Monday, December 31, 2007

On the Eve of Resolution

I could not let this year pass without a few simple comments about health and fitness.

Like many people I know in the northern hemisphere, winter brings with it a time of weight gain and exercise laxness. Throw in back-to-back holidays characterized by rich foods, cakes, pies and candies, and excessive alcohol consumption, and many of us find ourselves relaxing our belts, dreaming of diets, and redefining flab as love handles.

What did Rene say: I eat too much; therefore, I am fat.

Having a few extra pounds in colder climates might seem like prudent insulation. But the stress of trudging through deep snow and trudging through the deep stress of Xmas and New Years can put a lot of strain on the cardiovascular system. A few extra pounds doesn't help.

And I am not pointing fingers. I include myself in the category of those who may have indulged and bugled too much whilst exercising too little. In fact, this trend didn't start with winter or the holidays. I have been slowly gaining weight since my all-time adult low weight of about two and a half years ago.

What happened?

Well, I got happy. No joke. I was at that all-time adult low weight because I was experiencing a lot stress about a family member in the midst of medical crisis. I wasn't eating well or enough, and I was exercising incessantly in an attempt to preoccupy my racing mind and reduce the negative effects of stress. Needless to say, I wheedled down.

Then almost two years ago, the crisis seemed to be (relatively) fading, the stress began to lift, and I became involved in a very happy period of my life. Needless to also say, my relaxation wasn't only mental; my waist relaxed as well.

In the year 2008, therefore, I hope to reclaim a diet and exercise ritual that is healthy, safe, and effective. By the latter I don't simply mean in terms of losing weight, but instead, feeling and being healthy. I owe it to myself, to my family, and to my community. Happiness should beget healthiness, not hedonism.

And so, bring on the New Year!

Friday, December 28, 2007

Never Put New Nurses into Old Nursing Skins

I received an e-mail from a friend today that informed me she planned to enrol in nursing school. Knowing her, I think she will enjoy the challenges and diverse employment opportunities the career of nursing presents. Knowing her, also, I'm not sure she'll enjoy nursing school. I didn't.

Needless to say, I sometimes feel guilty when friends of mine decide to go into nursing. I have encouraged at least four friends to leave their previous professions and become nurses via, of course, nursing school. (The friend who recently e-mailed is not among them.) I feel so strongly about the personal and societal benefits of more people being nurses that I don't mind recommending the career to them. However, knowing they have to go through nursing school to get there fills me with a bit of remorse.

It is not that I don't think they'll be able to succeed in nursing school--I have smart friends. It is that I know such a pursuit will aggravate, frustrate, and probably disappoint them. Oh, they'll graduate and come out as nurses, but they'll do a lot in the interim that has little to do with being a nurse. Really.

Like most other associates and bachelors degree programs and most professional-technical education programs, nursing school is very much about busy work and tedious conformity to standards that have little to do with nursing and what nurses actually do. Instead, nursing school is mostly about...well, nursing school. It is about doing the work, making the grade, and passing classes, the ultimate goal of which is to get the degree. In short, a rather underwhelming experience.

One would think nursing school is about learning the professional skills and culture of nursing. That would make sense. But there is a disconnect between what nurses do and the organizations in which they do it and the experience of the nursing student. I don't think this has always been the case, but it is prevalent now.

I went to nursing school later in life, in my 30s, after having already completed a bachelors and masters degree in an unrelated discipline, and having worked in several professional pursuits. I knew how to get through nursing school, and I had enough sense to know that working as a nursing student wasn't going to be like working as a nurse.

But many of my fellow nursing school students were in their late teens, traditional students by college standards. Some of them seemed to chose the nursing program as as just another college major, similar to accounting or English or biology. There did not seem to be anything about their lives that propelled them toward nursing or encouraged them to become nurses. They had gone to college because that is what you do after high school. It was an expectation.

Choosing nursing probably felt good to them and others probably responded to their choice with support and encouragement. But did they know what they were getting into? Did nursing school prepare them for what they would be doing as nurses?

As a nurse, I have likewise had the opportunity to precept nursing students and orient new nurses. I have had nursing students who fainted at the site of blood, got sick to their stomachs because of the smell of feces or vomit, or couldn't handle the look of a surgical site or stand poking a patient with a needle. Wouldn't they have made better accountants? How come they didn't know this?

I've also had students and sometimes new nurses who couldn't reason what amount of medicine to give a patient when the order was for 1 milligram but the medicine vial contained 2 milligrams per milliliter. Clearly they shouldn't have been nurses, or shouldn't have passed nursing school anyway.

When precepting or orienting new nurses I try to communicate a single idea: that being a good nurse is not about doing it the way they told you to do it in nursing school, but to develop your own method and rhythm and style and become the nurse you want to be, not the nurse they tried to cookie cut.

So, I am glad that my friend is going into nursing. I suppose I've written this both as encouragement to her and also a warning. Nursing school is not about being a nurse. Get through it, learn the theory, the methods, and perform the skills the way they tell you to. And then, after graduation, forget it all and become the nurse you want to be.

That's what I did.

Wednesday, December 26, 2007

A Chatty Post-Holiday Entry

Okay. The holiday is over. Most of mine was spent, you guessed it, in the ER taking care of every nebulous, insignificant, and ridiculous complaint that this community could throw our way.

*** A sore throat that you've had for two and a half weeks is an emergency on Christmas Day, why?

*** A 9-month old's diaper rash is an emergency at 2 a.m. Christmas Eve morning, why?

Why?

Because in this community, we were the only health care available on the Eve and Christmas Day. Doc's offices aren't open; student health isn't open; the urgent care clinics aren't open. We were it.

To be fair, some patients did have legitimate complaints. I started my stretch by being called in to work on the weekend when two head-on accidents with passenger ejections occurred at the same time. The lone ER nurse (who was that because of double sick calls) was desperate for help. I thought I'd give her an hour or so of my time; I ended up giving her 4 hours.

Her patient ate a cement embankment after being thrown from the passenger window of a pick-up (wasn't wearing a seat belt!) and was found by EMTs face down in a pool of congealed blood. Broke nearly every bone in her face except her jaw, had a transverse skull fracture, dislocated her elbow, and fractured her tibia. We stablizied her and then had to admit her because the inclimate weather didn't allow for either air or ground transport to a higher level trauma center. Last I heard, she was still alive at Harborview in Seattle. Lucky her, maybe.

My patient was a 13 year old who was thrown from the middle seat of a minivan despite the fact that he was wearing a seat belt. The sliding door had been ripped off, which allowed for his ejection. A fractured nose and fractured iliac crest of the pelvis and he had gotten off easy.

And that was it for trauma. The next three days, including Christmas Eve and Day, I heard as many clinic complaints of soar throats, tendonitis, urinary tact infections, etc., as I care to. Good thing we were here for them!

Sure happy I don't work for the New Years and its Eve. Happy, Healthy Holidays to all!

Friday, December 14, 2007

The Art of Children's Hospital

A friend of mine once surmised that hospitals are depressing because they are generally painted in browns and mauves and don't have any art on the walls. I agree with her.

But hospitals have changed. The one I am sitting in now, a Children's Hospital, is so brightly colored and has so much of all sorts of art that it is hard to tell that it is a hospital at all.

There are giraffe and zebra statues in the halls, giant fish tanks, a choo choo train on tracks in one corridor, and a huge Native American-inspired representation of an Orca, a sculpture measuring approximately 25 feet in length (life-size) and so heavy that it is suspended from the ceiling on thick metal cables. There are rocket ships and stylized balloons and an entire jungle creation in the radiology suites.

The idea, I suppose, is to help children forget they are patients in a hospital, or perhaps, help their visitors forget this. The relative success of the decor could be argued, but at least it is not a drab environment.

For me, however, Children's is a sobering and humbling experience. There is nowhere else I can spend time that makes me feel as fortunate to have the child I have, despite his relative disabilities and chronic illness. No matter how bad things have gotten for him and for us together, when we are here I do not feel as if things for us have been so bad, so depressing.

But it isn't the art or the colors that does this. It is the children in wheelchairs, the horribly disfigured children, the ones without hair, without limbs, with all manner of bodily insult, deprivation, chronic illness, life-threatening illness and injuries, and the sullen and depressed faces of their parents and visitors that helps me realize how good my son's life is and how good our life together is.

I know this is an odd observation, but who doesn't feel at least a little better when they realize they are not the worst off?

Monday, December 10, 2007

(Why Do) Things Fall Apart

In memory of my friend's brother...

Before studying nursing I wondered why people got sick, why bodies break down and fall apart. I was amazed by how capricious disease and injury seemed to be, and how the effects on the body seemed indiscriminate and sometimes unimaginable.

After studying the structure and function of the body in anatomy (with a cadaver lab) and physiology, and the dysfunction of the body in pathophysiology, I began to wonder how people maintain their health at all, why we all don't just fall down and break apart this very minute.

The complexity of the biological form and the intricacy of its functions amaze me. With all the ways in which the body could break down and with all of its susceptibility to disease and injury, the fact that it has such tenacious integrity places me in awe of it.

When a hammer doesn't work or work effectively it is usually easy to figure out why. A broken or too short handle, broken or too light head. But when a computer doesn't work, diagnosis is a little more difficult. The relative complexity of these tools determines our ability to understand the former easily and the latter with more difficulty.

The body is both and more. Physically, a mechanical, hydraulic system of levers and fulcrums, pumps and pulleys; an electrical, computer-like system of stimuli and currents, algorithms and feedback loops; a chemical system of neurotransmitters and pathways. Metaphysically, the systems and systems' components altogether are greater than simply their sum.

The human body, in health and in illness. Amazing.

Saturday, December 8, 2007

Ethics and Nursing Compensation

I am happy to report that the dispute between nurses and the administration of the hospital in which I work mentioned in the previous post has been resolved.

I am doubly happy to report that the administration has decided to eliminate wage disparity among staff nurses, moving all nurses to a single wage scale regardless in which department of the organization they work.

I take a modicum of pride in this resolution because the philosophical commitment to wage equity was the position for which I argued from the beginning of the struggle. The administration has, apparently, changed its organizational mind in order to agree with me (and other nurses who felt the same).

I could be magnanimous and believe that the administration's change of position is wholly based upon its ethical commitment to wage equity, that they have done the right thing because it is right. I could believe that the administration is made up of good people in this fashion.

However, good people or not, no organization does what it does not have to do. No organization risks financial insolvency if it does not have to, not simply so that it can be said to have done the right thing. No. The administration's actions are clearly based upon the fact that financially it could produce wage equity. The money was there; the money was there all along.

So then what is the lesson to learn from this struggle?

The lesson I learned is multi-faceted but simple: Organizations do what they can do in the context of good reasons to do it. What the administration of our hospital needed in order to make the decision it did was a good and compelling reason to do it.

We, the nursing staff, provided that for the administration by demonstrating our collective will to continually advocate for a single wage scale, even if it meant taking our case to the hospital's board of directors and eventually to the public. Both of these intentions were in formulation at the time the announcement of a single and increased wage decision was made.

What the administration did was devote the financial resources it has to avoid the uncharitable position of being called upon by the board of directors to answer for a dissatisfied nursing staff, a possible "don't show up for work today" action, and the negative publicity such would generate in a small town that has the general impression that the hospital is a decent, caring organization.

The other part of the lesson I learned is never doubt yourself or the value of your endeavors when you know that you stand up for a right and good thing. There were times that we could have accepted the mediocre offers made to us, offers that were somewhat generous but did not resolve the issue of wage inequity.

Despite the fact that some of us could have benefited from these offers, we stood up for an ultimate good over immediate gain. We're nurses, after all. We like to take care of ourselves, all of ourselves.

Wednesday, December 5, 2007

Wage Dispute

It is somewhat funny to me that many people think that being a nurse should be in and of itself satisfying. That the generally high esteem in which the public holds us should be reason enough to do the sometimes hard, sometimes gory, sometimes horrible job we do. To be an ER nurse, like being a hospice nurse, seems to double this sentiment.

People watch too much TV.

In fact, and I know this may come as a shock to some people, nurses like to get PAID for what we do. I don't know a single nurse who would work as one unless s/he got paid to do so. Like many workers, nurses may not be paid as much as they would want--no one goes into nursing to get rich--but they work at nursing in (perhaps unrealistic) hope of being paid for their labor what it is truly worth. Given that peoples' lives are often at stake, it seems that what we do should be worth a lot.

Recently, however, the hospital in which I work that employs over a hundred nurses has chosen to give a small minority of those nurses (approximately seven) a 15% wage increase simply because they are "surgery" nurses. There really is no other way to explain it.

The nurses in question have no more education, licensure, or skills than other nurses in the organization; they do not work harder or more; they are required to have fewer skill certifications than ER nurses (1 versus 4); and they do not even do what many other nurses in the organization are required to do: float to other departments, respond to codes, start IVs (the anesthetists or same day center nurses do it) or push medications (again, anesthetists or ICU nurses do it).

The administration's rationale for this unfair compensation increase is that surgery generates a lot of revenue for the hospital and we certainly can't allow the surgery department to close down. Forget the fact that it was not in jeopardy, that surgery nurses were not threatening to leave, and the fact that you can no more run a hospital without medical surgical nurses, same day center nurses, emergency room nurses, recovery nurses, etc.

The result has been that many of the other nurses in the hospital feel as if their labor has been de-valued. They feel that the organization has told them that they are not worth as much. There is foment of unrest and talk of walk outs.

I know the public is not used to the idea that nurses could refuse to work. It seems like patient abandonment. It seems wrong. But nurses who won't work for substandard or unfair wages or nurses who will not work under the stressful conditions of unsafe patient loads are not trying to be hurtful to patients. They are trying to demonstrate to health care organizations that they shouldn't be taken for granted.

I, for one, like being a nurse. But not being a nurse for nothing.

Monday, December 3, 2007

Types of Patients VIII: Frequent Flyers

Pardon the rather long absence. Sometimes I have things to share and the time to share them, sometimes not.

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Every emergency room has it's FFs (frequent flyers). FFs are individuals who utilize emergency room services over and over again, often for the same complaint, and often for complaints that are dubious at best. FFs become familiar with the ER staff as well as to the ER staff, and their complaints are often well-known and predictable.

Some FFs have psychological problems. Bipolar and Borderline personality disorders are common, as well as various forms of psychosis and schizophrenia. Sadly, some FFs have Munchausen Syndrome, a psychotic disorder in which an individual fakes illness or injury, or intentionally injures him/herself, in order to garnish sympathy and be cared for by others.

Sadder still, some FFs have Munchausen Syndrome By Proxy. These are individuals who encourage their child (usually) or other vulnerable relatives to fake illness or injury, or may intentionally injury these people for the same reasons as above.

Some FFs are drug seekers. (See, Types of Patients III)

FFs are usually on some form of public assistance (e.g., Medicaid) but this is not a hard and fast rule. It is amazing, however, how much paying for one's own care directly or indirectly through insurance tends to discourage frequent flying.

Some FFs, however, have real complaints. Migraine headache sufferers, patients with epilepsy, and patients with chronic diseases that are prone to exacerbation (e.g., emphysema, congestive heart failure, etc.) might classify as FFs. Many of these patients actually require emergency care, and yet, it is sometimes hard to feel good about the sort of "buff and polish" we are often required to apply time after time.

FFs also present the ER staff with a potentially serious dilemma: you've seen the patient what seems like at least a million times, and they always come in with the same complaint, and their complaint today is no different...what do you do?

I would like to say that what you do is the sort of comprehensive physical assessment and medical history as well as examination of the chief complaint like you were seeing this person for the very first time. I'd like to say that these patients' complaints are always taken at face value. I'd like to say that the ER staff takes no shortcuts when it comes to FFs.

There are so many things I'd like to say, if only they were all entirely true.

FF status invites shortcuts. It invites seeing the same thing time and time again simply because nothing new is looked for, and consequently, treating FFs in the same way they have always been treated.

Worse yet, FF status discourages the willing suspension of disbelief. If something novel should come up in the cursory exam and assessment, it is all too easy to ignore it. This is potentially dangerous for the FF and a tremendous liability for the ER staff. Unusual symptoms are unexamined; potentially dangerous problems are ignored because they are not found.

There is no easy answer to these problems other than vigilance. The onus of this solution, however, is almost completely placed on the ER staff's shoulders.

Some of us bear the weight better than others.