Thursday, September 10, 2009

Can I Go Home Now?

0630: I arrive at work, pick up my assignment sheet and quickly scan the written report describing the five patients the night shift charge nurse has deemed I care for during the next thirteen hours.

A: Morbidly obese, noncompliant diabetic with a really nasty wound on his backside. He’s also known for his verbal abuse. Let’s see how many times he tells me he won’t cooperate and he doesn’t need that medicine because we don’t know what we are doing in the first place. I’ll make it a “Hi Bob” game and get a beer tonight each time he tells me I’m stupid or refers to me as “girl”.

B: Her. Yeah, her. Fuck, I can’t stand this woman. I want to shake her and tell her to fucking get a shrink and get the hell over her childhood trauma that is leading to this chronic existential angst masquerading as belly pain. Twenty-five years old with chronic belly pain. Wow, all this belly pain, how did she manage to get obese? We’ve scanned her, scoped her, opened her up and have done everything but transplant her pancreas and liver. Everything is always normal. Let’s see…she refused the psychiatric consult the last time she was here. But she never EVER refuses the 2mg of dilaudid push every two hours. I thought she wouldn’t be returning to us because we no longer offer IV push phenergan on our menu of treatments at the Spa. Not enough beer if I get to take a swig each time she asks me for more dilaudid and it isn't time yet.

C: Oh for the love of God, this man is back? I knew it! I knew he would bounce back but in three days? Gah we spent hours with this daughter helping her make the decision to place her father because she can no longer take care of him. Hmm….did he fall…no…Oh great. “Weakness” Fuckin’ A we aren’t gonna get paid for this one, are we! Weakness is not a diagnosis it’s a symptom. Shit, I hope his daughter takes a respite day and stays the fuck away from the hospital. He‘s a piece of cake to care for if she isn‘t hovering over him. Such a dear sweet old demented guy. He’s funny and kind, doesn’t scream or hit. Any facility would LOVE to have this guy live with them! I wonder if we can get him a daughter transplant while he is here.

D: Son of a bitch. I thought this guy had died. I could have sworn he died last winter. “Fever” Oh great, this could be anything from liver failure to pneumonia to “I‘m hunger and some asshat beat the crap out of me under the bridge last night so I came here“. I’m voting for pneumonia and an ass kicking because I actually really like this homeless guy and I’m not sure I have the emotional fortitude today to attend to him at the end of his life. please god, let it be pneumonia pneumonia pneumonia“ Maybe I should rethink this whole drinking game so I don't end up with a liver like D's.

E: Nononono NO! We fixed you last time! You were better! And had a home! You agreed to take your meds and live at the half way house! If the case manager didn’t hook you up with enough meds and directions to the homeless clinic: she gets to come up here and sit with you, follow you around the unit making sure you don’t wander off and listen to your endless--oh thank goodness or not, your liver function is off the map. GREAT!! YAY way to go God! The meds killed her liver! Yay! Now we get to find a place for her to live. Yup, she’ll be a resident with us for a month or so because this country absolutely sucks when it comes to mental health care and well there aren’t any beds for people like this poor soul; just streets and alleyways.

After report, I start planning my first cocktail at 1955, should I stick to beer or have something stronger. . . oh yeah, I need to think about my liver.

I take a deep cleansing breath outside of A’s room.

“That goddamned nurse gave me insulin last night for my blood sugar and she gave me ten units! “
“Well good morning to you, too! Hmm…your blood sugar was 450! Of course she gave you insulin.“
“But now I’m only 200 and I feel funny! I’m too low, I’m gonna go into shock!!“

(What I want to say) “Oh boo-fucking-hoo that stupid nurse gave you insulin for a high blood sugar. Why we oughta report her to the state for...I dunno...doing her job you stupid asshat. If you don't want us to treat you then don't come to the fucking hospital and don't call 911! And, Dude, if you go into insulin shock, I will eat your nasty shoes. Yeah buddy you feel funny because your blood sugar averages at 300. But hey, you won’t have much of a brain left in about a year, so make your complaints now while you can string a coherent sentence together. Oh and I hope you aren't too attached to your toes or legs cuz those are outa here too if you keep this up.”

I do the hair patting thing through gritted teeth, and by rote explain to him what a normal blood sugar is and if he would just work with us we would bring his glucose down to manageable levels…“blah blah blah…sir…blah” Is what he hears.

I exit the room and brace myself for B’s room and ask God to deafen me against her whining. She’s sleeping soundly and I weigh not waking her up but I know her dilaudid was given exactly two hours ago and if I don’t wake her and she wakes up in an hour or so, she will see the time and realize it’s been three hours since we hooked her up with a fix and “OMG WTF I’m having a pain crisis!!” I would rather wake her up and get her high than have to explain to the patient over and over again why she can’t have an additional two milligrams of dilaudid.
“B, good morning, I’m your nurse today. How is your pain?”
“Really? Your nurse said you were sleeping every time she rounded through the night.”
“Why didn’t you tell the nurse?”
“I DID AND NO ONE LISTENED TO ME” (cue her tears)
“B, I trust the nurse who gave me report. I want you to think and feel carefully; how bad is your pain right now this minute. Is it the worst pain you’ve ever felt or is it just the pain you normally feel.
(cue baby voice added to tears)”It’s not the worst I’ve ever felt but it’s…it’s…really…really…bad!”

(What I want to say)”You know what you need B, you need a shrink. You need drug rehab and a shrink. I shutter to imagine the serial sexual and or physical abuse suffered upon you when you were a child or a teenager. And it makes me sick one person or a few people have broken you like this. But you know what? You are an intelligent 25 year old woman with her whole life ahead of her. Other people have gotten over these things and have gone on to more than look forward to spending a few days in the hospital! So just suck it up and go to rehab and see a shrink and move up and away from the abuse. YOU ARE LETTING THE ABUSER WIN EVERYTIME I GIVE YOU DILAUDID OR BENADRYL OR YOU ALLOW THE GI DOCS TO DO SCOPES AND THE SURGEONS TO CUT YOU OPEN. THE BAD PEOPLE ARE WINNING HERE!” (And yes I want to shout at her, because I am Nurse Tough Love in my head unlike my hero who said it out loud and to the patient. “Oh I forgot, you don’t work and have Medicaid and drug rehabs for people like you--the people who need it--are few and far between. It isn’t your fault the system is broken. So I’ll get your two milligrams of dilaudid, dear. (Insert hand pat)

After medicating B, I find myself outside of C’s room girding up for the daughter with her apologies and excuses for bringing her father back to the hospital. I luck out and she isn’t there yet. I gently stroke the top of his dear head and softly call his name. His eyes flicker open and his smile is distant and vacant. “Where am I?”
“At the hospital and I‘m lucky enough to be your nurse Mr. C.”
“Why am I here? I want to be at home in my chair.”
“I know but your daughter felt like you needed to stay with me a few days.”
“Is she here, where am I?”
(What I really want to say) “She isn’t here; It seems like she is greedy and won't sell your million dollar house in Very Prestigious Hills so you can live at a lovely Alzheimer’s facility. My guess is she is taking a well deserved spa day on your nickel because she quit her job to care for you. So she tells us you have fallen or almost fallen or might have had a stroke or were choking or couldn’t wake up or had a fever or stopped speaking or lost the feeling on one side of your body or something which will lead the ER to admit you to the hospital; when really she needs a break because it must be hard to take care of a frail elderly man who is confused and incontinent 24/7. I know I couldn’t take care of a demented loved one 24/7 for all the million dollar houses in the world. So daughter feels it is her right to contribute to the bankruptcy of the Medicare system with your frequent admissions. So you’ll stay here for 72 hours, get some fluids (when you keep your IV in); we will hover over you to make sure you don’t fall; keep your skin dry so you don’t get a wound; make placement recommendations--which will be ignored--and send you home. Again. Please don’t stop breathing or allow your heart to stop because I really don’t want to do compression on your 90 year old ribs; they will break with the first compression and it will make me physically ill. Find it somewhere in your mind to lucidly explain to your daughter you don’t want CPR because at this point, we must attempt resuscitation. Attempt is the key word here.”

D’s room is as quiet as a tomb. Damn, what if he died in the last hour and he was alone, how terrible for him he always liked lots of peo-- D interrupts my conclusion jumping with a twitch of a leg. I take his hand; it’s hot to the touch, clammy and very edematous. I say good morning and he speaks to me without opening his eyes. “I feel like crap.”
“I’m sure all this fluid is very painful. I’ll do my best to make you comfortable today. You’re burning up, too. Hey, I thought we had an agreement, the next time we saw each other it was going to be downtown on your corner!“
(What I want to say) “You look like crap, too. I think you might just die this time. Dude, you need a new liver. Hell, you need a new body. So I’m going to do my best to make you comfortable, k? And hopefully if your liver doesn’t kill you, the alcohol withdrawal won’t land you in the ICU for a few days. D, I think you just won today’s Most Medically Fragile award! And your prize is I get to treat your fever, your infection, your edema and make sure you don’t have seizure when you finally start withdrawing from the booze. And all of this with--you guessed it-drugs that could damage your liver with a side order of renal failure! Oh and another thing, I thought you were dead when I came in the room. Please don’t die today. I really want you to get well enough to tell me those crazy stories that may or may not be true.”

I press my ear to D’s door; I can hear her chanting to herself. Its quiet and a sing song repetition of the word: “camping”. Sure enough, she’s in the Veil Bed. A huge tent of a thing over the bed. It keeps us from harms way and we can sorta kinda control her behavior with limits and threats to “put her in the bed”. D doesn’t actually mind the bed and the last time she was here (cellulitis or gout or something like that) I remember she quietly approached me at the desk: “Lady I’m going to go off and I need to be put in that there bed so I don’t hurt you or anybody else what’s here today.” After I helped her to bed, she told me thank you and we had a very quiet afternoon until she called and said she felt better. It was a Zen moment. The split second before I awakened her I promised Buddha an orange slice if she had a quiet day because between crowd control in A’s room, liver control in D’s room and pain control in B’s room, E was going to have to give me a break. We don’t have the budget for a sitter so the bed and meds are going to have to keep all of us safe. I was in luck, D was smiling when she saw me and told me she was very hungry and wanted to sit in a chair because “camping” time was over.
“Camping? What do you mean?”
“Nurse yesterdee tol me I was a campin’ in this here bed! I likes to camp! Good thing too cuz wheres I lives is a sayin I cain’t come back there.”
“The group home?”
“Uh huh. The voices made ‘em tell me I couldn‘t live there no more” Tears spill from her eyes and she doesn’t bother to wipe them away. I gently reach toward her, asking, “My I?” and wipe her cheeks with a Kleenex. “I don’t have any answers for you, E but I can get your breakfast set up. The case manager will see you later and you can make a plan with her.” E follows my directions and safely maneuvering around the bed’s curtain and lets me lead her to a chair. Her gait is unsteady and my hands on help keep her from falling when her knees buckle.
“I’m too fat, I shouldn’t eat.”
“It isn’t fat, it’s fluid from your liver and it’s building up around your stomach.”
“I’m not fat?”
“Nope, hardly. You’re very thin.”
(What I want to say)”You’re very thin because sometimes your thought processes are so disorganized you don’t eat. I fear for you and if I dwell too long on what your future is without a group home. I will weep for the injustice of it all because the best place for you, Fort Public Mental Institution, is closing in a few months. We treat our stray animals better than the mentally ill in this country. I’m so deeply saddened your psyche is broken. If I had a magic wand I would wave it around your heart and head and you would have the capacity and the competency to care for yourself.”
“E I will be back in thirty minutes with your medicine.”
“Oh OK lady. I’ll be here.”

*Patients A, B, C, D and E are composites of patients I care for. When I say “care” I sincerely mean this. As much as the drug seekers make me crazy and the Notreallysickjustreallysuffering people make me; I care for them. But I’m allowed to have an opinion about their stupid, self-destructive and dangerous behaviors. If you leave me a nasty comment, I’ll match your nasty. And if you keep a blog, well let’s just say you were warned. . .

I glance at the clock in the hall and the little hand is resting on the eight. Only eleven more hours. . .

I wish I could call my professional malaise burn out but it’s more like caregiver fatigue. For the most part, my fatigue isn‘t from the patients, their diseases and their demands on me but it stems from the system. Our system is hopelessly broken. If I knew the answer I would shout it from the mountains twenty miles to the west of where I’m writing and hope the powers that be hear me.

I’m fortunate my own psyche is such that just writing this blog entry helps me see the value of the work I do which in turn buoys me up I can face the five patients assigned to me tomorrow morning at 0630.

First and foremost, I will do no harm.


jas faulkner said...

Oh June, have a power nap and soak up some well deserved rest when you can. Fixing broken people is hard with the most efficient of systems in place. You have my sympathy and admiration.

Anonymous said...

This was intense and insightful and something that desperately needs to be discussed. The system is broken -- yet the reason it's held together with some semblance of success even this long is because there are absolutely dedicated people like you working in it.