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One of my patients returned from hyperbarics with a bleeding wound on her back.   Once I had changed her dressing (and linens) several times, I was ready to page her doctor when he showed up for rounds.  Since I had recently changed everything, it looked good to him.  I spoke to him outside the room and described just  how much she was bleeding.   As in, I wasn’t seeing some small spots on the linen but rather  a blood-stained sheet from  the waist down.  Vitals were fine.  The doctor said to keep changing the dressings as needed and check her H&H in 4 hours.

Four hours later, the labs showed her hemoglobin dropped from 11.3  that morning to 7.5 that afternoon.  Still bleeding, though it had slowed.  I paged the doctor and read him the labs.

MD:  Let’s just check her labs again in the morning.
Me:  [long pause]  Really?
MD: [long sigh]  Call Dr. Consult.  If he says its okay, give her 2 units of blood.

Click.

I got pulled at 3pm.  Granted, it was most definitely my turn as my last pull was sometime in August.   It was also, however, my worst pull ever.

I was taken away from a fairly easy group of five and sent straight to hell.  Or as close as you can get on a four-hour stint to the back corner of the telemetry floor.

I walked into a mess: one patient leaving AMA, two discharges, and one ER admit.  Just as my blind, confused, ESRD  with recent AKA was returning from dialysis – whose room was right across the station and who proceeded to holler and moan the whole time.  Her favorite expressions were “You bitchslutwhorebitch” and “Get out of my room.” Charming.

It was just one of those shifts where I did my best to keep my head above the water.  Sometimes you don’t want to win the race.  You just want to survive.

Some time ago a particular doctor with a proclivity for petulance sat down next to me at the only available computer during a busy morning. I was reading my strips and had calipers in hand when he turned to stare.

I finished my stack and turned to meet his gaze- with a smile, of course. He raised an eyebrow and said dryly, “Calipers? I’m impressed” before turning away.

It made me laugh (inside), and later I shared it with Debbie/Former Preceptor who then shared with me that this particular doctor had shown in the past a proclivity for persons of the female persuasion – the younger the nurse the better. “Be careful,” she teased.

Last week I walked into the station, and the ward clerk motioned to the phone.  A doctor was on hold.  For who?  A consult on one of my patients.  I grabbed the chart and scanned the latest order as I picked up the phone.

It was our favorite grouch on call for the cardiologist consulted.  He wasn’t happy to get the consult.

“When was the consult ordered?”

I glanced back at the chart.  No time stamp by the doctor, just that of the ward clerk when she put in the orders at 12:30p.  It was now five after one.  And Chuckles was upset that he wasn’t told about the consult when he had been at the station earlier.  Never mind that he had made rounds before the attending.

” You couldn’t tell me while I was there? What? Too busy ordering lunch?”

What? Too busy being an ass? “The order was made after you came by. And no one here has been able to stop long enough to eat.”

Click.

Dear me. And I thought we had something special.

It was 6:50p, and I was giving John report. One lady was confused and frequently had to be guided back to her room.  I was giving him report on the rest when he asked, “A crazy lady and two bilateral amputees?”

“Well, at least you won’t be finding them out in the hall,” I replied.

biphasic-p-wave1

I saw my first biphasic p-wave.

“A ‘double hump’or notched P wave is diagnostic of LAE [left atrial enlargement] if the peaks are one small box or more apart. A biphasic P wave indicates left atrial enlargement if the downward portion of the P wave is one box or larger in both depth and length. Left atrial enlargement often occurs in mitral valve disease (either stenosis or insufficiency). Because of this association, a broad notched P wave is often called ‘P mitrale.’ In addition LAE often occurs with any cause of left ventricular hypertrophy.”

Micro EKG Manual

I think we should start paying family members under the table to go down to administration and complain for us since they care more for their feedback than our own.

“I didn’t bring my mother here to be cared by people who can’t even take her temperature.  You need to get some damn machines that work.”

“How on earth are you supposed to take care of my dad with only one aide out there who barely has time to give him his food and check his vitals much less answer his calls for help?”

etc

In order to thank the nurses for all their hard work this year (“Thank you for a wonderful magnet year!”), our chief nursing officer sent each station a bag of marshmallows and a box of hot chocolate.

The very same box that sits in our supply closet for patient use.

I thought that we should send her an individual packet from each nurse in the building with a little note: “Thanks for thinking this much of me.”

The night nurse sat down heavily and asked if I was ready for report. I said I was. He assured me that I wasn’t . “Long night?” I asked. “And you’re going to have a long day.”

She called herself a nurse, but it turns out that her late husband had been a doctor.  When I asked about her daughter – who I knew was a nurse , the woman snorted and said disdainfully, “Just a two year degree.” She had a bypass and valve repair scheduled for Monday morning.  It was only Saturday.

From the beginning I could see her confusion.  She simply could not remember that nurses had given her any of her meds.  By noon she was demanding her morning meds, refusing to believe that I had already given them to her. She insisted that no one gave her a single pill for 3 days.  She spoke viciously of  John, the night nurse, and demanded that he be drug tested.  He was lying.  She never received any pain meds, and she knew how nurses were with drugs.  When I asked her if she’d like me to bring her something, she waved me off and said she took care of it already.  I saw a bag of home meds in her closet, so I spoke to her daughter privately of my concerns of over-medication.  Her daughter agreed to take them with her when she left.

And all hell broke loose.  I would say that she was a holy terror, but there was nothing holy about her.  She ranted and bitched up and down the hall, foley in hand.   She demanded to have her medications back in her room and threatened to leave AMA, call the lawyer, call the police, pull the fire alarm…  She’d stop any doctor in the hall to tell of her mistreatment.  There was absolutely no reasoning with her. At one point I was in her way (unintentionally), and she moved to grab my shoulders.  I simply said firmly, “You touch me,  and I will call security on you.” She soon tired and calmed down enough for me to walk her back to her room.  Still very upset, she sat on her bed and  attempted to call all her family and friends (not understanding the need to dial 9 first, thankfully).

I went back to the station and printed out a MAR to show it to her.  I told her it was a list of all her meds, and we went over each one.  I showed her on the print-out when she had received each medicine.  I handed her my pen and told her that she could use this paper to document meds received.  She seemed wary at first, but then I told her these could be her court papers.  That seemed to please her, and she was happy to sign by each med I gave her.  (She drew a line through each med administered by the night nurse.)  I turned to grab my pen before I left, and she pushed it away from me.  Fine.  Keep the damn pen.

It worked beautifully.  She was still a needy patient, but there were no more arguments about her medications.  I printed her a new MAR before I left and told John about our system.

The next morning I was getting report from the same nurse, when she hit the call light.  He rolled his eyes and said he’d go in with me. We found her at the bathroom door.  She held out her foley and said, “This needs to be emptied, and my bed needs to be straightened.”  Whatever.  He took care of the foley, and I moved to the bed.  I pulled back the covers to find a lot of random objects, including the thin, white turban she wore on her head.  I put those things aside and was just finishing folding back the blankets when she and John came out of the bathroom.  I took a double take and nearly bust a gut trying not to laugh.  We tucked her in bed and made it out to the hallway before asking,  “Was she..?” “Did you..?” and bursting out in laughter.  And maybe it’s wrong, but I took such great pleasure  in seeing this proud, disagreeable woman wearing her panties on her head.

* “Dickie Roberts: Former Child Star – Anyone.. anyone?

5 patients – nice morning….Discharge 1… Transfer 1 to nursing home… Finally sit down to eat lunch at 2:30… Come back from lunch to find a patient is slow to respond with BP in the 80s/40s… Transfer said patient to ICU… Find out at 4p (after ICU mess is over) that I have 3 new patients from a nurse who left at 3p… Immediately have to discharge 1 of the 3… New transfer from sister hospital arrives without any clear list of current meds… Realize previous nurse didn’t administer any of her 1400 meds… Clock out at 8:30 after doing all charting from 1200 – 1900.

Everyone who undergoes a bypass gets a little heart-shaped pillow and marker for signatures. I never know what to write. The cardiac rehab nurse uses her line “Keep walking.” An MD wrote “God bless your heart” the other day. Most everybody else writes some variations of “Take care,” “Get well soon,” “It was a pleasure caring for you.” I always seem to be at a complete loss for original thought when a patient hands the marker to me. I want my own signature note, dammit.

My Happiness Project

1. Set a bedtime.
2. Make my bed every morning.
3. Always be reading something.
4. Move more.
5. Toss and organize.
6. Give proofs of love.
7. Leave the past.
8. Fight right.
9. Don't expect praise or appreciation.
10. Kiss more, hug more, touch more.
11. Aim higher.
12. Find some fun.
13. Ask for help.
14. Smile.
15. Realize it's possible.
16. Don't compare;be inspired.
17. Focus on what I have.
18. Beware of drift.
19. Take a chance.
20. Listen.
21. Be mindful.
22. Cultivate gratitude.
23. Spend out.
24. Do good, feel good.
25. Show up.
26. Have the courage to be imperfect.
27. Find joy in the ordinary.
28. Work smart.
29. Enjoy now.
30. Talk to strangers.
31. Go outside.
32. Start where I am.
33. Show up on time.
34. See art everyday.
35. Love with abandon.
36. Be colorful.
37. Dress the part.
38. Revel in accomplishments.
39. Learn something new.
40. Fear less.
41. Take pictures.
42. Speak with integrity.
43. Don't be critical about small things.
44. Manage my pain.
45. Surround myself with creative people.
46. Practice, practice, practice.
47. Don't force it.
48. Deal with something once.
49. Trust my instincts.
50. Avoid gossip.
51. Choose to see the best in people.
52. Take time to be silly.
53. Throw my own party.
54. Be a mentor.
55. Lean into my fears.
56. Find the others.
57. Do the unexpected.
58. Don't break the chain.
59. Do things others aren't.
60. Slow down.
61. Be cool with not being cool.
62. Be kinder than necessary and more generous than reasonable.
63. Pretend I'm good at it.
64. Keep in touch.
65. Row my own canoe.
66. Do what only you can do.
67. If it doesn't work out, find something that does.
68. Dream bigger.
69. Notice what's right.
70. Stop talking. Start doing.
71. When in doubt, choose laughter.
72. Don't let the perfect be the enemy of the good.
73. Respect everyone.
74. Be early.
75. Delete the unnecessary.

Three Simple Rules

1. If you do not GO after what you want, you will never have it.
2. If you do not ASK, the answer will always be no.
3. If you do not MOVE forward, you will always be in the same place.

All I Need

1. Someone to love.
2. Something to do.
3. Something to hope for.

What I’m Reading

Blood Meridian
by Cormac McCarthy
Their Eyes Were Watching God
by Zora Neale Hurston

U.S. States I’ve Visited

Alaska
Arizona
Arkansas
Colorado
Georgia
Florida
Louisiana
Maryland
New Mexico
North Carolina
Ohio
Oklahoma
Pennsylvania
Texas
Utah
Virgina

Countries I’ve Visited

Mexico
Colombia
Thailand
Vietnam
Bermuda (British territory)

I write about…