Happy Mother’s Day to my mom, who should have been a nurse; when i had the patient who had leeches revascularizing his ear, she not only wanted to hear all about it but volunteered to come sit at his bedside all night to watch for the full ones to drop off so that i didn’t have to go in his room every fifteen minutes. She watches open heart surgery while eating lasagna, loves to hear my grossest, goriest stories, and sends me cards for Nurses’ Day that always mean more to me than any trinkets or freebies a hospital might give.

And Happy Mother’s Day to my nurse mamas, the experienced nurses who have and continue to mentor and teach me. Thanks, Pat, for being my preceptor and guiding me as i took my first tentative steps as a new nurse, and for continuing to support me as i figure out what kind of nurse i want to be. Thanks, Becki, for showing me the night shift ropes and for being a sounding board, whether i need to figure out what the big clinical picture is or if i’m trying to figure out how to navigate the political waters. And thanks, Corinne, for not only being a supportive and encouraging clinical instructor back when i was a student, but for being a supportive and encouraging colleague and mentor when i told you i was going back to school to become a clinical instructor.

I wouldn’t be the nurse i am today, and the nurse i’m becoming, without these moms in my life. Thank you.

…and our boss is so embarrassed by our gifts from the hospital that she hasn’t handed them out yet.

(We got a $10.00 gift certificate from the hospital foundation for any of the special “Centennial Merchandise” in one of our gift shops - in other words, ten bucks to spend on a small selection of stuff in a hospital store - and a small, dinky first aid kit. As one of our nurses said, “Now when i come across an accident, i can jump out and say ‘I know CPR! And i have bandaids!‘”)

There’s a part of me that’s just as insulted as my boss - i mean, really, you’d think they could put a little effort into it. But there’s a part of me that really wishes that they just wouldn’t give us gifts at all. I mean, really - instead of restrictive gift certificates on stuff we don’t really want, or jumper cables that melt when we try to use them, or first aid kits for people who probably have better ones at home, save your money. Better yet, i’d love it if my hospital made a donation to a charity like Habitat for Humanity or one of the local homeless shelters or mental health programs in our name.

This year, at least, they’re not insulting us directly. Last year’s campaign for Nurses Week was aimed around the idea of nurses as quiet heroes. While i agree that we save lives every day and don’t expect a big fuss about it, nurses are anything but quiet. We’re often the voice of advocacy for our patients. It’s part of our job to be loud and vocal for our patients.

So what has your hospital done for Nurses Week? Do you wish they’d just stop, or do something better with their money? Do their activities make you feel like a respected member of the team, or do they make you feel like you’re being patronized because it’s expected?

I think i’m going to see what i can do about starting a campaign at my hospital to get money donated somewhere else for Nurses Week. It has to be better than the junky stuff they’ve been giving us lately.

Regardless, whether your hospital does a good job expressing it or not, take some time this week to congratulate yourself for the damn good job you do. Nurses are the backbone of the hospital, the clinic, and the community. We deal with a lot of poo, metaphorically and literally, and don’t get a lot of recognition for it.

Yep, i’m back. Didja miss me?

First, i don’t think trying to blog as a new nurse works. I was too busy trying to absorb the things i was learning to be able to translate them into words and blog posts. Hell, i was hardly able to process the fact that i was learning them in the first place, much less identify the effects they were having on my life.

It was an interesting year.

Anyway, i’m far from experienced, but there are several things going on that make me want to blog again, and things i think it’ll be helpful to blog about. For one, i’ve recently finished training to work in our Progressive Care area; that would be exciting enough, but next week i start training to be one of the charge nurses.

On top of that, i’ve taken on some other responsibilities at work - i’m working as part of a committee to implement bedside reporting on our floor, and i’m going to do a journal club/lunch and learn in June on the nursing care of transgender patients. So i’ll have lots to talk about here.

Finally, i’ve decided to go to grad school and get my MSN in Nursing Education. Ideally, i’d like to be a Clinical Educator, but i’m not going to close the door on doing anything else. Regardless, i’m hoping to be a hospital-based hands-on sort of educator, at least to start. I’m pretty excited about grad school, which i’ll be doing part-time, online. I’m sure it’ll give me plenty to say - hopefully i find the time to write about it. (;

So, that’s it. Other than that, trauma’s been trauma. I’ve got a few posts percolating, and some site redesign in mind, so stay tuned!

-Nurse Bear

The trees add shade to shade, lights out in the houses, we’ll both be lonely.
-Allen Ginsberg

A year ago today, i walked into Metropolis Hospital and started to work as a nurse. Well, actually, i spent the day filling out forms and going through hospital orientation; that makes the day no less remarkable and the anniversary no less important.

I find myself both exactly where i thought i’d be and miles away from where i imagined i’d land. I’m still learning, each and every day, but i’ve settled into a routine and have hit a point where i know what to expect each night - which is still different from what happens, but knowing what to expect also means having the tools to deal with the unexpected. I’m looking at my future in the job - whether to stay when my contract ends in July (most likely i will, unless something changes dramatically in the next six months), and what steps to take next to grow both as a nurse and as a member of my team. I’m dangerously close to becoming senior leadership, at least on night shift, which is disturbing in what it says about the state of my floor, and affirming in what it says about me and my qualities as a nurse, a person, and a colleague.

I’m taking classes to be trained to work in our floor’s PCU in February, the soonest they’re offered. I’m an inch away from accepting my boss’s offer to take over the diversity coordinator position currently open on our floor, because i think i have a lot to offer from a GLBT perspective - and it’s one that i think is often overlooked and underserved. In the next few months, they’re going to ask me to be trained to be a charge nurse, and i’m currently trying to take steps to make sure that two of my colleagues get trained at the same time so that none of us have to do it all the time. And on top of all of that, i want to continue to learn and grow as a nurse.

Wow. I have goals.

I’ve been sorely neglecting this blog, however. In retrospect, it’s no surprise. I’ve had a lot on my plate this year. There are few things more daunting than being a new nurse - you’ve climbed the mountain that is nursing school, but when you get to the top you realize you’re only to a plateau, and you’ve got twice as far to go. I thought that i’d be able to blog about everything i was learning, but the lessons weren’t the kinds of things you can write down in books. Instead, they were lessons on how to deal with death, both in front of you and offscreen; lessons on how to interact with other people, whether patients, family members or colleagues; lessons on how to stay on top of yourself and your duties while not getting swamped by the wave of new orders, crashing patients and the mess the shift before left for you to deal with. I have no idea how to translate these things to words - it was hard enough to realize that i was learning them at the time. Mostly i looked back and realized how i’d adapted and changed.

And blogging fell by the wayside - first, the things i had to say; then, the things others did. There are a lot of things i never did that i really wanted to - i never got the site whipped into shape, never got the graphics up or the formatting and coding right. I didn’t interact with other bloggers like i wanted to - i’d leave comments here or there, but i never really managed to have conversations with you all. I’d come home with a story and have no idea of how to tell it; i’d come home with a gripe and have no desire to rehash it. And i never really felt comfortable trying to explain the lessons i was learning when i wasn’t sure i was getting it in the first place. (The piles and piles of spam were also a huge pain.)

In other words, i’m not much of a blogger these days. So, for now, i’m shuttering my doors. The site will still be here, and i may come back at some point, but i’m relieving myself of the duty of updating here - a role i’d abdicated a long time ago, to be honest. We’ll see how i feel when the url is due to be renewed, although i imagine i’ll keep it, at least for a little while - i’m still proud of the name Nursa Minor.

Thanks to all of you who’ve kept checking in despite my long silences; it means a lot to me to check my sitemeter, even after a long absence, and see so many familiar names. Thanks to everyone who’s commented here - it helps to not feel like a voice alone in the wilderness. And thanks to Kim and Beth, especially, for their encouragement. It’s nurses like you who help new nurses like me learn how to fly.

Take care, everyone. If i ever put my shingle out again, i’ll be sure to let you know.

“JD, I spend most of my time here getting orders barked at me by people who take credit for my work and blame me for their mistakes. And all the while i’m expected to hold the doctor’s hand. You should try trading places with me for one day.”

-Carla, RN, Scrubs - “My Nightengale”

…And she didn’t even mention poop once.

We bonded because his partner noticed my bear necklace and commented on it, and the three of us shared A Look that said “not that kind of Bear, but yes, i get it.”

He came to us several weeks ago with what was thought to be a minor complication of the AIDS process marching through his too-thin body. The minor complication turned out to be major, and along the way a couple of his organs have decided to go on strike.

His partner went to the cemetery earlier this week, to begin making the arrangements. We all love his partner, all check in on him to see how he’s doing with attention equal to what we give our patient.

“This is why i picked med/surg trauma, why i came to work here,” one of my friends fretted. “Trauma’s quick - they get banged up, we patch ‘em up and ship ‘em out. They don’t stay, we don’t get to know them, and they don’t die.” We’re grieving already, waiting, all of us - his partner, him, us.

Yesterday, after work, i had a dream about him - my first dream about an Actual Patient. In it, i hugged his partner. He thanked me for everything, and i told him not to worry about it - “Family takes care of family.”

I got cancelled from work tonight, so i don’t know whether or not our patient’s still alive. I wouldn’t be surprised to find out if last night was my chance to say goodbye. If so, i’ll be comfortable with that - it was a powerful, peaceful dream. But i’m hoping for the chance to say it in person, to be there for him and his partner. It’s a strange wish, i know. But i’m comfortable with death, and they’re family. And even though i’ve been incredibly happy with the way my colleagues have treated our patient and his partner, openly gay men with AIDS, with the same care and concern that would be given to our other patients, i still hope to be there for them if possible.

I don’t usually get into the holiday spirit until after Thanksgiving, but this is something that is not only near and dear to my heart (in several ways!) but also something i wanted to give you time to consider.

I know several of you are gamers, and several of you like kids, and several of you are just good people, and i’m sure everyone knows someone who’s had the misfortune to be hospitalized at some point. If you fit any of the above criteria, or are looking for a way to help some kids who are in a fairly lame place (even when they have fabulous nurses!), check out Child’s Play. Child’s Play is a charity that donates toys, games, books and money to children’s hospitals. You can donate money directly, or make a purchase through a specific hospital’s wishlist on Amazon, ensuring that you not only know what your money is used for but can ensure that it goes to a hospital of your choice.

One of the hospitals you can donate is Riley Children’s Hospital in Indianapolis, which is near and dear to my heart for several reasons. It’s one of the hopsitals where i did my training at, and even more importantly, several of my friends and my friends’ kids have been patients there. Riley takes care of kids from all over the state, from several neighboring states, and even from other countries. They’re one of the best hospitals out there, they do everything they can to make the kids and families that they treat as comfortable as possible, and i’m happy to support them in any way that i can.

Riley’s list can be found here, or you can go to the Child’s Play website and support the childrens’ hospital of your choice or simply donate cash to the organization.

The hospital is rarely a fun place to be if you’re an adult and know what’s going on. It can be even less fun if you’re a kid and don’t quite know what’s up. Having toys and games and things to distract you from being sick and/or in pain can help make that experience better. Please think about it, keep these kids in mind, and if you have the money to donate, please do. There are plenty of kids out there who will thank you.

This week’s edition can be found here, and i’m pleased as punch to be included. It’s a great edition with a Price is Right theme.

And i have to admit, i use the phrase “come on down!” all the time at work, too, usually when we’re rolling someone to clean them up or get the transfer sheets from under them. I usually say it when we’re rolling them back over onto their back.

Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.

I’ve been off for nearly a week because i’ve been sick, and the time away has been frustrating, in some regards - there are so many things i’ve wanted to do around the house, but being sick left me with no energy to do them in - and eye-opening and revelatory in others.

With regards to the latter, i’m realizing how toxic my work environment really is. I described it as kafkaesque in conversation with close friends, and that’s true: optional and anonymous surveys that require 100% participation and each person to turn in a certificate with her or his name on it; emphasis placed on impossible goals and patient satisfaction surveys; blatant favoritism and flat-out lying among management; punishments being doled out without prior warning. It’s a shame, because i really love my co-workers on nights and many of my colleagues on days, but i really hate our management. It’s frustrating to watch them poison the water without any recourse towards stopping them. If i were to go to my manager with a complaint, for instance, by the end of the day everyone would know about it. It’s not a pretty situation. I feel like i’m trapped in a cave with my manager standing guard at its mouth, only allowing certain information in or out.

Poor chap, he always loved larking
And now he’s dead
It must have been too cold for him his heart gave way,
They said.

My contract is up next summer, and technically, it’s only a contract to the hospital, not the unit. I’ve just gotten solid ground under me here, and it seems like defeat to start over again. But i may, at year’s end, try to transfer to the ED or another unit. Everyone i love at work with one or two exceptions are counting down the days until their contracts end.

I spoke with a friend this weekend who’s in an entirely different line of work, and told him my troubles. He told me about the coup his office held, how they got their management to straighten out and back off. I told him i think my shift is days away from open revolt. His advice was patience - that even if we couldn’t change anything, the 50% turnover on our floor alone would be a big red flag to upper management about what a lousy job our boss is doing. I hope so, but i’ve been hoping so since i began working here.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life
And not waving but drowning.

I work tonight. I’m not very excited about going in. I’m not doing a very good job of staying positive anymore, not even about the good things.

(Poem: Stevie Smith - “Not Waving But Drowning”)

“Dear Nurse Bear,

“A recent survey of call light answer times showed that you had several incidences where call lights weren’t answered in under six minutes. Blah blah patient satisfaction blah blah answer your call lights faster blah blah.

“A copy of this notice - the first you’ve heard of this subject - has been placed in your file as ‘informal counseling.’

“Smooches, and Let’s Keep Those Patient Satisfaction Scores Up,
The Management.”

You all have been discussing patient satisfaction surveys recently, and i’m too tired and frustrated to go into the litany of very good reasons you all have brought up in regards to why they’re such a crock. I agree with you entirely - that the only people who fill out surveys are either Very Happy or Very Angry, that there’s no way to get to that targeted 100% satisfaction and still take care of patients safely (by not letting them out to smoke, or not feeding them two hours before a surgery) or effectively (it is impossible for a nurse with five patients to be at each one’s beck and call every single moment of the shift). I agree that there are much better things to spend our time and money on besides surveys (more nurses on the floor, focus on patient care and nursing duties over the Almighty Dollar) that would increase patient satisfaction.

I also think that i work on a floor with a lot of patients who crap themselves, and a lot of patients going through alcohol withdrawal, and a lot of patients who’ve recently been banged up pretty badly and need two sets of hands and twenty minutes to get from the bed to the bedside commode, and a lot of patients who need a lot of pain medicine, and a lot of patients who need blood sugar checks and then insulin, and a lot of patients who need us to fetch water because the State Board of Health won’t let them or their family members into the kitchen. And i think i do a pretty decent job - not a great one, but a decent one - of asking patients if they want pain medicine as soon as it’s available instead of waiting for them to ask me. I think i do a decent job of checking on my incontinent patients often so that they don’t have to sit in shit for very long, and a damn good job of being sympathetic when they are incontinent and need us to help clean them up. And i think i do a decent job of being ridiculously polite and unflappable when i’m asked to get water out of the kitchen at the other end of the hall for the thirty seventh time that evening when all i really want to do is sit down and eat my damn lunch.

And i’ve only been a nurse for nine months, which means that i still think it a minor miracle when i manage to get everything done on time and none of my patients crash and i don’t make any major (or moderate) mistakes.

And none of it makes me feel better when i get “informal counseling” out of the blue like this. Dammit…some nights i’m doing everything i can to keep my head above water - and answering other people’s call lights when i can, to boot - but apparently that’s just not good enough.

I’m a good nurse. I don’t get along with every patient, but i’ve got my share of patients who tell me thank you, who ask to have me back the next night. And i’ve got my share of patients who hate me, too, because i don’t let them get away with everything. But apparently i’m not answering my share of call lights.

I give.

A graduate nurse thinks psych patients are interesting.
An experienced nurse thinks psych patients are crazy.

-Miss Ellie, RN/Running with Scissors

Before i ever entered the wonderful world of nursing, i was fascinated by Munchausen Syndrome, a psychological illness characterized by patients who either falsify illness or deliberately cause themselves to be sick. Part of my fascination comes from my fondness for The Adventures of Baron Munchausen, Terry Gilliam’s movie about the farcical adventures of the character from whom the syndrome gets its name. Never was a fan of Munchausen Syndrome by Proxy, where parents harm and sicken their kids to get sympathy and attention, because child abuse is not cool. But Munchausen’s - now that must be interesting.

Now, two - two! - Munchausen’s patients later, i can tell you - Munchausen’s patients are not interesting. They’re crazy. And what’s even more fun is that they don’t like it if you give them even the slightest hint that you don’t believe them. Now, i pride myself on not being one of those nurses that rolls my eyes at patients. (I wait till i’m out of the room, and usually make sure there’s a locked door between us first.) The less i like a patient, and the more ridiculous she or he gets, the more polite and cool i get. However, there’s a difference between a polite “oh, really?” and full blown tacit agreement, and our Munchausen’s patients both felt the need to convince me that they were serious. The less annoying one would writhe in pain all night long for no apparent reason. The more annoying one would complain about how incompetent we all were and how she couldn’t believe that she kept getting these infections mere moments after we caught her pouring cleaning fluid into her PEG tube.

Un-frickin’-believable.

I take it back. I no longer find Munchausen’s fascinating, and i would be tickled pink to never see anyone with it ever again.

It can be found here, and it looks like a good one. I swear, lately i’m marking the passage of time by the emails showing up in my inbox from Kim to announce that CoS is live. Of course, that’s usually the morning i’m asking myself, “i wonder when the next CoS is up? I should submit something.”

Will there be any bartenders up there in Heaven?
Will the pubs never close, will the glass never drain
No more D.T.’s and no shakes and no horrors
Very next morning you feel right as rain

I’d traded one drunk for another - this one sweet where the last had been crude, this one quiet where the last had been boisterous. I’ve never minded the drunks. I have no problems giving Ativan - in fact, it’s soothing to watch the way it swirls as you draw it up - every hour if need be. And most of the time they know they’re going out of their heads and are apologetic, fumblingly kind.

O God loves a drunk, the lowest of men
With the dogs in the street and the pigs in the pen
But a drunk’s only trying to get free of his body
And soar like an eagle high up there in heaven
His shouts and his curses are just hymns and praises
To kick-start his mind now and then
O God loves a drunk, come raise up your glasses, amen

He’d slept most of the night, waking only for his Ativan and some orange juice from time to time. His roommate was an older man who kept asking me to do things for him - empty his urinal, adjust his CPAP, and he’d wave from behind the mask every time i walked in to check on my patient - so much that his nurse and i joked that he had a bit of a crush on me, perhaps.

Does God really care for your life in the suburbs
A dull little life of dull little things
and bring up the babies to be just like Daddy
And maybe you’ll be there when He gives out wings

I can still remember all the details - the tattoos on his arms and shoulders, the closecropped hair, the way he kept sliding his feet out of one side of the bed, his head slid down to the other side. I still remember the way he kept trying to lay on his broken side, turning over painfully to take his Ativan pills and juice, extending trembling fingers to let me draw his blood sugar.

But God loves a drunk, although he’s a fool
He wets in his pants and he falls off his stool
He can’t hear the insults and whispers go by him
As he leans in the doorway and sings Sally Racket
Can’t feel the cold rain beat down on his body
And soak through his clothes to the skin
O God loves a drunk, come raise up your glasses, amen

Then the next day he was gone - to the PCU and finally to the Unit. Stories trickled down for a week or so, and then by that point we’d had almost complete turnover of our patients, and we moved on.

Will there be any pen-pushers up there in Heaven?
Does clerking and wage-slaving win you God’s love
I pity you worms with your semis and pensions
If you think that’ll get you to the kingdom above

All the details came seeping back last night when i saw him again, face twisted, rocking back and forth. He’d had a brain bleed while in the Unit, and the years of alcohol and drugs looked to have caught up to him viciously. He’s even skinnier now - hard to believe, he was already rail thin - his face gaunt, cheeks hollow. He can’t speak, can’t find the words. But they’re there in his eyes and in the way he rocks back and forth, back and forth, trying to get out.

But God loves a drunk, although he’s a clown
You can’t help but laugh as he gags and falls down
He don’t give a cuss for what people think of him
He screams at his demons alone in the darkness
He’s staying alive for just one more pint bottle
Won’t you throw him few pennies, friend

God loves a drunk, for ever and ever, amen

Lyrics: Richard Thompson, “God Loves a Drunk”

Last night i walked into a patient’s room and found him dead.

His son called about twenty minutes before i found him. “I just want to check on his status,” the son said. “We were there all day and i know he’s scheduled for this procedure tomorrow, i just wanted an update on how he’s doing.” Weird, i thought, you already know everything, but i launched into the Reassure the Family Everything’s Fine speech - vital signs were stable (they were), he was starting to develop a bit of an appetite again (he was) and he’d been in a better mood tonight (he had been). I made sure we had a phone number where we could call the son if we needed to.

And then twenty minutes later i walked in to find the patient dead. We coded him, but i knew before we started that he’d likely been gone since his son’s phone call.

The chaplain called the son to tell him we were coding his father and that he should come to the hospital right away. The son didn’t make it until after the code was called - a blessing, really, because we were able to clean his father up first. But it meant that when he arrived and we told him that his father had passed, he looked right at me with a deeply wounded glare that said “you told me he was fine.”

Back when i was still in orientation, my preceptor and i came in one morning to find that our patient from the day before had coded and died an hour or so before shift change. Because the family spent some time with the body, it became our responsibility to prepare the body for transport to the morgue after they’d left. “You’re the only student i’ve ever had that experience with,” she told me. “I’m glad we did,” i replied, “because it meant i knew everything that needed to be done.” Last night, my favorite CNA and i washed the patient and took all of the tubes and lines out. It was cathartic. It was my chance to apologize, to make amends for any mistakes i might have made in my short career as his nurse.

It’s not enough. But it was what i could do.

I’ve got two insect bites on my foot that not only are blistering, the blisters are swelling. As in, they’ve both tripled in size in the last two hours.

Greeeeeeeat.

I’m a pretty lousy patient, so let’s hope this doesn’t need medical intervention. My worry at the moment is that they’re brown recluse bites - not unlikely given my location and the fact that i was hanging out on a rock cut last night, but surprising considering i was wearing shoes at the time (albeit ones with webbing over the toes).

I’ll let you know when the ulceration starts. </melodrama>

I swear i saw more penis on Wednesday night than i had since i’d started nursing school, and frankly, on a trauma floor, you end up seeing a lot of dick.

There were the two teenaged roommates, one who grabbed his urinal every time i walked into the room and whipped it out to pee, the other who had the habit of tossing his sheet off in his sleep and refused to wear a gown, leaving him spread-eagled and naked on the bed all night. (And before you ask, he had an injury that made it pretty much impossible to attempt shorts, even the kind that button on.) He also wasn’t shy about peeing in front of me. In the other room, i had the guy who *couldn’t* pee, and hadn’t peed all day, but kept falling asleep in the urinal. Frankly, considering he still had his gown up and his sheet down the next night, after the plumbing had started back up again, i’m pretty sure that it had nothing to do with peeing and everything to do with penising.

Creep.

The worst part is, what do you do when you walk in to find the gown at the bellybutton and the sheet at mid-thigh? If you say something, he gets that grin on your face that lets you know that he knows it’s getting under your skin and he likes that. If you don’t say something, you just get to stand there and feel like a victim. I kept flipping sheets over him, but it was still a shock - and a violation - to walk into the room the next night, when he wasn’t my patient, and come face-to-dick with him.

I’m fairly unflappable when it comes to nudity. I’ve seen all shapes and sizes and have no problem staying professional about it all. But i’m not a fan of a guy showing me his penis just to be a dick. It’s offensive and worse, it makes me feel rather helpless. What’s the proper course of action when you’ve got a patient who insists on forcing his or her nakedness on you just to be a jerk?

We had a smart intern!

…And now he’s gone because they all rotated this week. Sigh.

Dr. Right was not only smart, he was confident enough to make decisions when he knew what to do, and to ask questions to make sure he was on the right track. Regardless, he didn’t put the burden on nursing to make the call, and he didn’t ride roughshod over us, either. Every single nurse on our floor was a big fan of his, and several of my patients thought he was the bee’s knees, too, and told me so.

I’m still a bit bugged by a conversation he and i had on our last day working together. When i found out he was done (till his trauma rotation, but still, that’s several months away) i went up to him and said “hey, i just wanted to tell you that we’re all really big fans of you around here, and everyone thinks that you’re doing a really good job and we’ll miss you. Thanks for not sucking.”

“Thanks,” he replied. “That’s really nice to hear, especially since the attending doesn’t seem to think so.”

All i could do was blink at that. “He doesn’t know what he’s talking about,” i replied. And i’m still a little annoyed. Dr. Right was the only intern any of us liked, and the only intern who seemed to have any idea what he was doing. I have no idea how intern and resident politics work, or what else happened with Dr. Right when he wasn’t on our floor. And i’ll be the first to admit that i’ve been a nurse six whole months now, so i’m not the best person to judge. But from everything i saw, he’ll make an awesome doctor. His colleagues, however, still have a long way to go.

Okay. So we talked, here and here and here and also here about nurses refusing to take patients on their floor, or take report on the patients that have transfer orders.

What do you do when it’s the doctors standing in the way of the transfer?

Last night was pretty traumatic. I clocked in early to help with a new admit who we were all pretty sure was going to the PCU - an MVC who was lethargic and unable or unwilling to answer our questions. “You need to get her out of here,” the day shift nurse who was handing her over to me said. “I’m not sure if she’s snowed or what,” the doctor said, and then rattled off a handful of orders (which he thankfully then went and wrote in the chart).

We also didn’t have a CNA until 11pm, something i didn’t know until 10 because i was running around with Lethargic Lady and getting set up to sink an NG and pass pain meds on Formerly Pleasant but Now Anxious and Nauseated Guy. This is important, because although i did a hurried assessment of Slick, i barely saw him in the first three hours of the shift because i was hanging boluses and changing suction cannisters and passing PRN meds to the other two. This was the third night i’d had Slick, and he looked a little tired and grumpy, but that probably had more to do with him getting yelled at for getting out of bed all day.

See, Slick had a bad habit of getting up out of bed without telling us, and had managed to hurt himself pretty badly one time. “I’m about to tie him up,” the day shift nurse told me in report, frustrated. “He keeps getting up.” At 8pm, Slick looked like he was settled in for a nice night’s sleep, and i did a quick assessment, figured the CNA would tell me if his vitals sucked, and went on to my other patients.

Until one of the other nurses called and had me get in there. She’d found Slick half out of bed, wheezing and exhausted. They’d gotten him back, but she looked up at me when i walked in the room and said in no uncertain terms, “He looks like shit.” And he did. We grabbed vitals: pressure in the 80s over 50s, which is way low for your normal adult and in the basement for someone who’d been in the 160s-180s over 90s-100s the previous two nights and was getting hydralazine every four to eight hours for it. Heart rate was up, respirations were up, skin was cool, temp was down, urine output for the shift was zero and his H&H were dropping like rocks in a bucket. Slick had lost an unspecified but worrisome amount of blood when he’d hurt himself. All of these points added up to one conclusion for those of us on our med-surg floor:

“This guy needs to get out of here,” Experienced Nurse said. “This guy needs to get out of here,” Charge Nurse replied when we told her. “This guy needs to get out of here,” i told the doctors.

“Hang a liter of normal saline,” they replied.

And so it went. At one point we got them to agree that he needed to go to PCU; trouble was, there were no PCU beds available. There was a bed in Critical Care, however. “Cancel the transfer to PCU,” they said. “Just keep a close eye on him.”

(I must stop at this point to let you all know how much my fellow nurses came through for me. They basically took over on my other patients, passing meds and answering my call lights. Florence Nightengale herself must have smiled on me, because my other two patients slept through most of the night. I’ve said it before and i’ll say it again: the night shift is unbeatable on our floor, because they’ve always got your back, and it’s never a problem. Thanks, guys.)

At five twenty in the morning, as saline and blood and all of our other interventions had done nothing to stop my patient’s downward slide, and as the doctors continued to drag their feet, my charge nurse picked up the phone and called the Critical Care charge nurse. I have the feeling that there was almost a nursing mutiny there - at that point, we were inches away from packing up and wheeling him over, orders be damned. I didn’t have to find out, though, because the resident called to check up on Slick.

“Sounds like this guy needs to get out of there,” he said.

I’ve been saying that all night, i thought, but instead said “So we’re transferring him to CCU?” My fellow nurses in the nursing station all stopped and waited, holding their breath. “Yeah, let’s go ahead and do it.” I nodded to them and they all lined up to ask what they could do, because every single one of us wanted him off our floor and into a place where they could monitor him more closely. “Good job,” Experienced Nurse told me as i hung up the phone.

There were several moments of agonized and frustrated conversation last night, because it was apparent to us that Slick was far beyond our level of care. Do we call the critical response team even after the doctors have already said no? Do we keep calling the doctors and harassing them? Do we wheel him over to Critical Care ourselves, consequences be damned?

I kept my cool with the doctors because being snippy wouldn’t make them transfer him any faster, and would have made me look less competent. And hey, i’m not a doctor. But all of my alarms were going off, and all of the experienced nurses’ were, too. “If i’d wanted a night like that,” i exclaimed when i returned from wheeling him over to CCU, “i’d have been a critical care nurse.”

Oh, and a postscript about the MVC who we thought we were sending to the PCU? She’s fine . . . just stubborn. She wasn’t talking because she didn’t want to talk.

Woot!

Change of Shift (Vol. 2, No. 3) is up at Musings of a Highly Trained Monkey. Pun absolutely intended - this looks like a very colorful issue! (Yuk, yuk, yuk…)

Anyway, check it out, yo.

There’s been a lot of debate going on about floor nurses refusing patients or refusing to take report, causing a backup of patients in the ED. ERnursey started it all off here with her charge that “plenty of times when we are holding patients due to staffing there are nurses on the floors with all their work done sitting around the nurses station” (which is more a shot at nursing ratios than the floor nurses, but still stung a bit). Geena from Code Blog weighed in here and asked for other folks to chime in, which May from About a Nurse did in this post, which pretty much sums up my thoughts.

The one thing i wanted to add, though, was that we have the biggest problems with this around shift changes. I understand that it’s easier to give report to me at shift change instead of giving report to another nurse who then has to report to me. But still - you’re passing the buck.

The other problem is that nurses use shift change as an excuse - “sorry, i have to give you report right this second” (nevermind that i’m literally elbow deep in whatever right this second) “i’m going off shift.” We get this from the PACU a lot at 10:55pm.

I understand in both cases that they’ve got more patients coming in and they need the beds. But it’s unsafe to expect me to be able to take report when i’ve got my hands literally full. I can’t leave my paraplegic patient lying on his stomach with his sacral ulcers open. I can’t stop halfway through a two minute push of pain medication for the patient who’s crying because it hurts so much (and you know, not all of those are fakers or drug seekers). I can’t let go of the arm or leg of the guy who’s swinging at me and his girlfriend and all of the staff members in the room until one of my colleagues gets back with the Posey vest and restraints. Sorry…but i can’t take that patient just yet.

And finally, i may be sitting at the desk chatting when you’re frantically running around a loaded ED trying to clear patients out. But that’s often the calm before the storm - a quick chance to grab lunch and talk to my coworkers before my patient comes back from PACU, or before the Ativan wears off and my guy going through the DTs starts ranting and raving again. And i might have the time to take someone right now…but that doesn’t mean i’ll be able to add another patient to my load all night. Just because i’m not busy right this second doesn’t mean that i’m not busy.

Anyway…sorry to get so cranky about this. But i think it’s very important for floor nurses to have the right to refuse - to take report right that second, or to take a patient that shift. I think that refusal should only be used if necessary, rather than if convenient, but it’s important for a nurse to have the right to be an advocate for her patients and herself when taking a patient would be unsafe.