Dear Family or Friend of my patient

I will be your nurse today.  As such, I want to make just a couple of things clear.

I do not love your loved one.  I do not share your history, memories, admiration, or intentions.  I do, however, care that he or she receives absolutely the best care possible with the best outcomes in mind.  I will stop at nothing to make sure pain or other discomfort is relieved, you are kept in the loop, and the doctor has all information necessary to make informed decisions about the treatment plan.  I will do oral care, peri care, skin care.  I will turn and reposition every two hours at a minimum.  I will comply with all measures to prevent pneumonia, UTI, DVT and ulcers of the gastric and dermal varieties.  I will monitor vital signs, lab results, and perform an initial as well as ongoing physical assessment.  Sounds good, right?  Now let's talk about what prevents me from doing this.

1) The doctor disagrees or won't listen to my findings.  In that case, I'm bound and constrained by his or her orders.  No matter how much you think differently, short of you contacting the doctor directly and duking it out, there's not much I can do.  The corollary to that is if the doctor is practicing negligently or unsafely; in that case I have a chain of command I may utilize to rectify the situation.  Grandma's super expensive, noxious smelling lotion does not qualify.  Don't ask again.  And don't put it on when you think I'm not looking.  I'll smell it and wash it off.  There are reasons for that that you don't know and no, I'm not going to explain it to you.  It falls under the category of "because I said so."  

2) I do not have the ordered medication, treatment, etc currently.  In that scenario, rest assured I am working to get it.  The more urgent it is, the more persistent I am in getting it.  But if the treatment happens to be something like "clean patient's toenails" and I have another patient in pain, you lose.  Routine chest xrays for a patient not in distress or not intubated are about mid-level on my list of priorities.  If you come out to get me to ask me to pour water from the pitcher to the cup in your family member's room, you lose.  

3)  You.  Pretty simple, isn't it?  Your demands for the same information repeatedly, for things that are nonurgent in nature, or your bad attitude can all factor into the mix.  I will be totally honest here: if you are an asshole, I and my coworkers will minimize our time in the room and interaction with you when at all possible.  Realize that screaming at the top of your lungs that you have things to do and you will not wait for me to contact the doctor does nothing but make me walk a little slower to the phone.  I won't be checking in when I have a free minute just to see if your loved one needs anything.  Us wanting to be away from you means we're not in proximity to our patient.  Don't get me wrong, we won't ignore the call light or allow anything untoward to happen physically.  We can see all of his or her vital signs on our slave monitors outside the room and we're watching them.  We're also probably watching on the camera.  But we're not going in the room until we absolutely have to.

Another way to guarantee a tight lipped, minimally interactive nurse is to attempt to do what we call "splitting."  That's when you tell someone who wandered in to answer your call light how much better they are than your current nurse.  We talk amongst ourselves; we know when you pull this stupid shit. Or when you ask one doctor if he agrees with another's assessment and plan. Here's a tip: even if he doesn't, he'll never tell you.

If I have to part the seas because you and your family, extended family, neighbors, acquaintances, postman, pastor, and dentist are piled three deep at the door I will avoid the room.  And possibly call security.  How are you irritated by the lack of practitioner presence when no one can even get in the damn door, much less walk across the room to your family member?  There are visiting guidelines for a reason.  Oh, and here's another tip: because of the recent H1N1 outbreak, we are following the CDC guidelines on visitors.  Which means no one with flu like symptoms, no more than 2 people in the room, and no one under the age of 16.  Period.  And just stop your sputtering to think about this for just a second: knowing how many people around you potentially have H1N1, never mind MRSA, VRE, C.diff, why would you want to bring your infant/toddler/child/tween in?  And that's just the stuff people know about.  The people in the beds are protected for the most part.  You aren't.  And neither are your kids.

Lastly, I'm not a member of a "death panel" so no, I don't want to kill granny.  But I also don't want to flog granny.  This is pretty simple to translate: granny has reached the ripe old age of 81/88/92/whatever.  She has Alzheimers, arthritis, gout, heart disease, TIAs, diabetes, obesity, peripheral vascular disease.  I do not want to shock her to restart her heart.  I do not want to break her ribs doing compressions.  I do not want to put her on a ventilator that she'll never come off of which will then necessitate a tracheostomy and feeding tube.  I personally don't care if she's a chemical code; all we're going to do is put drugs in her noncirculating circulatory system.  If you love granny, you'll request I withold electrical therapy, CPR, and artificial respiration.  You'll at least listen and think about enacting comfort measures.  Yes, we'll put her on morphine.  No, it won't kill her.  Yes, she'll go out of the ICU.  No, she won't be ignored.  She'll go to a floor where people do comfort care for a living and the nurses are accustomed to guiding patients and families through the dying process.  Let it happen.  And do not.  Do not let me know that you want me to prolong his life so you can continue getting his checks.

You do your job.  Let me do mine.

I don't care where you're from

If you:

Tell me my patient is shivering because his body temp is 36.5 I will think you're stupid.

Tell me that my patient's kidneys won't start working until I stop the CRRT I will think you're beyond stupid.  If you then tell the nephrologist that and disbelieve him when you are schooled to the contrary I will think you should choose a new career.

Tell me that the person who awake enough to answer yes/no questions and has broken through two sets of soft wrist restraints trying to self extubate is "comatose" I will always provide you with plenty of subsequent telephone conversations regarding level of arousal.  You are wrong and I will badger you until the end of time, or the end of my shift, until I get what the patient needs.

Tell me to paralyze my patient instead of sedating her I will report you as far up the chain of command as is necessary to have you in time out long enough to think about what an asshole thing that is for you to do.  If I can, I will ensure that you are paralyzed without sedation should you ever need to be intubated.  I want you wide awake to experience what you made sure you would not witness the first time.

Tell my patient's family that their family member is in pulmonary edema because they (read: I) gave her too much fluid yesterday for "low blood pressure" I will find a way to embarrass you as publicly as I can.  You know as well as I do that not only did I not give any fluid for hypotension, I was on the phone to your lazy ass all day for beta blockers for the hypertension/tachycardia YOU caused by previous unfavorable decisions.

I will not accept that you are "culturally" impaired.  You are here now.  You may only bring your MD license in the door.

We (the nurses) will continue to save you from yourself all day every day and save our patients from your bad decisions too.  But remember: there will come a day when your poor decision will not adversely affect my patient and I will leave you out to dry.

Once in a while

It's been twice in the last couple of months now.  Someone who shouldn't be sick is sicksicksick.  No previous medical history.  No risk factors.  No reason.  Nothing isolated, nothing cultured, absolutely no reason at all.  But there they are, in the ICU.  Sedated, morphine or dilaudid drips, possibly paralyzed to boot so they don't buck the vent and we try to slow down the insidious progression of ARDS.

So down down they go.  And because they're young they compensate until they just can't.  So the spiral is quick and tight.  Quick, intubate.  Quick, start pressors because the addition of PEEP and propofol has knocked their blood pressure in the gutter.  Try to maintain a MAP that will keep their kidneys and brain alive.  Quick, run fluids wide open.  Quick, draw labs.  Quick, start every broad and narrow spectrum antibiotic, antifungal, and antiviral we can throw at them just to be sure everything's covered.  Quick, get that specialty bed.  Then everything slows down to an interminable crawl.  

Now we've got APRV and CVVHDF and IPV and the kitchen sink on standby.  CPS is a possibility.  We're flogging the heart with pressors because we hope it can take it.  It's only 20 ish so it... should anyway.  Day by day try to wean APRV to A/C.  Try to wean PEEP from 15 to 5.  Try to wean FiO2 from 100%to 75%.  Try to wean pressors.  But their kidneys just aren't coming back.  So quick, change the dialysate or replacement fluids.  Quick, try to keep up with their bicarb, calcium, potassium then quick, take them back off.  Then wait some more.  And the mothers and fathers who thought they got their kids past the "dangerous" ages of crossing streets and stranger danger and high school drugs; parents who just want to rewind and get a do over or fast forward to the day when their son or daughter opens their eyes with recognition.

And when you get home at the end of the day, once in a while, for these kind of patients, you aren't just spinning your wheels.  You aren't intubating 88 year old grandma with more effusion than lung tissue.  You aren't maxing out neo, levo, and vasopressin on grampa with an EF of <10%>

So once in a while, you throw everything you have into your shift, use every brain cell at your disposal, tax your body to its limits and give a part of your heart to a boy or girl you've yet to meet but lovingly change sheets and wipe eyes and perform passive ROM on.  And you hug mom and put your hand on dad's shoulder.  And instead of coming home depleted from all of this giving, you come home wired and excited at the small gains he or she made that day.  He kept is PaO2 > 50 on FiO2 100%.  Her K came down from 5.7 to 4.9 just by changing the dialysate solution.  

Once in a while you come home with more than you left with in the morning.

No new orders.

I'm waiting with bated breath to see how Nurse K responds to HH's "no new orders" post.  I have the gauze, adaptic and tape ready for his inevitable blistering.

I did stop to think a moment about why I document this.  And I'll admit it is primarily a CYA measure.  Since the docs at my hospital are not employees, they are not subject to the HIPAA/JCAHO/DHS bullshit that the rest of us are.  They can blissfully "look at the whole picture" while not signing telephone orders, chitchatting about their patients in the middle of the hall, and generally flaunting their immune status.

I am intelligent.  I've been doing this a number of years.  I've developed an ability to size up a patient and determine which needs are critical and which can be addressed later.  But I am required to call you for things that Those-Who-Do-Not-Practice have deemed critical or noteworthy.  I understand a K of 3.3 probably won't kill my patient, nor will an INR of 2.3, in the absence of other mitigating factors.  And when I call you and inform you of something we both know is not truly critical and I receive "ok" as a response, I have to document what the result of my call was.  You guessed it, no new orders.

BUT, when I call you for a Hct that has dropped significantly, the patient's belly is so hard you could bounce a quarter off of it and the IAP is 32, the NG output is > 1L/shift, and I'm having to increase my pressors I want answers.  If, given this information, you are still unsure of what our plan is, I will document specifically what I told you and that you gave me... wait for it... no new orders.  Because I'm not allowed to document "Physician Cavalier was notified of all s/sx of incredibly bad process, requested surgical consult.  Physician said "what can you do for a belly?"  Physician is incredibly dense or incredibly stubborn, either way he's risking this patient's life and my license and I will not have it supposed that I failed to understand the gravity of this situation."

But I will also document that I have called you prn with the patient's deteriorating status and lack of new orders until you give me what I want.

You can document my assessment lacks substance (unlikely BTW) or that the IV pole was beeping or that the patient was sitting in stool when you rounded.  That's ok.  Those things are directly controlled by me and I have an acknowledged responsibility.  But pull your head out of your ass long enough to see that I've walked into the room with you, answered your questions, then sent my aide off to get another full bed change for this patient while I head to the med room to replace the empty bag.  Or look in my other room to see that the stool ranks as low as you being called for a Tylenol order when my other patient is unstable or actively coding.  Or don't.  Just realize that those things do NOT affect your practice or licensure in any way but I am ultimately responsible for every single individual, department, and substance that interacts with my patient at any time.  If PT drops the patient, my responsibility.  If the patient has a med reaction because you ignored a cross-allergy, my responsibility.  If my patient has a low RBS because you've made him/her NPO and I haven't reminded you to throw some dextrose into the IV, my responsibility.  

Recognize it or not.  Either way I will keep calling you.

Dear Dr.Halfway

You are indeed halfway there.  The problem is, you can't seem to go all the way.

1) You can write orders but you can't remember them.  If I get chewed out one more time in front of a patient and family for following your NPO orders instead of feeding them we're going to have a problem.  I don't just starve people because I have a fat phobia.  

2) If you're going to treat a really really sick patient that's out of your depth, you MUST listen to those around you who know what they are doing.  Rigors that look like seizures with a temp of 40C unresponsive to Tylenol with a HR of 160's is not ok.  There's a reason God made vecuronium.  

3) If you're going to do the right thing and feed the gut, do not blow off the dietician who spent over an hour reviewing your extensive list of useless medications, calculating the kcal in the propofol I'm infusing at over 80mcg/kg/min and backtracking through our cumbersome charting to find that patient's dry weight.

4) It is good that you have actually provided us with contact information.  It only took you two months.  But now you must answer your pages.  

5) I, along with most of the other RNs around you, do not care who your partner is.  And we do not want to see you googly eyed when you talk to that hot neurologist.  He bats for my team.

6) Most men buy overpriced, loud, shiny cars to make up for their shortcomings.  You admitted you drive a hybrid so you must have decided shoes were the way to compensate.  Hint: if they're slipping totally off your heel when fully tied they are too big and you look ridiculous.  Watching your size 9 self kalump around in size 11 shoes is annoying.

Dude, you're killing me!

I've been having some increased discomfort in the tolerance region of my brain.  It all started with the moving of gastric bypass patients to the unit I was working on some years ago.  It was like trying to put the same poles of a magnet close together; impossible.

**** I will allow that 0.00000000001% of the population genuinely has some physiologic reason why they are morbidly obese*****************

That said.

If you won't take care of yourself before you get to me, why the hell am I obligated to take care of you in a way that will injure myself and/or my coworkers?  If you can't put the damn cheeseburger down, why should I pick up my compassion card?

I've been watching this show called "Obsessed" where people with OCD are given exposures to the ideas or things they fear most.  It's not for lack of exposure that my obsessively negative thoughts are nurtured.  We have a couple of superfat nurses on the unit along with the odd assortment of chubby, middle aged spread, or post baby nurses.  One superfat nurse is loud, abrasive, and has no regard or respect for others.  The other is loud, abrasive, has no regard or respect for others AND is pregnant AND wears skin tight clothes in lieu of scrubs.  Always has.  I'm not sure why management allows this to continue.

I do not want to see your mooseknuckle.  Ever.

Then the mooseknuckle option is removed because now they're in the bed.  Nekkid.  And I have to push the rolls of fat over, up, under, around to get the ECG electrodes on.  Hold the arm up to get a BP cuff on.  Fat people, you may never have seen the numbers the scale brings up, but let me give you something to chew on (pun intended).  I have to stretch before and after lifting your dead weight arm up just to put a cuff on it.  I has to weigh 50lbs.  Watching your face go purple as you're having the fat that's normally supported by your thighs/knees now actually on your abdomen as I try to get a foley in is absolutely not one of the highlights of my shift.  FINDING the place the foley goes through the abdominal and thigh fat requires an extra two people and a minimum of one flashlight.

I just read that in Kansas (I think) an ambulance company is going to increase the costs for caring for and transporting those over 350lbs.  I found myself startled initially reading it, not because I had any opinion either way, but because I'm so freaking inundated with those >400lbs that 350lbs seemed a pittance!  I reframed my thinking and found myself cheering!  What if nursing did the same thing?

1. Q2h turns requiring > 3 people: $50/person/turn
2. Bathing >  qshift r/t offensive diaphoresis or odor: $50/person required to assist/bath
3.  Foley placement: $100/person required to place
4. Isolation: $5/hr more for the nurse assigned, $10/hour more if airborne and the nurse has to wear the hood.