Report

It never ceases to amaze me the condition my transfer patients arrive in from other hospitals or units.

Some healthcare providers on other units or in other hospitals are perfectly diligent and follow protocols and really look at the big picture.

Others send patients and stress the main problems are weakness and oral thrush and in comes a febrile, emancipated-looking man with no white blood cell count.

An accurate report is really, really important. Just so you know.

Quip

"I see you and your husband have been married for 65 years."
"You think that's a GOOD thing? Take my advice - get out while you still can!"

The Meaning of Hospice

At the end of October, I had an elderly woman who was truly ready to go to hospice. She had been accepted and was just waiting on a bed to open up. After years with her cancer, treatments no longer worked and physicians had nothing more to offer.

I had her for two consecutive nights and one of her sons never left her side. It was obvious that he had his mother's best interests in mind and no matter what she needed, every single time, he just said "Anything for Mama," and did whatever it was. The combination of all the treatments she had been through and being an older person in general made her very weak. She was barely able to move. She was incontinent but could tell us when she needed to be changed and her son helped me re-position her, slowly, because it hurt her to move.

I left to go home in the morning, being told the hospice center had a bed and would be taking her later that day. Overall, I was relieved. Her son made one comment to me toward the end of my shift about how he was hoping to get her out of hospice very soon but I thought that either the physicians or the hospice center would explain to him the goal of hospice.

I returned a few days ago to find a familiar name in my assignment. I knew who it was immediately but I was puzzled as to why she was still here.

I went in the room early on and that same son was with her. He asked me to help change her, so I did, and then started my rounds on my other patients.

A little later, she needed to be changed again. This time, her other children were there. My tech and I started cleaning her up. Suddenly, her other son began screaming that we were too rough, cursing at us and ordered us to leave the room. When a patient hurts just to move at all, there isn't much you can do about that but I can see how a distraught family member may not see it that way.

When the evening quieted down, I asked my charge nurse what happened with hospice. I looked through the previous documentation. Apparently, she had been doing quite well from the palliative chemotherapy they were giving her in hospice and her children took her out of hospice and back to the hospital.

Cancer is hard on the body. Chemotherapy and radiation are hard on the body. Sometimes it works and patients leave cancer-free and that's amazing. But sometimes the cancer spreads. Sometimes the treatments don't work or stop working. In this woman's case and many others, we know what the outcome will be and the only thing left to determine is how and when it reaches that point.

It's incredibly difficult watching someone you love die in front of you. Even when that person is in hospice care being kept comfortable, you may not understand. You might feel that hospice is cruelly starving your loved one when in reality, it's difficult for many patients who qualify for hospice to eat and they're usually getting some kind of drip so as not to feel the hunger. It's important to understand that hospice is not a step in between hospital and going home. Your loved one is dying, likely from something very painful. Even as a nurse, I can't imagine seeing a loved one in hospice wouldn't elicit some very powerful emotions. I'd want this person to stay with me as long as possible. I wouldn't think it's fair that they're dying, not now, not from "this," whatever "this" may be. But it's important to try your best to take yourself out of the equation. Your loved one probably doesn't want to leave you, either, and also may not think it's fair that they're dying now and from "this." They don't want to suffer as much as you don't want them to suffer, which is why it's so important for family members to understand hospice.

The fact is that this person is dying. It can't be stopped. The best that we can do is let the person die comfortably and with dignity. As healthcare providers, we truly do want to do what we think is best for your loved one, and what's best for you, too. But your loved one comes first. If you don't understand why we are doing whatever we may be doing or why we think your loved one should go to hospice or what will happen there, ask us!

Yes, as a nurse I've had thousands of patients. But please don't think even for a moment that I don't care what happens to your loved one. I became a nurse because I WANTED to care about all of these people and each and every one of my patients matters to me.

I've had a few people ask me about this whole nursing situation and why nurses are so offended, especially since we talk about how our job entails us letting a LOT of things roll off of our backs. I'm going to try to give an answer based on my experience. Take it as you will. I can't speak for all nurses, I am only speaking for myself.

There IS a difference. When we're taking care of patients, they're not just patients. They are people who are not feeling well who are suddenly being told what to do to feel better - a situation no one plans to be in! They're out of their element with no control over anything and suddenly, someone who is used to being independent has to call a nurse just to walk to a chair or go to the bathroom. We're not judging but know that we'd feel embarrassed if it were us, too. When people are upset or not feeling well, they say things they don't mean. Sometimes, it's a lot easier just to be angry than to learn that suddenly you're sick and it could be forever when you might feel fine at that moment. I'm a cancer nurse. Sometimes people get a diagnosis during the day and it doesn't hit them until 3 a.m. when they're suddenly wide awake and crying or questioning or praying or any combination. I sometimes have to tell people that their bodies are literally not producing any healthy cells and aren't going to, and who wants to hear that? If taking anger out on me helps you cope somehow, then I want you to do what you need to do. And when you need a hug or just want to talk, I want to be there to do that, too.

Now, onto the rest of the world. Nursing is a profession that requires a lot of education and quite an extensive skill set, which we work hard to develop. People ask me why I didn't go to medical school, as though nursing was a second choice. I did not go to medical school because I did not want to be a doctor. I went to nursing school because I wanted to be a nurse. I love and respect the doctors I work with - and don't forget the physical and occupational therapists, social workers, respiratory therapists, dietitians, etc.! We are part of a healthcare TEAM and we each have important but different roles to contribute to the care of each and every patient. Nursing is a field with a lot of stereotypes which, unfortunately, die hard, especially being a field that is primarily women. We are intelligent and skilled people, not just props. My male colleagues have to deal with stereotypes as well. Instead of people saying "I'm proud of you for becoming a nurse," they get strange looks and have to defend their chosen career. Why do we live in a world where people need to defend themselves for wanting to care for others?

When you belittle us, you are reinforcing years of stereotypes. I didn't become a nurse for the appreciation but I worked hard to do what I do FOR YOU. I spent hours at clinical rotations and long nights reading textbooks so I could get through nursing school to learn skills to make YOU feel better. 

I don't wish anyone ill. If any of the women from The View, or anyone with a similar view, is my patient, I will not treat that person any differently. All I want from you is for you to know that I am doing everything I do to help you feel better and perhaps develop a greater understanding of just what it takes to be a nurse.

This Is Me

This is me in my nursing scrubs last night during my 12-hour shift, wearing my NURSES stethoscope. During those 12 hours, I do many things for my patients. I treat them by administering their medications, those that are scheduled and those for an unwanted bout of pain or nausea. Sometimes I just hold a hand or give a hug while listening to a patient as he or she takes in a new cancer diagnosis or experiences an all-too-familiar feeling of chemotherapy treatment really hitting the body and causing pain and clumps of hair to fall out onto the pillow. Sometimes I tell people that it's OK to be afraid to brush your hair.

But I also perform a head-to-toe physical assessment.

I listen to lung sounds - is your breathing labored? Are you wheezing? Coughing up blood? Possibly overloaded with fluid?

I listen to your heart. Can I hear a beat? Is it abnormally fast or slow? Is the rhythm a bit off? Does the EKG performed by my tech or myself show something concerning?

I listen to your bowel sounds. Can I hear the gurgling that lets me know your insides are doing what they should be? Are you constipated? When was your last bowel movement? Are you having diarrhea? Is your stool loose or bloody? Does the touch of my stethoscope or hands suddenly cause you pain?

I am proud of what I do. To Joy Behar and the rest of The View, I don't wish you ill. But if ever you find yourself under the care of a nurse, I hope you realize the true extent of our knowledge, abilities, and how much we care about and do for you, our patient, both when you are strong and at your most painfully vulnerable moments.

The First To Go

This week, I arrived at work to find a neatly printed memorial booklet on the desk at the nurse's station.

I looked at it closely and found the name to be a familiar one: my very first patient had passed away.

Working as an oncology nurse, it was not unexpected that sooner or later, some of my patients will pass away.

Unlike my other patients, I saw this man's treatment from start to finish. He and his wife came from out of town to visit a friend for his child's Christening or Baptism. I don't remember which.

I forget the symptoms that brought this man into the ER initially, but they were certainly not expecting a cancer diagnosis. The patient was admitted to our unit and we began his chemotherapy regimen. He came in walking and talking and as his treatment progressed, he became unable to breathe on his own and was in and out of the ICU.

I hadn't had this man for weeks but I did see his wife in the hallway and talked to her all the time about not just her husband's care but how she was doing and what was new in her life, where the local CVS was, how her dog was and many other things.

She and her husband were wonderful people. While it saddened me immensely to see that he had passed away, witnessing the weeks of unconditional love and support his wife provided made it an honor to know and care for them.

Out

Today was my last day at Sinai.

Neurology isn't what I want to do forever and so I'm excited to move on to the next adventure. For me, this means oncology, something I've wanted to do since my last semester of nursing school.

It seems so long ago that I felt like I was mindlessly clicking buttons and writing the same but slightly different cover letters over and over and hoping for someone to say SOMETHING, even if it was rejection. After six months, I finally had a job. At the time, I had no interest in pulmonary and infectious disease but if they were willing to give me a pay check, I was willing to work for one.

The idea of me being able to move on because I decided I wanted to do something else was unfathomable.

Nursing school friends, it gets better.

On Death and Dying - The Distraught Niece

Recently, I've had a few patients pass away on my shift. We are not a hospice unit; the majority of our patents are admitted for some kind of neurological issue. But we do get other types of patients on occasions. This is one of them.

All of our patients have some kind of order set put in by their physicians. They dictate the frequency and type of vital signs to be taken, when and what labs are to be drawn and what the patient is allowed to eat, if anything. There are other orders, but these are the most common ones.

All patients are required to have a code status, which is perhaps the most important one. At any moment, a patient could stop breathing and we need to know what to do. If we have no information, the default is full code and all appropriate interventions are used as necessary. This may include CPR, oxygen therapy (intubation or an external mask), medications, etc.

For patients who want no interventions in the event that they stop breathing, our facility uses AND - Allow Natural Death. A more common term used at many other facilities is DNR - Do Not Resuscitate, but the meaning is the same.

The first of these patients came to our unit from the ICU as AND. She was elderly and non-responsive. The orders for her were comfort care only. This means that, among other things, no vital signs are ordered. Many times, as was the case for this patient, pain assessments were ordered at regular intervals and a constant morphine drip was running. When she arrived, the charge nurse, tech and I went into the room to set her up but unlike other patients, there wasn't much to do. We set her up comfortably in the bed and left her to rest.

The charge nurse didn't say it, but he didn't have to - take care of the patient and let him know when it was over.

There were no family members in the room for most of her time there so my hourly rounding was uneventful. The patient arrived with a breathing pattern that is called Kussmaul. It describes a breathing pattern that is one sign that death is near. It's a shallow kind of breathing that sometimes will skip a breath. You learn about it in nursing school and it's hard to describe but when you finally hear it, it's very distinct and you know what it is.

Eventually, some family did arrive. Her niece came along with her husband. The niece was in tears over the bedside, while her husband stood a foot or so away from the bedside and calmly introduce himself to me. I left the room and not half an hour later, I was told there was an emergency in that room.

Now the only irregular breathing pattern belonged to my patient's niece. In tears, she asked me if I was absolutely sure there was no pulse. As a nurse, I'm not allowed to pronounce someone dead; that responsibility belongs to the physician. At her request, I hooked up a vital signs machine. The error messages on the screen seemed both comforting and frightening to this woman.

The physician arrived and shortly thereafter told the family she had passed. He asked me to do an EKG (also known as an ECG - electrocardiogram. EKG is its German abbreviation and is sometimes used to differentiate it from similar-sounding procedures like EEGs). The print-out showed the expected straight lines where a heartbeat would have been a few hours ago. Was an EKG necessary? In theory, no, absolutely not. There was not even the slightest indication that this woman might be alive.

But one thing they often fail to address in school is that you don't have just one patient. If there are family members or friends at the bedside - they are just as much your patients. This niece needed that visual to give her some closure.

For her, yes, the EKG was absolutely necessary.

Patient Quote

"Sorry about all of that foreskin."

You know you're a nurse when hearing that is just a normal day at the office.

Today I was getting dressed for work and my sister told me my scrub top reminded her of our grandmother's scrubs.

My grandmother passed away before I started nursing school but I like to think somehow she knows I grew up and became a nurse, too.

Clocking In

I walked into work almost an hour early today because that's when my ride could pick me up.

I saw the nurse I gave my patients to last night and thought about asking how they were last night but then I thought, "She can tell me at 6:54."