trying to get your ears to *pop* and just want to take in a good deep breath. I couldn't breathe in deep enough. I felt heavy. I felt like you feel in an air plane when the cabin pressure isn't quite normal... I literally felt the atmosphere around me.
But that didn't last all day.
What happened next was amazing. My whole unit was very supportive of me, encouraging me on the "good job" I did in the code, asking me if I needed to take a break, etc. When things settled down, a few of us found ourselves in the lounge drinking coffee and mulling over the event. As the conversation progressed, we started telling our favorite "Ms. G stories", of her sassiness and strength, her family and her resoluteness. I said that I felt like she would stay with me for my entire career as the first patient I'd really grown attached to... and then, one by one, every nurse told me about their own "Ms. G". Many of them were patients from the CCU, so other nurses could join in on talking about those patients and their personalities. Everyone had their own version of my Ms. G.
I told her mother what an impact her daughter will make on my career as a nurse. Because she was a nurse, she knew what I meant by that, and she was very thankful for it.
I feel like I've really experienced the heavy privilege of being a nurse; daring to care for people and risking the potential for grief. And each of those more-experienced nurses had stories just like my Ms. G, but they told them with laughs and contented smiles and a gentle attitude of thankfulness for the experience; the privilege of caring.
I've shared my feelings about being a nurse on this blog before, and to many of my friends and family. I know that, for all of its lifestyle difficulties and absurd personalities, I'm incredibly blessed to be in a job I feel called to do... in a job I feel God created me to do (for now, at least). There's a movie, Chariots of Fire, about an Olympic runner who is a Christian, and at some point in the movie he describes why he loves running: "I believe God made me for a purpose, but he also made me fast. And when I run I feel His pleasure." I don't always feel God's pleasure when I'm at work, but I do feel it sometimes. And in that moment after Ms. G died, when I felt alien to the atmosphere around me, I think I vaguely felt what God was feeling then, too. Not pleasure, but grief, like when Jesus wept after Lazarus died. He knew he was on his way to bring him back from the dead, but he experienced the grief of human loss all the same.
And after the code, sitting among others who had lived through their own heavy days on the unit, I think I felt His pleasure. And now after 2 years of heavy days and joyful days, I see the arch of His emotions even better. His pleasure isn't always there, but it doesn't leave me for long.
Saturday, September 18, 2010
Monster
There is a patient who came with the report that he was a "real charmer", with a glossy sarcastic tone. His story says it all: he has a drug history, including present use, and had a major heart attack while committing a crime. Ironically, it's lucky the police sought after him, otherwise he likely would have had the heart attack and accompanying cardiac arrest alone somewhere, doing drugs or passed out. The police involvement may have saved his life.
This was the report the unit received. He came to us intubated, all 4 limbs restrained, and on high doses of sedation. Per report, when he "woke up" from sedation, he became "a wild man", trying to pull out his breathing tube and fighting to hit or kick anyone near his bed. This is what necessitated the restraints and the heavy dose of sedative. This is all we knew about this man.
By the time I came to care for him, he had been extubated and his sedation was wearing off. He was beginning to show some personality, something most of us were dreading. "I'll bet he's a peach!", the nurses would add, giving me a "best of luck" look as they left. Truth be told, I was hoping he'd sleep for most of my shift so I wouldn't have to interact with The Monster.
It seems harsh to characterize a patient as a monster. After all, our patients are critically ill and usually desperate for good news or a sense of control. This context rarely brings out the good in people... desperation is an ugly color on anyone. Politeness and patience aren't commonly shown by even the most "civilized" patients in the early recovering stages from a major heart attack or arrhythmia. Gratitude and understanding may develop later, but we don't expect it at first. From this Monster, I didn't expect it at all.
To my surprise, he was pretty easy to speak with. His sedation (and illicit drugs) were slowly wearing off, so he was often disoriented and agitated/scared, but he re-oriented easily and was generally easy to care for. He didn't want to be in the hospital, and he was very clear about his intentions to leave if he didn't get exactly what he wanted. He used coarse language and yelled most of the time, but he wasn't really unlike many of the other patients that I've had... aggravated from not being able to eat, thirsty for anything with more flavor than "a few ice chips" as ordered by the physicians, and generally feeling caged into his bed without much say in matters. Add the shadow of confusion and residual discomfort from a breathing tube and a sore chest from CPR, and most of my patients express themselves in this way at some point in my care... just with less colorful language and a more mild volume. In fact, he was actually a little less offensive, in some ways, because his agitation was clearly directed at his situation and not the nurse "subjecting him to this", as some other patients imply.
The nurse passing him on to me that night began describing him to me in this way, and I commented, "He's not such a monster after all". We laughed, and she said 'good night' to our little Monster, and she headed for the exit. I slid into his room, finding him hot and sweaty from a fever, and confused (again). I went into his room to turn up the AC, and took off his covers, and offered to order him a fan. He grunted something obscene, and kept looking at his bed.
I went to his eye level and said, "Do you know where you are right now?"
"No." ... and some other expletive.
"You're in the hospital."
"I know that!" ... another expletive.
"Do you remember why?"
"No." ... you get the picture.
"You had a major heart attack. We had to restart your heart and give you a breathing tube. That's why your chest and throat are sore."
"Why am I so ** hot?!"
"You have a fever from an infection in your bladder and in your lungs."
"I had a heart attack?"
"Yessir."
"How did I get here?"
"The police found you and called an ambulance and revived you. The paramedics brought you to us. You've been in this room since then."
"The police found me?"
"Yessir."
"What do we do now?"
... I went on to tell him about all the different options. He scoffed at all of them, saying he hates doctors and doesn't want to stay here another minute. I did my usual song and dance about the necessity of staying in the hospital "a little bit longer", or else he'd leave and get sicker and have to return to a hospital for even longer, if he lived to return at all. Sounds harsh, huh? It's a reality. We see it again and again: patients who "hate doctors" and ignore chest pain until they can't breathe anymore and pass out... and usually end up with some degree of brain damage and/or need a major operation. This reality check usually helps with patients, but my Monster didn't care for any of it.
"There's no way I'm coming back after I leave."
"You have a lot of medicine still in your system, so it's not safe for you to leave yet. And you have two major infections that need to be treated or they'll get worse."
"I don't care. I won't come back. I'm just like that... I don't go to doctors."
"With all due respect, Mr. X, you didn't come to the doctors this time... you died and someone brought you back and here you are."
"Well that won't happen again."
I didn't pursue that response... what won't happen again? His heart stopping? Someone finding him? Him finding his way back to the hospital, conscious of it or not? None of these options sounded therapeutic, so I just let it go. At this point, because of the crime he committed and the medicine/drugs still in his system, he wouldn't be allowed to leave the hospital anyway. But I wouldn't tell him that. Again, that didn't sound like therapeutic information.
Reading through this conversation, I'm surprised at myself at how sympathetic I've become towards him. Again, he's not unlike many of my patients that come in with similar health issues. He just come in with a juicy story and sordid reputation in addition to his run-of-the-mill health crisis. But it was so easy to think of him as a monster when he was sedated and intubated, occasionally lashing out (not consciously), but otherwise totally unable to interact with the staff or show us his personality. When the opportunity to see his personality came, even his noxious language and demeanor couldn't obscure the Truth that he was a human being sitting in front of me, not a monster. He effortlessly transformed, in my mind, from a body to a person; a history to a story; a situation he survived to an experience he endured.
This may not be a universal perspective, but I know I'm not alone. People love movies and TV series about "the bad guys". American Gangster. Boondock Saints. The Sopranos. Goodfellas. Even the Ocean's 11/12/13 movies. All about bad guys with a heart of gold... or rather, a human heart. All about bad guys with underlying situations and pressures that explain their misgivings. All about bad guys who are conflicted and fighting with themselves... their "lesser demons". There's a new show on HBO about to premiere, Boardwalk Empire, set in Atlantic City at the beginning of prohibition, following the corrupt characters that profit from the radical law. I cannot wait to see it-- it looks so intriguing, and I know that I will be swayed to adore these characters which manipulate and enslave and abuse others for their selfish gain. I love knowing that I'll walk into this series disgusted with their behavior and lack of ethics, but will end each episode with a softer heart for them, until eventually I'll be cheering on their evil-doings because I want to see them succeed and be happier; and probably rooting against the "good guys" trying to shut down their operation.
I'm not cheering for my Monster's resolve to leave the hospital or to evade the police. But I do love that I feel a little more sympathetic for his situation. I love that, by the end of my shift, we were discussing his son and how he adores him and how his son thinks the world of his daddy. He showed me his tattoo for his son, and he softened when I asked him if he wanted to live long enough to watch his young son grow up. We talked about how he hates feeling confined. We talked about how after I leave at the end of my shift, another nurse will take over and propose a lot of the same things I've been talking about-- further care of his heart to prevent this from happening again. And he looked a little sad at the notion that I would leave him and someone else would take over.
I went into his room at the end of my shift to say 'good bye' and to wish him luck with whatever decision he made. He had already fallen back asleep. And like most sleeping people, he didn't look like a monster.
This was the report the unit received. He came to us intubated, all 4 limbs restrained, and on high doses of sedation. Per report, when he "woke up" from sedation, he became "a wild man", trying to pull out his breathing tube and fighting to hit or kick anyone near his bed. This is what necessitated the restraints and the heavy dose of sedative. This is all we knew about this man.
By the time I came to care for him, he had been extubated and his sedation was wearing off. He was beginning to show some personality, something most of us were dreading. "I'll bet he's a peach!", the nurses would add, giving me a "best of luck" look as they left. Truth be told, I was hoping he'd sleep for most of my shift so I wouldn't have to interact with The Monster.
It seems harsh to characterize a patient as a monster. After all, our patients are critically ill and usually desperate for good news or a sense of control. This context rarely brings out the good in people... desperation is an ugly color on anyone. Politeness and patience aren't commonly shown by even the most "civilized" patients in the early recovering stages from a major heart attack or arrhythmia. Gratitude and understanding may develop later, but we don't expect it at first. From this Monster, I didn't expect it at all.
To my surprise, he was pretty easy to speak with. His sedation (and illicit drugs) were slowly wearing off, so he was often disoriented and agitated/scared, but he re-oriented easily and was generally easy to care for. He didn't want to be in the hospital, and he was very clear about his intentions to leave if he didn't get exactly what he wanted. He used coarse language and yelled most of the time, but he wasn't really unlike many of the other patients that I've had... aggravated from not being able to eat, thirsty for anything with more flavor than "a few ice chips" as ordered by the physicians, and generally feeling caged into his bed without much say in matters. Add the shadow of confusion and residual discomfort from a breathing tube and a sore chest from CPR, and most of my patients express themselves in this way at some point in my care... just with less colorful language and a more mild volume. In fact, he was actually a little less offensive, in some ways, because his agitation was clearly directed at his situation and not the nurse "subjecting him to this", as some other patients imply.
The nurse passing him on to me that night began describing him to me in this way, and I commented, "He's not such a monster after all". We laughed, and she said 'good night' to our little Monster, and she headed for the exit. I slid into his room, finding him hot and sweaty from a fever, and confused (again). I went into his room to turn up the AC, and took off his covers, and offered to order him a fan. He grunted something obscene, and kept looking at his bed.
I went to his eye level and said, "Do you know where you are right now?"
"No." ... and some other expletive.
"You're in the hospital."
"I know that!" ... another expletive.
"Do you remember why?"
"No." ... you get the picture.
"You had a major heart attack. We had to restart your heart and give you a breathing tube. That's why your chest and throat are sore."
"Why am I so ** hot?!"
"You have a fever from an infection in your bladder and in your lungs."
"I had a heart attack?"
"Yessir."
"How did I get here?"
"The police found you and called an ambulance and revived you. The paramedics brought you to us. You've been in this room since then."
"The police found me?"
"Yessir."
"What do we do now?"
... I went on to tell him about all the different options. He scoffed at all of them, saying he hates doctors and doesn't want to stay here another minute. I did my usual song and dance about the necessity of staying in the hospital "a little bit longer", or else he'd leave and get sicker and have to return to a hospital for even longer, if he lived to return at all. Sounds harsh, huh? It's a reality. We see it again and again: patients who "hate doctors" and ignore chest pain until they can't breathe anymore and pass out... and usually end up with some degree of brain damage and/or need a major operation. This reality check usually helps with patients, but my Monster didn't care for any of it.
"There's no way I'm coming back after I leave."
"You have a lot of medicine still in your system, so it's not safe for you to leave yet. And you have two major infections that need to be treated or they'll get worse."
"I don't care. I won't come back. I'm just like that... I don't go to doctors."
"With all due respect, Mr. X, you didn't come to the doctors this time... you died and someone brought you back and here you are."
"Well that won't happen again."
I didn't pursue that response... what won't happen again? His heart stopping? Someone finding him? Him finding his way back to the hospital, conscious of it or not? None of these options sounded therapeutic, so I just let it go. At this point, because of the crime he committed and the medicine/drugs still in his system, he wouldn't be allowed to leave the hospital anyway. But I wouldn't tell him that. Again, that didn't sound like therapeutic information.
Reading through this conversation, I'm surprised at myself at how sympathetic I've become towards him. Again, he's not unlike many of my patients that come in with similar health issues. He just come in with a juicy story and sordid reputation in addition to his run-of-the-mill health crisis. But it was so easy to think of him as a monster when he was sedated and intubated, occasionally lashing out (not consciously), but otherwise totally unable to interact with the staff or show us his personality. When the opportunity to see his personality came, even his noxious language and demeanor couldn't obscure the Truth that he was a human being sitting in front of me, not a monster. He effortlessly transformed, in my mind, from a body to a person; a history to a story; a situation he survived to an experience he endured.
This may not be a universal perspective, but I know I'm not alone. People love movies and TV series about "the bad guys". American Gangster. Boondock Saints. The Sopranos. Goodfellas. Even the Ocean's 11/12/13 movies. All about bad guys with a heart of gold... or rather, a human heart. All about bad guys with underlying situations and pressures that explain their misgivings. All about bad guys who are conflicted and fighting with themselves... their "lesser demons". There's a new show on HBO about to premiere, Boardwalk Empire, set in Atlantic City at the beginning of prohibition, following the corrupt characters that profit from the radical law. I cannot wait to see it-- it looks so intriguing, and I know that I will be swayed to adore these characters which manipulate and enslave and abuse others for their selfish gain. I love knowing that I'll walk into this series disgusted with their behavior and lack of ethics, but will end each episode with a softer heart for them, until eventually I'll be cheering on their evil-doings because I want to see them succeed and be happier; and probably rooting against the "good guys" trying to shut down their operation.
I'm not cheering for my Monster's resolve to leave the hospital or to evade the police. But I do love that I feel a little more sympathetic for his situation. I love that, by the end of my shift, we were discussing his son and how he adores him and how his son thinks the world of his daddy. He showed me his tattoo for his son, and he softened when I asked him if he wanted to live long enough to watch his young son grow up. We talked about how he hates feeling confined. We talked about how after I leave at the end of my shift, another nurse will take over and propose a lot of the same things I've been talking about-- further care of his heart to prevent this from happening again. And he looked a little sad at the notion that I would leave him and someone else would take over.
I went into his room at the end of my shift to say 'good bye' and to wish him luck with whatever decision he made. He had already fallen back asleep. And like most sleeping people, he didn't look like a monster.
Sunday, September 12, 2010
Security & Significance
I heard a sermon today that mentioned, in passing, that people are always looking for security & significance. This is the motivation behind people's ambitions, fears, standards, and goals: establishing some form of security and significance. This wasn't the point of the sermon, but in typical-Jenn-fashion, I managed to hear this one line and have it transport me immediately to my patients. I thought about it on a personal level, too, and quickly came up with a list of a dozen fears and goals motivated by gaining security and significance for myself. But I mostly thought about how often I recognize this in my patients, and how often I unknowingly try to appease or appeal to this motivation.
One of my favorite parts of working in an ICU is that I feel like I see people at a very raw state-- totally scared of a diagnosis, totally grateful for a treatment option, etc. In the rest of my world, people express emotions on a more muted scale, not wanting to be over-dramatic in fear or appear to be gloating in joy. But that veil doesn't appear in the ICU-- there's no energy for it. People leave the "socially accepted approach to sharing emotions" at the automated doors of the ER. What's left is a near-raw form of a human, untainted by learned social boundaries. And seeing a sliver of the population in a raw state sheds light on the rest of the population with whom I engage. My patients show a desperate yearning for security and significance, which is no different from "regular" people... it's just more obvious. EVERYONE is seeking security and significance.
(I'm not saying it's wrong to seek these things... I'm not even hinting towards that. The sermon just made the point that what determines how you define security & significance is what will harm or heal you.)
People seeking significance is easy to see in everyday life: wanting to be treated respectfully; not wanting to be just "a number" or "a statistic"; wanting to be unique and admired among colleagues and peers. And it's easiest to spot this desire when it is being threatened-- someone being rude to you and how you respond indignantly; people staying in jobs they detest for the coveted title or opportunity to leave a legacy; even titles like "best friend" or "one true love" indicate ways we appeal to people's desire to be stand out apart from others.
People seeking security is sometimes harder to identify. These ways are kept more subtle, not wanting to "show our cards" for fear of losing their value. But it's there, nonetheless: in how we save or spend money; in which relationships we keep or let fizzle away; even in how we fill up our schedules or claim our free time and hold it tightly. The primary motivation may be difficult to obviously see, but it's deeply there.
If in the real world people's motivation for significance is more obvious but their desire for security is less pronounced, how interesting that it seems to be the opposite for me in the hospital. I recognize both motivations in my patients, but the difficulty in soothing the fears related to losing significance is far harder than soothing the fears related to losing security. Let me show you.
Security: I can reassure my patient that my ICU is exceptional in caring for critically ill patients. I can assure them that we know how to identify issues and how to respond to them appropriately. I can declare that, even when the doctors and I aren't in their room, we are often doing a lot of work related to helping them move towards their health and comfort goals. I can promise them that I care deeply about their pain and relieving it; I can promise to return after 30 minutes to assess how their pain is responding to medications I've given; I can promise that my knowledge of pain management is extensive and that I have many safe methods of pain relief available to them. I can promise to explain things to them to the best of my ability, using videos and pictures, to ensure their understanding. I can pledge to take every reasonable precaution against exposing them to infections or allowing them to accidentally fall, to prevent allergic reactions or causing unnecessary pain. I can guarantee families that I'll call them with updates if anything changes, and I'll promise to be equally diligent in my care, even if they aren't at the bedside "reminding" me.
Significance: Oh dear. I don't even know where to start! This is where people want to stand apart form others and have unique value. I can promise my patients that, during my shift, they are my foremost priority. But the reality is: when my shift ends, so does my compulsion towards them. The reality is: whether that patient dies or improves enough to be discharged, there will soon be another patient in Room 4126 who will become my priority, and another patient after that, and another after that. I will care for, on average, 10-18 different patients per month. So, when my patient seeking to have significance is assigned to me, they are my priority... until 7pm shows its face or that patient evacuates my room. That seems to be a pretty short-lived significance.
Just because they stop being my assignment doesn't mean I never think of them... of course I do! This blog proves it: interactions stay with me, episodes of raw emotions are burned in my memory, and miraculous healings or devastating downturns remain with me longer than I'd like, at times. I remember names and faces and quirks about many of my patients. But how do I assure them of that, without naming a dozen other patients that have significance to me? Telling someone s/he is significant by identifying my hefty list of other "significant" people belittles the designation.
I have no fears that I actually consider patients insignificant. That is ingrained in me, so deep that I can't really identify where I got the notion, but the weight with which I respond to that notion testifies to how fundamental it is in me. Let me show you again.
While I was in nursing school, I had a conversation with a few friends about the eccentricities of being a nurse. One girl, another Christian in the nursing school, made the comment, "What good is it to help these people if we can't preach to them about the Gospel? Why bother helping their physical bodies if we can't help their souls?" I was disgusted. DISGUSTED. Why bother?? Because everybody is valuable, that's why! People don't deserve my attention because I can "save their soul"-- they deserve my attention because they have a soul! The image of God in all of us; the fact that every good thing comes from God whether the recipient believes that or not; the truth that Grace is offered to everyone, not just those who will accept it or those to "earn" it... these are things that are common to everyone, just like the yearning for security and significance. And because of that, because His imprint and His gifts are distributed to everyone, we are called to love everyone. People aren't projects-- they're image-bearers. And there is innate significance from that fact alone.
But how do I show that to my patients? How do I show them that I love them because they merely exist and are in my presence?
One thing I do know is that I can prioritize recognizing their significance over asserting my own significance because my significance rests securely in Christ: I don't have to assert it 24/7. I can strive to offer security by honoring my promises, and by continuing to love and care for and forgive people despite their faults. But I also know that my significance doesn't come from my ability (or, more often, inability) to keep these promises perfectly. Nor is that the source of my security. My security and significance come from promises that have already been fulfilled and other promises He will faithfully keep. As long as I try to remember that Truth, I can try to help others recognize it for themselves, too.
In the meantime, I guess I'll do the only thing I know how to do for my patients: give them my full attention. That's what everybody deserves, afterall.
One of my favorite parts of working in an ICU is that I feel like I see people at a very raw state-- totally scared of a diagnosis, totally grateful for a treatment option, etc. In the rest of my world, people express emotions on a more muted scale, not wanting to be over-dramatic in fear or appear to be gloating in joy. But that veil doesn't appear in the ICU-- there's no energy for it. People leave the "socially accepted approach to sharing emotions" at the automated doors of the ER. What's left is a near-raw form of a human, untainted by learned social boundaries. And seeing a sliver of the population in a raw state sheds light on the rest of the population with whom I engage. My patients show a desperate yearning for security and significance, which is no different from "regular" people... it's just more obvious. EVERYONE is seeking security and significance.
(I'm not saying it's wrong to seek these things... I'm not even hinting towards that. The sermon just made the point that what determines how you define security & significance is what will harm or heal you.)
People seeking significance is easy to see in everyday life: wanting to be treated respectfully; not wanting to be just "a number" or "a statistic"; wanting to be unique and admired among colleagues and peers. And it's easiest to spot this desire when it is being threatened-- someone being rude to you and how you respond indignantly; people staying in jobs they detest for the coveted title or opportunity to leave a legacy; even titles like "best friend" or "one true love" indicate ways we appeal to people's desire to be stand out apart from others.
People seeking security is sometimes harder to identify. These ways are kept more subtle, not wanting to "show our cards" for fear of losing their value. But it's there, nonetheless: in how we save or spend money; in which relationships we keep or let fizzle away; even in how we fill up our schedules or claim our free time and hold it tightly. The primary motivation may be difficult to obviously see, but it's deeply there.
If in the real world people's motivation for significance is more obvious but their desire for security is less pronounced, how interesting that it seems to be the opposite for me in the hospital. I recognize both motivations in my patients, but the difficulty in soothing the fears related to losing significance is far harder than soothing the fears related to losing security. Let me show you.
Security: I can reassure my patient that my ICU is exceptional in caring for critically ill patients. I can assure them that we know how to identify issues and how to respond to them appropriately. I can declare that, even when the doctors and I aren't in their room, we are often doing a lot of work related to helping them move towards their health and comfort goals. I can promise them that I care deeply about their pain and relieving it; I can promise to return after 30 minutes to assess how their pain is responding to medications I've given; I can promise that my knowledge of pain management is extensive and that I have many safe methods of pain relief available to them. I can promise to explain things to them to the best of my ability, using videos and pictures, to ensure their understanding. I can pledge to take every reasonable precaution against exposing them to infections or allowing them to accidentally fall, to prevent allergic reactions or causing unnecessary pain. I can guarantee families that I'll call them with updates if anything changes, and I'll promise to be equally diligent in my care, even if they aren't at the bedside "reminding" me.
Significance: Oh dear. I don't even know where to start! This is where people want to stand apart form others and have unique value. I can promise my patients that, during my shift, they are my foremost priority. But the reality is: when my shift ends, so does my compulsion towards them. The reality is: whether that patient dies or improves enough to be discharged, there will soon be another patient in Room 4126 who will become my priority, and another patient after that, and another after that. I will care for, on average, 10-18 different patients per month. So, when my patient seeking to have significance is assigned to me, they are my priority... until 7pm shows its face or that patient evacuates my room. That seems to be a pretty short-lived significance.
Just because they stop being my assignment doesn't mean I never think of them... of course I do! This blog proves it: interactions stay with me, episodes of raw emotions are burned in my memory, and miraculous healings or devastating downturns remain with me longer than I'd like, at times. I remember names and faces and quirks about many of my patients. But how do I assure them of that, without naming a dozen other patients that have significance to me? Telling someone s/he is significant by identifying my hefty list of other "significant" people belittles the designation.
I have no fears that I actually consider patients insignificant. That is ingrained in me, so deep that I can't really identify where I got the notion, but the weight with which I respond to that notion testifies to how fundamental it is in me. Let me show you again.
While I was in nursing school, I had a conversation with a few friends about the eccentricities of being a nurse. One girl, another Christian in the nursing school, made the comment, "What good is it to help these people if we can't preach to them about the Gospel? Why bother helping their physical bodies if we can't help their souls?" I was disgusted. DISGUSTED. Why bother?? Because everybody is valuable, that's why! People don't deserve my attention because I can "save their soul"-- they deserve my attention because they have a soul! The image of God in all of us; the fact that every good thing comes from God whether the recipient believes that or not; the truth that Grace is offered to everyone, not just those who will accept it or those to "earn" it... these are things that are common to everyone, just like the yearning for security and significance. And because of that, because His imprint and His gifts are distributed to everyone, we are called to love everyone. People aren't projects-- they're image-bearers. And there is innate significance from that fact alone.
But how do I show that to my patients? How do I show them that I love them because they merely exist and are in my presence?
One thing I do know is that I can prioritize recognizing their significance over asserting my own significance because my significance rests securely in Christ: I don't have to assert it 24/7. I can strive to offer security by honoring my promises, and by continuing to love and care for and forgive people despite their faults. But I also know that my significance doesn't come from my ability (or, more often, inability) to keep these promises perfectly. Nor is that the source of my security. My security and significance come from promises that have already been fulfilled and other promises He will faithfully keep. As long as I try to remember that Truth, I can try to help others recognize it for themselves, too.
In the meantime, I guess I'll do the only thing I know how to do for my patients: give them my full attention. That's what everybody deserves, afterall.
Saturday, August 28, 2010
Just a Nurse
I had a patient several times last week. The man was in his 60s, admitted for a heart rhythm that continued to come & go, despite several procedures and medications to stop it. So, after being at multiple advanced medical venues, he had been sent to UVA Hospital for further evaluation of what last-ditch-effort we could offer him.
Mr. Y was curiously normal. I'm used to patients with severe medical issues, and usually some accompanying mental issues... severe anxiety, depression, anxiety, control disorders, anxiety, massive trust issues, and ANXIETY. But Mr. Y had none of these things... besides this heart rhythm that occasionally made his implanted defibrillator go off, make him slightly short of breath, and generally drained his energy, he was totally normal! He didn't need to wear extra oxygen, have multiple medications to stabilize his blood pressure, or require dialysis to recover his kidneys. He just mulled about his room, reading newspapers and shaving his face and watching the building construction across the street. He was waiting for the procedure our docs decided was his best option.
The only two issues with this individual that I had to handle were his significant hearing loss and his apparent short-term memory deficit. I don't think he even really knew that he had a short-term memory problem, but after caring for him for 4 days and having essentially the same 5 conversations with him again and again, it became abundantly apparent to myself and my staff. His room was near the nurses' station and the break room, so anyone not in another patient's room would hear us repeat one of these 5 convos LOUDLY (hearing loss to the degree of needing to sit 6 inches from his "good" ear or kindly yell at him from the end of the bed).
*My co-workers, jokesters that they are, made many comments like "deja vu?" or "50 first dates" or "memorized your script yet?". Humor... it gets us through many 12-hour shifts.
The conversations we'd have over and over again would mostly pertain to the upcoming surgery, why his heart wasn't responding to normal therapies, or what other options he'd have if the surgery didn't work. Because these require extensive explanations, and because he was so hard of hearing, I would usually sit next to his bed to explain them to him. After any of these conversations, as I was about to leave to do other work, we would nearly always have this conversation:
Him: Thank you so much for explaining that to me.
Me: No problem. I hope you understand it better and feel more confident about the plan.
Him: I think I do, thank you. You did a great job explaining it to me.
Me: Well I have to explain this stuff to patients all the time, so I've found what works and what doesn't.
Him: Have you thought about going to medical school?
Me: No-- I have no desire to be a doctor.
Him: Really? I think you're too good to just be a nurse. You're wasting your talent. I think you'd be a great doctor.
Me: I think you think that because I sit down and explain things to you, make general conversation with you, and help you with little things.
Him: Exactly! If other doctors were like you, they'd be great!
Me: But I can only do those things because I'm not a doctor-- it's my job to do stuff like that with my patients. My job lets me focus on just you and one or two other patients, but our doctors care for a lot of patients, so they don't have time for that.
Him: Well I think you're wasting your talent. You're too smart and nice to be a nurse. It's a waste.
Me: I don't think I'm wasting it at all-- clearly I can use my understanding of this stuff to break it down for my patients-- and that's a worthwhile use of my talent!
Him: I think you could do better for yourself.
*I had this near exact conversation with him several times, but the last few times I would just say "I like being a nurse and never want to be a doctor" and basically change the subject... I can only be accused of "just being a nurse" so many times...
He was trying to compliment me. Or encourage me. Either way, I'm not offended by the interaction at all... just very disappointed that this is the way some people view doctors and nurses. As if all nurses had the goal of becoming a doctor, but fell short because of lack of money or lack of motivation or lack of intelligence... that all nurses were lacking. I wish I could send out a massive Public Service Announcement that made this point abundantly clear: Nurses go to Nursing School; Doctors go to Medical School. Two different schools... two different curriculums... two different goals... two different JOBS. Of course there are areas of overlap in what we learn-- we both have to understand the body and how it reacts to disease and medicines, we have to know medicines and how they interact with each other, and we have to understand the fundamentals of law/ethics/cultures as they relate to medicine.
But being a superb nurse doesn't mean I'm just a stone's throw away from being an MD any more than being a mediocre MD means you might as well be a nurse; it's a different job altogether! And the things that make me a good nurse often wouldn't translate well into a job as a physician. Can you imagine if I spent all this time explaining things to patients over and over again, for each of the 17 patients I'm in charge of that day? There's already a shortage of healthcare providers and appointments, and that is with very efficient doctors and nurse practitioners guiding it! Or if, in my preparations for morning patient rounds, I notice that one patient has urinated on himself and I took the time to give him a full bath and change all the sheets on his bed? I'd never get my act together in time for morning rounds! And that would hold-up the discussion and planning for the very patient I was trying to help! What if for every concern expressed about lack of insurance, expensive medications, the awful food, or difficulty getting up the stairs at home, I made a phone call to the social worker, pharmacist, dietician, and physical therapist. For each patient? Everytime I interacted with them?? Medically, nothing would get done!
There are just under 1 million doctors and approximately 2.5 million nurses. This is a legitimate ratio-- the nurses need to be more abundant because of all the minutiae we handle while the doctors' primary role is to handle the "big picture" and give orders. Both of us are problem-solvers, require creativity and ingenuity, necessitate skills in prioritizing and delegating, and must be compassionate to some degree. But we focus our efforts in different ways.
Remember back to being a student and having a great teacher. What made them a great teacher wouldn't necessarily translate into being a great principal or adminstrator. Their charisma, organization, and availability to the students are amazing attributes for teachers, but there are other priorities for adminstrators. It's natural for some teachers to take the path of eventually becoming an adminstrator, but I bet you could talk to any principal about their early months in that new role and hear about how their great teaching strategies didn't immediately "translate" into being a superb principal... different skills had to be developed to achieve that!
I'm slowly on my way to getting my Masters in Nursing degree. I'm pursuing it for many reasons-- while I love my job now, I recognize that I can't maintain this lifestyle for 20 years. What will I do that's still challenging and rewarding when that day comes? Having my MSN will prepare me for more options (unit nurse manager? transplant coordinator? patient educator?). I also recognize that one of my skills in nursing is that I can explain things to people easily. I would love to translate that skill into being a clinical instructor and help prepare future nurses! I need my MSN to (officially) do that.
The first time I had that conversation with Mr. Y, I had just found out I'd gotten into my first graduate nursing class. I was elated! And then I had that conversation with him, and the distance between his mind and mine felt immeasurable.
I want to invest in this field, and he thought I should abandon it entirely. But wouldn't that be a waste?
Mr. Y was curiously normal. I'm used to patients with severe medical issues, and usually some accompanying mental issues... severe anxiety, depression, anxiety, control disorders, anxiety, massive trust issues, and ANXIETY. But Mr. Y had none of these things... besides this heart rhythm that occasionally made his implanted defibrillator go off, make him slightly short of breath, and generally drained his energy, he was totally normal! He didn't need to wear extra oxygen, have multiple medications to stabilize his blood pressure, or require dialysis to recover his kidneys. He just mulled about his room, reading newspapers and shaving his face and watching the building construction across the street. He was waiting for the procedure our docs decided was his best option.
The only two issues with this individual that I had to handle were his significant hearing loss and his apparent short-term memory deficit. I don't think he even really knew that he had a short-term memory problem, but after caring for him for 4 days and having essentially the same 5 conversations with him again and again, it became abundantly apparent to myself and my staff. His room was near the nurses' station and the break room, so anyone not in another patient's room would hear us repeat one of these 5 convos LOUDLY (hearing loss to the degree of needing to sit 6 inches from his "good" ear or kindly yell at him from the end of the bed).
*My co-workers, jokesters that they are, made many comments like "deja vu?" or "50 first dates" or "memorized your script yet?". Humor... it gets us through many 12-hour shifts.
The conversations we'd have over and over again would mostly pertain to the upcoming surgery, why his heart wasn't responding to normal therapies, or what other options he'd have if the surgery didn't work. Because these require extensive explanations, and because he was so hard of hearing, I would usually sit next to his bed to explain them to him. After any of these conversations, as I was about to leave to do other work, we would nearly always have this conversation:
Him: Thank you so much for explaining that to me.
Me: No problem. I hope you understand it better and feel more confident about the plan.
Him: I think I do, thank you. You did a great job explaining it to me.
Me: Well I have to explain this stuff to patients all the time, so I've found what works and what doesn't.
Him: Have you thought about going to medical school?
Me: No-- I have no desire to be a doctor.
Him: Really? I think you're too good to just be a nurse. You're wasting your talent. I think you'd be a great doctor.
Me: I think you think that because I sit down and explain things to you, make general conversation with you, and help you with little things.
Him: Exactly! If other doctors were like you, they'd be great!
Me: But I can only do those things because I'm not a doctor-- it's my job to do stuff like that with my patients. My job lets me focus on just you and one or two other patients, but our doctors care for a lot of patients, so they don't have time for that.
Him: Well I think you're wasting your talent. You're too smart and nice to be a nurse. It's a waste.
Me: I don't think I'm wasting it at all-- clearly I can use my understanding of this stuff to break it down for my patients-- and that's a worthwhile use of my talent!
Him: I think you could do better for yourself.
*I had this near exact conversation with him several times, but the last few times I would just say "I like being a nurse and never want to be a doctor" and basically change the subject... I can only be accused of "just being a nurse" so many times...
He was trying to compliment me. Or encourage me. Either way, I'm not offended by the interaction at all... just very disappointed that this is the way some people view doctors and nurses. As if all nurses had the goal of becoming a doctor, but fell short because of lack of money or lack of motivation or lack of intelligence... that all nurses were lacking. I wish I could send out a massive Public Service Announcement that made this point abundantly clear: Nurses go to Nursing School; Doctors go to Medical School. Two different schools... two different curriculums... two different goals... two different JOBS. Of course there are areas of overlap in what we learn-- we both have to understand the body and how it reacts to disease and medicines, we have to know medicines and how they interact with each other, and we have to understand the fundamentals of law/ethics/cultures as they relate to medicine.
But being a superb nurse doesn't mean I'm just a stone's throw away from being an MD any more than being a mediocre MD means you might as well be a nurse; it's a different job altogether! And the things that make me a good nurse often wouldn't translate well into a job as a physician. Can you imagine if I spent all this time explaining things to patients over and over again, for each of the 17 patients I'm in charge of that day? There's already a shortage of healthcare providers and appointments, and that is with very efficient doctors and nurse practitioners guiding it! Or if, in my preparations for morning patient rounds, I notice that one patient has urinated on himself and I took the time to give him a full bath and change all the sheets on his bed? I'd never get my act together in time for morning rounds! And that would hold-up the discussion and planning for the very patient I was trying to help! What if for every concern expressed about lack of insurance, expensive medications, the awful food, or difficulty getting up the stairs at home, I made a phone call to the social worker, pharmacist, dietician, and physical therapist. For each patient? Everytime I interacted with them?? Medically, nothing would get done!
There are just under 1 million doctors and approximately 2.5 million nurses. This is a legitimate ratio-- the nurses need to be more abundant because of all the minutiae we handle while the doctors' primary role is to handle the "big picture" and give orders. Both of us are problem-solvers, require creativity and ingenuity, necessitate skills in prioritizing and delegating, and must be compassionate to some degree. But we focus our efforts in different ways.
Remember back to being a student and having a great teacher. What made them a great teacher wouldn't necessarily translate into being a great principal or adminstrator. Their charisma, organization, and availability to the students are amazing attributes for teachers, but there are other priorities for adminstrators. It's natural for some teachers to take the path of eventually becoming an adminstrator, but I bet you could talk to any principal about their early months in that new role and hear about how their great teaching strategies didn't immediately "translate" into being a superb principal... different skills had to be developed to achieve that!
I'm slowly on my way to getting my Masters in Nursing degree. I'm pursuing it for many reasons-- while I love my job now, I recognize that I can't maintain this lifestyle for 20 years. What will I do that's still challenging and rewarding when that day comes? Having my MSN will prepare me for more options (unit nurse manager? transplant coordinator? patient educator?). I also recognize that one of my skills in nursing is that I can explain things to people easily. I would love to translate that skill into being a clinical instructor and help prepare future nurses! I need my MSN to (officially) do that.
The first time I had that conversation with Mr. Y, I had just found out I'd gotten into my first graduate nursing class. I was elated! And then I had that conversation with him, and the distance between his mind and mine felt immeasurable.
I want to invest in this field, and he thought I should abandon it entirely. But wouldn't that be a waste?
Wednesday, July 28, 2010
Joy Comes In The Morning
This has been an incredible summer at work-- I feel like I hear of a new heart transplant recipient every other week. Because I see heart failure patients, I am used to seeing the same patients over and over again... as their hearts get worse, they need hospitalization to readjust medications and (temporarily) reverse other organ damage from their ill-equipped heart. In addition to that, new devices have been released that help heart failure patients survive longer on the heart transplant list. Between these exacerbations in their heart failure and the placement of these heart-helper devices, I see these patients and their families relatively frequently. It's one of my favorite parts of my area of medicine-- I love that there is the potential for me to see patients go through their whole heart failure course, and come out healthier.
That's what Ms. X is to me. She came into the hospital because her heart stopped suddenly. The rescue squad was able to revive her, and in her stay at the hospital she received a pacemaker with a built-in defibrillator (in case her heart stopped again). That was the first heart issue she'd ever had-- completely out of the blue! And she got her money's worth of that defibrillator-- hospitalization #2 was because of multiple shocks from her implanted defibrillator. So many shocks, in fact, that it nearly drained the battery in her pacemaker (the average pacemaker battery lasts YEARS and her lasted maybe 3 months). Her heart kept stopping because it was failing-- the muscle just didn't want to function anymore. She had cycles like this for a while-- she'd get shocked, she'd have medications adjusted or pacemaker settings adjusted, and she'd go home only to be shocked again a while later. Finally her heart wasn't able to maintain this mode, and she needed an artificial heart device to sustain her while she waited for a heart transplant. She had the intense surgery to place the device, recovered in the hospital, and was sent home to wait for a new heart to become available.
That's the language we use-- "wait for a new heart to become available"-- as though we were waiting for the iPad to be restocked at Best Buy. What we really mean is that we're waiting for a relatively healthy person to die in such a way that their heart can be preserved and then be given to Ms. X. We're waiting for a tragedy to enable a miracle.
And it's always a tragedy that makes hearts available. Kidneys and livers and lungs can come from healthy living (consenting) people. Hearts can only come from healthy deceased persons ("healthy deceased"? Even describing the process is difficult...). It can't come from someone who has been ill for a while, so the families have had time to prepare and make arrangements. It comes from a diving accident that destroys the spinal cord, or a motorcycle accident that damages the brain, or a bleeding in the brain that was totally unforeseeable and unable to be remedied. These are the families that are approached for organ donation-- families in the midst of calamity are being approached with an opportunity to offer hope to someone else.
I have recently been focusing on God's faithfulness in my life. I've been taking time to remember the processes that got me to where I am now-- boarding school, nursing school, the unit I work on currently, and how I happened to meet some of my best friends. It's amazing how easy it is for me to be totally ignorant of how God arranged these events in my life. While focusing on God's faithfulness, I heard a sermon called "Praying God's Faithfulness" about Psalm 30. I won't print it all here, but the message is basically about how there are times of trouble, but looking back at when God provided before helps David have hope and confidence in God's presence even in the midst of the present pain. Past (memory), future (confidence) and present (hope).
Psalm 30:5 For his anger lasts only a moment, but his favor lasts a lifetime; weeping may remain for a night, but rejoicing comes in the morning.
That is what we are hoping people will understand when we approach them with organ donation. We hope, for their sakes and for organ recipients, they'll remember that joy comes in the morning.
Ms. X received her new heart this summer. While caring for her one day, I asked how she felt about having a new heart. Most patients feel an ocean of emotions-- fear of organ rejection, anxiety over the intense anti-rejection pill regimen, hope of returning to a semi-normal life... and oftentimes a little bit of guilt over getting someone else's heart. She said she felt selfish praying for a heart transplant because she knew someone had to die in order that she can live. I reminded her her that her heart transplant didn't kill anyone-- it just kept that heart from being buried in a coffin or cremated into dust. The tragedy would have happened anyway, but organ donation gives families an opportunity to see a silver lining in the tragedy. I'm struggling to accurately describe how families report feeling about this... silver lining sounds too simple and almost making them content. Basically, families are given an opportunity to see the disaster as being more than just futile pain-- there can be a purpose after the tragedy that they can take part in. I've seen a family receive news that the patient was unable to be an organ donor (due to other health issues), and it sincerely looked as though they were receiving the stamp of futility on what was an already barely-bearable circumstance.
I love organ donation for many reasons, but seeing hope in the midst of heartbreak is the foundation of my passion. It challenges our culture's selfishness and focus on the present circumstances and asks us to consider others and the future... the look to the morning.
That's what Ms. X is to me. She came into the hospital because her heart stopped suddenly. The rescue squad was able to revive her, and in her stay at the hospital she received a pacemaker with a built-in defibrillator (in case her heart stopped again). That was the first heart issue she'd ever had-- completely out of the blue! And she got her money's worth of that defibrillator-- hospitalization #2 was because of multiple shocks from her implanted defibrillator. So many shocks, in fact, that it nearly drained the battery in her pacemaker (the average pacemaker battery lasts YEARS and her lasted maybe 3 months). Her heart kept stopping because it was failing-- the muscle just didn't want to function anymore. She had cycles like this for a while-- she'd get shocked, she'd have medications adjusted or pacemaker settings adjusted, and she'd go home only to be shocked again a while later. Finally her heart wasn't able to maintain this mode, and she needed an artificial heart device to sustain her while she waited for a heart transplant. She had the intense surgery to place the device, recovered in the hospital, and was sent home to wait for a new heart to become available.
That's the language we use-- "wait for a new heart to become available"-- as though we were waiting for the iPad to be restocked at Best Buy. What we really mean is that we're waiting for a relatively healthy person to die in such a way that their heart can be preserved and then be given to Ms. X. We're waiting for a tragedy to enable a miracle.
And it's always a tragedy that makes hearts available. Kidneys and livers and lungs can come from healthy living (consenting) people. Hearts can only come from healthy deceased persons ("healthy deceased"? Even describing the process is difficult...). It can't come from someone who has been ill for a while, so the families have had time to prepare and make arrangements. It comes from a diving accident that destroys the spinal cord, or a motorcycle accident that damages the brain, or a bleeding in the brain that was totally unforeseeable and unable to be remedied. These are the families that are approached for organ donation-- families in the midst of calamity are being approached with an opportunity to offer hope to someone else.
I have recently been focusing on God's faithfulness in my life. I've been taking time to remember the processes that got me to where I am now-- boarding school, nursing school, the unit I work on currently, and how I happened to meet some of my best friends. It's amazing how easy it is for me to be totally ignorant of how God arranged these events in my life. While focusing on God's faithfulness, I heard a sermon called "Praying God's Faithfulness" about Psalm 30. I won't print it all here, but the message is basically about how there are times of trouble, but looking back at when God provided before helps David have hope and confidence in God's presence even in the midst of the present pain. Past (memory), future (confidence) and present (hope).
Psalm 30:5 For his anger lasts only a moment, but his favor lasts a lifetime; weeping may remain for a night, but rejoicing comes in the morning.
That is what we are hoping people will understand when we approach them with organ donation. We hope, for their sakes and for organ recipients, they'll remember that joy comes in the morning.
Ms. X received her new heart this summer. While caring for her one day, I asked how she felt about having a new heart. Most patients feel an ocean of emotions-- fear of organ rejection, anxiety over the intense anti-rejection pill regimen, hope of returning to a semi-normal life... and oftentimes a little bit of guilt over getting someone else's heart. She said she felt selfish praying for a heart transplant because she knew someone had to die in order that she can live. I reminded her her that her heart transplant didn't kill anyone-- it just kept that heart from being buried in a coffin or cremated into dust. The tragedy would have happened anyway, but organ donation gives families an opportunity to see a silver lining in the tragedy. I'm struggling to accurately describe how families report feeling about this... silver lining sounds too simple and almost making them content. Basically, families are given an opportunity to see the disaster as being more than just futile pain-- there can be a purpose after the tragedy that they can take part in. I've seen a family receive news that the patient was unable to be an organ donor (due to other health issues), and it sincerely looked as though they were receiving the stamp of futility on what was an already barely-bearable circumstance.
I love organ donation for many reasons, but seeing hope in the midst of heartbreak is the foundation of my passion. It challenges our culture's selfishness and focus on the present circumstances and asks us to consider others and the future... the look to the morning.
Wednesday, June 30, 2010
Worth It
"Patients, doctors, nurses, and others may not share a common set of beliefs around the meaning of life, value of extended life, significance of suffering, or the appropriate use of technology... To truly benefit patients, the health care team must ask, 'In what ways does this patient need our assistance and support to achieve the patient's desired outcome?'" Roots of Interdisciplinary Conflict Around Ethical Issues, Sarah E. Shannon, PhD, RN
I read this article as part of a packet I'm supposed to read for a Moral Distress Consult Service I'm joining through the hospital. I thought it was going to be a service where we basically went through and heard people's issues with a particular ethical debate about a patient. Based on this packet, however, it doesn't sound like we'll be educating people on the actual ethics of any situations, but rather their own personal p.o.v. and how it is playing into their distress.
I don't think it'll come as a surprise that sometimes nurses and doctors disagree. Basically, the conflict boils down to nurses feeling like they really know the patient and the situation better than the physician and should therefore play a larger role in the decision-making about the medical plan for said patient. Physicians, on the other hand, feel more of a responsibility for the medical plan because they sign off on it with their license, earned through mastering the information. The picture is this: physicians sign off on orders that nurses carry out, so if nurses disagree with the plan of care, they feel that they are literally going against their beliefs when they act out these orders. Nurses often forget, however, that physicians sign off on these orders, and are generally held to a higher legal obligation than nurses are.
Even this summary is biased-- it paints doctors as being mostly concerned for themselves and ensuring they can keep their license, while nurses care more about the actual patient. This isn't so; everyone in the health care team prioritizes the patient... but I don't know how to paint a different picture because of my job position. This is what I experience in my job and what I hear other nurses experience. I'm sure if I was a fly on the wall of a doctor get-together, I'd hear their frustrations in a different light.
But you get the point.
The quote at the top is trying to make a different point, though. Not that it's RNs vs. MDs, but person vs. person. Every individual has a different set of values. And in America, it's your own individual values that determine your medical treatment. This means that, almost inevitably, your medical decisions will conflict with your medical team. And the different members of the medical team will conflict with each other.
I can hear it within myself all the time.
Situation: Patient is unconscious, family is indecisive on what to do, and physicians offer them many options, including many extreme life-sustaining measures with little percentage of a meaningful life, even with recovery.
My P.O.V.: I can think of 100 patients who die and/or recover to a minimal quality of life for every 1 patient who has a meaningful recovery. I also paint the physician as having an attitude of "Because we can do tests means we should do tests".
Problem: I base my opinion on my experience, not on statistics or the values of the patient and family. I also undervalue the use of technology (compared to the Md's perceived value of technology). I also use my own beliefs to determine what a "meaningful life" looks like, rather than the patient or family.
Situation: Patient has terminal illness, has been hospitalized a dozen times for the same issues related to the progression of the terminal illness. Each time the patient is discharged home with less and less ability to lead a "normal" life. Their quality of life exponentially decreasing, and inevitably this patient will code and we'll bring them back for maybe a day or two before they code again, and again and again, until finally we are unable to help them. The medical team conveys this likely course of illness to the patient, but the patient still insists on "having everything done" for them to prevent (or, realistically, barely delay) dying.
My P.O.V.: The patient is afraid to die and is being cowardly about his/her own mortality. Or this patient clearly doesn't know what they're getting themselves into! They don't know how painful it is to have CPR multiple times, be electrically shocked multiple times, or have a plastic tube inserted into their lungs multiple times! They don't really understand that they won't recover. They don't really understand how miserable their life will be when they have a permanent breathing machine attached to the surgically-implanted breathing tube, have a surgically-placed feeding tube placed in their abdomen, and have multiple sores from being bedbound and vulnerable to infection. They just need more education.
Problem: I am undervaluing the value of extended life (compared to the patient). In most cases, patients have been educated to the likely course of the illness and make an educated decision to have the full plan anyway. Another problem is that I have a different understanding of the meaning of life, and therefore the meaning of dying, and that makes me feel superior compared to their meaning. Yet another problem is that I am overvaluing the significance of suffering (compared to the patient). It's not that that patient doesn't understand how uncomfortable life will really be (especially because most of these patients have been intubated and resuscitated before, so they have more experience in those areas than I do, seeing as my heart and lungs have never stopped functioning before...), but that patients really do want every opportunity to recover and extend their life, and the suffering is therefore worth it.
Oh that phrase... worth it. This is the silver bullet when arguing with physicians, patients, and families. We all view our priorities and values as a set-in-stone hierarchy that determines if something is worth it. And if someone else's values differ, it's because of ignorance or fear of dying or over/undervaluing something (technology, quality of life, suffering, the financial cost of the care, the cost to the family for extending care, etc).
Everyone has a set of beliefs about these things, mine just happens to come from the Bible and from hospital experience. I have seen too many people die in pain to ever want undue pain in my own hospital stays-- if it doesn't have a definite outcome to benefit or save areas of my life that are important to me (i.e. having kids, rehab from surgery, etc), I don't want it. I also have a different sense of quality of life. I love my brain and listening to music and stories, so if I lost the ability to appreciate any of those things (i.e. major brain damage) I would have a strong hesitancy to extend my life... but I'm not all too-attached to my physical abilities (like an athlete might be, for instance) so the loss of those functions would be less devestating (still devestating, but still worth it to keep living).
But the biggest determinant of my values is my confidence in salvation and knowing that there's something more for me. I know that when I die, whether through disease or disaster or natural lifespan, I'm going to the same place. I know that I have been put on this earth, in this life and this job and this community, for God's purposes; so when He calls me Home, I can go Home. I can suffer to preserve my role in His purpose (i.e. continuing to raise children, or continuing in a career or vocation), but not for the sake of preserving my life. I don't need to keep living to solidify an identity for myself, or leave a legacy, or answer life's questions... I can die and gain all those things in Heaven. And I have a larger fear of suffering than I do of dying for this reason-- which is why I probably overvalue suffering (even from a Biblical perspective, suffering is necessary and I drag my feet to accept that) and undervalue extending my life.
My perspective isn't perfect because it still comes from my sinful heart and is acted out by my sinful body and is thought-through by my sinful mind. But other people have perspectives that can come from the wrong foundation-- from fear of dying because they don't have salvation, or fear of losing their current quality of life because they don't have anything else as a base for their identity. And, as a Christian, these are the foundations I'm supposed to rattle. I'm supposed to make you think about Eternity and the Purpose (and gift!) of life.
... but I have to admit, sometimes even that battle with people doesn't feel worth it.
I read this article as part of a packet I'm supposed to read for a Moral Distress Consult Service I'm joining through the hospital. I thought it was going to be a service where we basically went through and heard people's issues with a particular ethical debate about a patient. Based on this packet, however, it doesn't sound like we'll be educating people on the actual ethics of any situations, but rather their own personal p.o.v. and how it is playing into their distress.
I don't think it'll come as a surprise that sometimes nurses and doctors disagree. Basically, the conflict boils down to nurses feeling like they really know the patient and the situation better than the physician and should therefore play a larger role in the decision-making about the medical plan for said patient. Physicians, on the other hand, feel more of a responsibility for the medical plan because they sign off on it with their license, earned through mastering the information. The picture is this: physicians sign off on orders that nurses carry out, so if nurses disagree with the plan of care, they feel that they are literally going against their beliefs when they act out these orders. Nurses often forget, however, that physicians sign off on these orders, and are generally held to a higher legal obligation than nurses are.
Even this summary is biased-- it paints doctors as being mostly concerned for themselves and ensuring they can keep their license, while nurses care more about the actual patient. This isn't so; everyone in the health care team prioritizes the patient... but I don't know how to paint a different picture because of my job position. This is what I experience in my job and what I hear other nurses experience. I'm sure if I was a fly on the wall of a doctor get-together, I'd hear their frustrations in a different light.
But you get the point.
The quote at the top is trying to make a different point, though. Not that it's RNs vs. MDs, but person vs. person. Every individual has a different set of values. And in America, it's your own individual values that determine your medical treatment. This means that, almost inevitably, your medical decisions will conflict with your medical team. And the different members of the medical team will conflict with each other.
I can hear it within myself all the time.
Situation: Patient is unconscious, family is indecisive on what to do, and physicians offer them many options, including many extreme life-sustaining measures with little percentage of a meaningful life, even with recovery.
My P.O.V.: I can think of 100 patients who die and/or recover to a minimal quality of life for every 1 patient who has a meaningful recovery. I also paint the physician as having an attitude of "Because we can do tests means we should do tests".
Problem: I base my opinion on my experience, not on statistics or the values of the patient and family. I also undervalue the use of technology (compared to the Md's perceived value of technology). I also use my own beliefs to determine what a "meaningful life" looks like, rather than the patient or family.
Situation: Patient has terminal illness, has been hospitalized a dozen times for the same issues related to the progression of the terminal illness. Each time the patient is discharged home with less and less ability to lead a "normal" life. Their quality of life exponentially decreasing, and inevitably this patient will code and we'll bring them back for maybe a day or two before they code again, and again and again, until finally we are unable to help them. The medical team conveys this likely course of illness to the patient, but the patient still insists on "having everything done" for them to prevent (or, realistically, barely delay) dying.
My P.O.V.: The patient is afraid to die and is being cowardly about his/her own mortality. Or this patient clearly doesn't know what they're getting themselves into! They don't know how painful it is to have CPR multiple times, be electrically shocked multiple times, or have a plastic tube inserted into their lungs multiple times! They don't really understand that they won't recover. They don't really understand how miserable their life will be when they have a permanent breathing machine attached to the surgically-implanted breathing tube, have a surgically-placed feeding tube placed in their abdomen, and have multiple sores from being bedbound and vulnerable to infection. They just need more education.
Problem: I am undervaluing the value of extended life (compared to the patient). In most cases, patients have been educated to the likely course of the illness and make an educated decision to have the full plan anyway. Another problem is that I have a different understanding of the meaning of life, and therefore the meaning of dying, and that makes me feel superior compared to their meaning. Yet another problem is that I am overvaluing the significance of suffering (compared to the patient). It's not that that patient doesn't understand how uncomfortable life will really be (especially because most of these patients have been intubated and resuscitated before, so they have more experience in those areas than I do, seeing as my heart and lungs have never stopped functioning before...), but that patients really do want every opportunity to recover and extend their life, and the suffering is therefore worth it.
Oh that phrase... worth it. This is the silver bullet when arguing with physicians, patients, and families. We all view our priorities and values as a set-in-stone hierarchy that determines if something is worth it. And if someone else's values differ, it's because of ignorance or fear of dying or over/undervaluing something (technology, quality of life, suffering, the financial cost of the care, the cost to the family for extending care, etc).
Everyone has a set of beliefs about these things, mine just happens to come from the Bible and from hospital experience. I have seen too many people die in pain to ever want undue pain in my own hospital stays-- if it doesn't have a definite outcome to benefit or save areas of my life that are important to me (i.e. having kids, rehab from surgery, etc), I don't want it. I also have a different sense of quality of life. I love my brain and listening to music and stories, so if I lost the ability to appreciate any of those things (i.e. major brain damage) I would have a strong hesitancy to extend my life... but I'm not all too-attached to my physical abilities (like an athlete might be, for instance) so the loss of those functions would be less devestating (still devestating, but still worth it to keep living).
But the biggest determinant of my values is my confidence in salvation and knowing that there's something more for me. I know that when I die, whether through disease or disaster or natural lifespan, I'm going to the same place. I know that I have been put on this earth, in this life and this job and this community, for God's purposes; so when He calls me Home, I can go Home. I can suffer to preserve my role in His purpose (i.e. continuing to raise children, or continuing in a career or vocation), but not for the sake of preserving my life. I don't need to keep living to solidify an identity for myself, or leave a legacy, or answer life's questions... I can die and gain all those things in Heaven. And I have a larger fear of suffering than I do of dying for this reason-- which is why I probably overvalue suffering (even from a Biblical perspective, suffering is necessary and I drag my feet to accept that) and undervalue extending my life.
My perspective isn't perfect because it still comes from my sinful heart and is acted out by my sinful body and is thought-through by my sinful mind. But other people have perspectives that can come from the wrong foundation-- from fear of dying because they don't have salvation, or fear of losing their current quality of life because they don't have anything else as a base for their identity. And, as a Christian, these are the foundations I'm supposed to rattle. I'm supposed to make you think about Eternity and the Purpose (and gift!) of life.
... but I have to admit, sometimes even that battle with people doesn't feel worth it.
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