or is this how you know you're a nurse?

Walking down the hallway, it's only 8:30am but I'm already well into my day- stretched out, warmed up,  caffeinated, and halfway through a medication pass. But I'm hungry.

"Hey!" The man coming toward me yells. He is in a group of people who are all laughing at a joke. He's leaning towards the woman next to him, and she is looking at him adoringly, but he has inturrupted the moment by addressing me.

He points at me, "I had a great bowel movement! Thank you!"

"Awesome!"

And I mean it.

Pain Scale

This morning Nurse Sassy Lionheart introduced our unit to a new pain scale.

Depending on what your job it, it's work safe but not very relevant.

But if you work somewhere that it's relevant, it's probably not appropriate.

#10 is my favorite.

Happy Nurses Day!

Nurse Appreciation Week begins each year on May 6th and ends on May 12th.
Today is internationally celebrated as Nurses Day because it is Florence Nightingale's birthday.

Yesterday at work there was an amazing feast of food for all the nurses. Nurses gathered, not just from our facility but from several BHCHP sites. We chatted as we nibbled on our shrimp kabobs and tried to guess who was who in the black and white nursing school graduation photos.

The spread was prepared by our incredible kitchen staff and was maintained from 12pm to 4pm to bridge both the day and evening shifts. There were tote bags for everyone with snacks and Dunkin Donut giftcards, and in the corner of the atrium two massage stations had been set up.
During the course of the afternoon several touching speeches were given by RNs from the organization, and various staff members were recognized publicly for their work and dedication.

Later on, completely unrelated to the festivities a newly homeless patient said to me, "I'm so glad they brought me here. I know that here you'll take care of me."

It made me feel very appreciated, and made me proud to be a nurse. But there was one more gift, maybe the most affirming of all.

Upstairs in the nurses station there was a vase of roses. Pale pink, with dark edges, and fragrant.

"Did you like the flowers I got for the nurses?"
He was smiling. He had gone to great lengths to get them.
And it was the patient you might have expected least of all.

Rx: feline

"Sam*, can you at least take your antibiotics?"
"I'm not takin' any of 'em. Why should I? You weren't here."

He's had so many head injuries, that he's now a kid trapped in an adult body. His face is scarred and his body is scarred and his liver is scarred, and his heart hurts. Not his real heart. Sam's lonely.

"Sam, another patient needed me,"  I faltered, weighing  HIPPA against his anger.
"It was an emergency, I didn't know how long I would be in the other room when I went in."

"I don't care. You were supposed to be here. You weren't. I'm gonna go smoke."

He doesn't understand waiting in line, or being told he can't do what he wants to do.  What he wants to do is drink a lot of alcohol and smoke cigarettes and eat cinnamon buns until his glucose level is unreadable on the glucometer. He tells me the higher the number, the better. "Like basket ball scores."

Before they reach a certain stage in both their mental and emotional development children are unable to think abstractly enough to put themselves into another person's shoes, or to plan for the future, or to delay gratification.

Sam is a little like that. Unable to understand why a nurse would not be on time, or why he shouldn't cuss out the doctors, or why he should care about his blood pressure.

Just like a child, retarded emotional development doesn't mean Sam is a bad person. It just means he is where he is. Unlike a child, however, he's not going to progress. His brain is damaged. He may be able to learn behavioral modification - but he's not ever going to reach the next stage. He's stuck.

So whenever Sam is my patient I take my time to remember that and treat him accordingly.

"Hey Sam, you look nice today. I'm sorry I wasn't here for you earlier. Can you take your medications now?"

"No. I'm going to sleep."

Usually it's me who is called in to reason with Sam, some other nurse at her wit's end. Today, I'm the bad guy. Because another patient was vomiting and I was late with Sam's medication cup.

I'm putting out fires. Vomiting, hypotension, dressing changes, patients with frightening hallucinations. Pharmacy's on the phone asking about prescriptions never sent. Due to a "boil water" alert I'm rationing bottled water.  I have three patients with persistent elevated temperatures possibly related to their illnesses but much more likely caused by dehydration. I am watching everything.

As I run around, Sam is in the background of everything I do. Standing in the hall. Sitting in the clinic. Riding the elevator. He takes his meds from me, quietly, an hour after refusing them. He says little all day.

Then, as I'm leaving, he's telling a respite aide:

"I had three cats," he said, "named Mud, Mud Junior and Mud the third."
His eyes glow with excitement as he continues, "and I used to feed those cats better than I fed me. King crab. Shrimp. They loved that stuff. I'd go buy it for them."

It is the first time I see Sam smile all day, talking about his cats and how he took care of them. How he loved them and they loved him.

He notices me listening and waves cheerfully, the morning forgotten.

I leave the building deep in thought,  wondering how one would word a prescription for a cat.

----------------------------------------------------------------------------------------
*names, diagnoses, and situations have been changed to protect the privacy of patients and staff involved

very smooth

 The Charge Nurse was holding a nip of Christian Brothers brandy in his hand when I walked into the nursing station.

"I'll take care of disposing of it," Nurse Nightingale joked, pretending to grab at the bottle, "I know exactly what to do with it."

"So do I," joked Nurse Sassy, but I'm not a brandy person myself."

I grabbed the bottle and waved it dramatically. "Let's pour it on the cookies I baked, then we can- "

"Light them on fire?" suggested Sassy.

"Cookies foster," the Charge joked, taking the bottle back.

"We don't even know if it's actually brandy," Nightingale pointed out.

"It looks more like whiskey," Charge said.

"I bet it's Listerine," ventured Sassy.

"Where was it?" I asked.

"In the bathroom on the toilet:" came the answer followed by an agreement that it couldn't be brandy.

"No one would leave a whole nip of Christian Brothers in a bathroom," Nightingale pointed out.

"So Listerine," Sassy said, and then: "You know what?  I'll do it, I'll smell that."

Charge handed her the bottle and we watched, waiting. She unscrewed the tiny cap and brought her nose down to the tip of the bottle and immediately pulled her head back.



"Yeah. It's piss."

all you need is love, love is all you need

On the Thursday before Easter known to Catholics as "Holy" or "Maudry" Thursday, the gospel reading for the mass is about the Last Supper. When Luke, Matthew and Mark recount the story of the Last Supper, the focus is on the   covenant Jesus speaks of ( "This is My body...This is My blood.").
John, on the other hand, gives us the only account of the Passover meal where Jesus gets down on the ground and washes every body's feet.

Every parish does this next part differently, but in each church after the gospel and then the homily, there's  usually some literal foot washing. It's often the priest who washes the feet of some lay ministers. One year at the church I attended at college I was asked to be one in a handful of parishioners to have their feet washed. I sat rigid in my chair as my feet got washed. It felt weird. I hoped no one would ask me about it later.
This year, at St. Cecelia's in Boston, Fr. John closed his homily by introducing the foot washing saying, "For those of you who don't know us, here at St. Cecelia's we don't just wash the feet of the twelve men on the church board." The congregation chuckled knowingly and my mouth opened as I realized what was coming next.

Father John reminded everyone that they didn't have to participate, but he invited everyone who wanted in to ditch their shoes and socks in the pews. I shook my head in disbelief.

As the choir sang and bowls of water were set up, I reflected on the first half of Fr. John's homily. He had pointed out that in the midst of everything else going on with that Passover night Jesus told his disciples to wash one another's feet. "That's it," Fr. John said in his comforting Boston accent, "that's all it comes down to. Washing each other's feet."

He urged us to think about the feet we've washed, literally and figuratively. And to think about whose feet we should wash next. He asked us to think about those in our lives who need to be "scrubbed" by our forgiveness, or our compassion. He implored us to try to "rinse" those around us by being refreshingly positive in every day small talk rather than respond to those around us with sarcasm or negativity.

My thoughts tumbled as I stepped into the aisle and got in line with the other bare foot men, women and children. I thought about the people in my life who need compassion, patience and positive energy the most. I thought about the people in my life who provide me with the compassion and love I need to survive.

Then I couldn't help but start to think about the literal feet I've washed as a CNA and then as an RN.  For that reason alone I imagined this ritual was less scary for me  than for some of the other strangers in line. (Or the ones sitting with their shoes securely tied on in the pews).
That made me remember about the man who wouldn't let me wash his feet.

As I stepped up to the bowl to have my feet washed by the stranger in front of me, who had just had his feet washed by the stranger in front of him I thought about the people I met in Haiti. I remembered how most of the people doing the "foot washing" in those tents weren't blood relations of the injured or dying patients - they were just neighbors who were responding to the need they saw around them.

After the man at my knee was finished washing my feet he patted them dry with a clean towel. He put it down, and an altar server appeared to refill the bowl and replace the towel. As she did so, the man and I embraced and I thanked him. Then I took my place at the bowl and washed the feet of the next seated stranger. After I dried his feet he thanked me, and hugged me goodbye. I padded back to my seat, struck by a lack of discomfort in the whole thing. Mine and everyone else's too.

"We belong to a church with a ton of hierarchy, huh?" Fr. John had challenged at the top of the homily, "sometimes it seems like people are more interested in getting their feet washed than washing other feet."

He continued, "We have a lot of ways of describing the hierarchy and power and ritual, huh? High mass? Low mass? But no matter how you understand religion, or what parts (pahts) of it are attractive to you... in the end it is all about washing one another's feet."<

That, as it so happens, is actually exactly how I choose to understand religion.

what the patient smelled

"Are you my nurse?"
I looked up from the medication order I was faxing to the pharmacy.
"No,"  I said, "your nurse is at lunch, but she'll be with you in five minutes."
"Can you come look at something?"

I hesitated. I was also at "lunch", but had just interrupted my meal at my desk to fax this high priority order. Going to her room meant forfeiting my last five minutes of lunch. A lunch break I started twenty minutes late. Which left me with ten precious minutes of lunch.

"Is it an emergency?" I asked, "can it wait five minutes for your nurse to come back?"

"I need you to look at it. I can't tell you what it is here in the hallway."

"But is it an emergency? Five minutes. Your nurse will be right back." The woman stared at me and raised her eyebrows meaningfully.

Worried that there was a blood spill or drug paraphernalia, an illegal animal or something similar, I consented, tossing one longing look over my shoulder at the chicken fajita rapidly cooling next to my medication book.

 Entering  her room, I saw nothing out of the ordinary. She stood by the door with her arms crossed.
"Yes?" I prompted.

"Over there," she said, "stand by that mattress."

I complied. Her roommate rolled over, woken from a nap by our talking. The woman would not come any closer to where I was standing. I surveyed the room again, suddenly  remembering a lecture from the very beginning of nursing school on how a nurse is like a detective - when you enter a patient room you have to notice everything. I noticed the cell phones plugged into the wall, the dirty clothes in a plastic bag on the floor and the photos of family on the bedside table.

"I'm sorry, miss," I said, "will you tell me what I'm looking at?"

"Sniff." She ordered.

"Excuse me?"

"Smell that?"

I took a deep breath in. I smelled oranges. Every bedside table in the room had a bowl of fruit from lunch that day. I tried again.  Oranges. Oranges. I got closer to the bed. Oranges.

"I smell... oranges," I reported.

"No. No." she said impatiently, "smell again."

I did as I was told. I smelled nothing besides the oranges, and told her as much.
"Miss, will you please tell me what you are smelling, perhaps I can help you anyway." Dozens of scenarios went through my head, not excluding the possibility that she  had recently had or was about to have a seizure.

"No. Nevermind. If you can't smell that I'll just wait for my nurse." She motioned me out of the room in one quick gesture.

I still have no idea what that was all about.

this is where your psych training comes in

The patient is digging around in her medication cup.

Patient: What's this pill?

Nurse: That's an ace inhibitor, it's for your blood pressure.

Patient: I told them I'm not taking that.

Nurse: You don't have to if you don't want to. May I ask why?

Patient: I've been sneezing a lot.

Nurse: Excuse me?

Patient: I've been sneezing.

Nurse: Do you think it's the blood pressure medication?

Patient: No. I've never tried it since they ordered it because I don't want to get even sicker.

Nurse: Ma'am, your blood pressure is dangerously high. If you take it we'll monitor you to be sure  that there are no adverse eff-

Patient: (staring at RN threateningly) Sure. I'm going to take it but if I die YOU are personally responsible.

Nurse: If you feel that strongly then I'd rather- (the nurse reaches out, but the patient swallows the pill)

Patient: Remember. Remember, if anything happens to me, it's your fault. It's on you.

As if we could forget.

this is not a post about my hair.

"Hey- yo, Little Bit, come here!"
"That's NURSE Little Bit," I corrected him automatically, my way of gently reestablishing some semblance of boundaries.
"Right. Nurse Little Bit. You look like a cat today."

I patted the lumps of hair on top of my head, two symmetrical buns meant to mask my bed head.

"Oh yeah, I guess I do!"
"You went out last night. You stayed out late."
"I went out?" I raised my eyebrows to show... disapproval? denial?
He looked at me, head tilted sideways and the corners of my mouth twitched, spoiling my stern nurse face.

"Yeah I knew it," the patient laughed, " 'cuz you come in here with your hair up like that. You just rolled out of bed this morning and said 'eff it, I'm just gonna do my job.' Yeah, I know you went out."

They always know.

"Yesterday you were normal and today you're like the Chinese guy from the Karate Kid. What's with you today? "

I got to work on time today and within the first few minutes of report was informed of a patient being discharged for illegal drug use. Patient aware. Too bad, I thought. But a relatively easy discharge. Almost fifteen minutes later one of my patients walked by with the supervisor . The patient was yelling in a foreign language. Someone popped in to tell me that this patient had caned someone in a wheelchair across the skull. This patient was also being discharged, effective immediately. Ok, I thought. As soon as I'm done with the early medications I'll do the paperwork. I finished medicating the slew of patients with early morning appointments, completed the first discharge, and completely deescalated both a panic attack and (separately) an emotional breakdown in the hallway before the DON appeared and asked how much I knew about "the situation" with another one of my patients.

"Situation?" I asked.
"Don't be cute," the DON kidded me, laughing at my expression.
"Seriously, I have no idea what you're talking about."
She stopped laughing, visibly distraught at her role as official bearer of the latest news.
"The patient kicked someone, hard and for no reason. We have it on camera. The patient has to go."

It was only 9am. What's with today, today?

At the end of the day you're another day colder...

I don't like to share work anecdotes that could potentially link specific patients back to me for obvious HIPPA and human decency reasons. I wait until they are long gone from the building, no longer my patient. And I still change some of the details. Now it's been long enough for this one:

I had a patient who was in his mid to late eighties and has been living on the street for years. He came to us for an upper respiratory infection. He was quiet and barely made eye contact when I introduced myself. "I jus want to sleep, ma'am," he said, closing his eyes. Within 24 hours we realized he had a case of scabies. Another nurse and I helped him to the shower. He was frail, with paper thin skin, and almost cachectic looking. When I helped him undress to do the scabies treatment I drew in my breath sharply. Without his four protective layers of clothes his body bore a striking resemblence to the haunted photos of concentration camp survivors. He was a real life walking skeleton. That was when we noticed the mass on his back. The nurse practitioner and I shared a look. The man did not notice.

As the week rolled on, sleeping in a real bed and eating warm food began to liven Mr. S up. In his good moods he smiled and joked and wore a baseball cap. When he was angry the small man became so sassy and entitled that it was unintentionally comedic. "Damnit, woman!" he would scream, as I tried to hide my smile, "I wanted eggs for breakfast! "

For weeks I changed his dressings and medicated him against seizures while we waited for MassHealth to come through so he could go to a nursing home. We joked when he was in his pleasant moods. He could never remember my name and instead would simply ask for "My nurse. The little one." Meanwhile, the mass on his back went unchanged and he developed blood in his stools.

The whole team found ourselves in an ethical dilemma. The man was very old, and had come in for a URI. One of the docs argued against having anything followed up. "It's a can of worms we don't want to open. It's not why he's here." Another argued, "he has a right to know." We scheduled a colonoscopy. Mercifully someone finally realized, "let's ask him if he wants to know."

As it turned out, he didn't. He said, "I'm old. If it's my time, it will be my time." He refused to go through any kind of testing, he refused all procedures. Another week went by and then suddenly, without much fanfare we got a phone call and he was leaving.

The private ambulance arrived to pick him up but he wasn't ready to leave. And having to get ready put him in a sour mood. "Your coat?" I offered. "Now what am I going to do with a coat?" he asked, putting on his eighth sweater. The EMT waiting for us was the most patient I've worked with in the capacity of non emergent transport.
He never once sighed, never rolled his eyes. In fact, when Mr. S got particularly rude with me he and I exchanged a smile and a nod. We kept him waiting for about twenty minutes, and once I had Mr. S in the hall he began to tear into the EMT demanding that he "go on, I'll meet you there by cab." Mr. Amazing EMT was kind, firm and waved goodbye as he and Mr. S got on the elevator.

I was relieved but nervous. What if Mr. S didn't get in the truck? My fears were grounded. He did get on the truck, and even got off and into the nursing home. But a few days later he eloped. We got the phone call, but no Mr. S. I wonder if he's okay. If he's eating. If it was cancer we saw on his back. If he'll ask for help if he needs it again.

But the thing that always gets me about Mr. S is this: what if he had said he wanted to know? Or what if he wasn't actually mentally able to make that decision about his health? Who would have won? Would we have had the mass biopsied? Then what?
We were lucky, we got taken out of the choice because we gave it to Mr. S. But he could very well have demanded to know. And then demanded treatment. Treatment that probably would not have saved him in the long run but would have made his quality of life miserable while costing a ton of money. Or what if he couldn't have told us? What if he was mentally incapable? Would we have listened to doc #1 or doc #2? Run the tests or not?
For now, I don't have to think about it. But someday I know I will.

"Tell me more about that..."

Me: So forget us. What would you say is the biggest health issue you're facing right now?

New Admit:  I like to think of myself in this situation as a race car brought in to an auto shop. I got two flat tires (indicates swollen legs), my hydraulic fluids are low, I got some shot pistons, you know? I'm just here to get it all fixed up before I go out to the race again.

                                                 ***********radio static********************

Me:  So...  now what?

Patient Being Discharged:  I don't know. I just need to get away from everyone. People talking about drinking and drugging. That's what got me into this mess. I just want to be clean and sober. I don't even want to hear about it. You go out in the streets, even in the shelters, it's all over the place. I'm an addict. I can't be around it. I'm going to keep failing. All I want to do is quit and get my real life back.

                                            *********radio static *********************

Me:  You mentioned you're feeling "down." Tell me more about that.

LongTerm Patient: I'm feeling trapped here. I want to get out, but I can't. I'm sick and I have no where to go. I'm a person likes being free. I want it all. A door, a lock, my key. I want to come and go, no one tells me no. I'm just feeling bad. You know them birds like vultures? Like seagulls too? You see them circle around another one, can't do anything about it? That's how I feel now. Like that.

                                             ***********radio static*******************