I quilt therefore I am...

sane. Last year I taught myself to quilt. I scoured the Internet for tutorials and found Crazy Mom Quilts. Amanda Jeans style was just what I was looking for. I started small with a project that wasn't really anything. Then I made a small quilt. Then I bought a Juki (like Amanda's). Now, the only thing that stops me is time, and bursitis. Goodness I sound old.

I finished this baby girl quilt today. I used a cute little Moda pattern that I have had for about a year. I love the foxes and little red riding hood. I outlined it with a red I had cut and never used. The backing is a solid pink and shows off the quilting nicely.

Who knows, maybe I'll turn this into a quilting blog like my daughter Hannah suggested.

Changes (got the job!)

I know it's been a long time since I posted. But a lot has happened.

The second I gave up hoping for the educator job I was so bitter about in previous posts I was suddenly offered the job. And I took it! I didn't even negotiate salary. I just said yes.

I think most nurses have noticed the very real push from management to "improve productivity". They are under a lot of pressure to improve the organizations bottom line. Gone are the days of over staffing. Our staffing decisions at the bedside are being scrutinized with a microscope and people who may not really know what we need are expecting a tight ship, no excuses.

I remember the days when the nursing shortage was so bad that I got any and every job I wanted. Literally. I could walk in and they'd ask if I could start the next day (or that night--I said no to that one, it was a bad sign).

Organizations used to have to woo nurses and a big part of that was with education opportunities and certification pay. Those days are gone. Nurses have to bring their A game and work hard to keep their boss satisfied. I remember when any nurse would do. Employers can be choosy now. Money is right and they have to justify every position with hours of paperwork and requisitions. It's in their best interest to hire well and ensure they make the right decision.

I hope they made the right decision in choosing me. And I hope that I made the right decision in making the change.

Raising Five: Anticipating needs

I want to share this great post about anticipating needs. Raising Five has a nice blog and I thought this post was a great example of the work nurses do. It made me think about how some nurses are way more talented at anticipating patient needs than others. I bet those nurses are perceived as the good ones by the patient. Raising Five: Anticipating needs: Few experiences prepared me for the challenge of being a mom, but looking back, I can see how at least one part of my former life as a nurse...

The job

Well. I waited a month. A month. A month after interviewing for "the job" and I was told "the news is that there is no news and don't expect any news anytime soon. Financial reasons. And we received another qualified applicant so we're gonna interview them too."

WTF?

Sociopathy 1:25

Some people do not have a conscience. In fact, 1 in 25 people don't have a conscience. 1 in 25. They're called sociopaths. They're not all murderous villains. Some just don't want to work and can manipulate the system to make that happen for them. They have no inner voice telling them what they want is wrong. Some are murderers, criminals. Most are CEO's, teachers, police officers. No kidding. I learned this in a recent class I attended regarding toxic people. An it is probably the most important thing I have learned to date.

You see. All this time I thought everyone had a conscience. Everyone but crazy murderers that is. And that everyone operated on the same principles. Everyone wanted to do good, do the "right" thing. When you realize that 1 in 25 people don't care about what is right or wrong. Rather they care about how to get what they want weather it be fame, fortune, a promotion, power, to be taken care of, drugs. Right and wrong play no part. When you realize these people exist it all makes a little more sense.

That jerk boss who stole your ideas and got promoted. The co-worker who scapegoated you. The peer who bullied you. The boss who manages to look good at the expense of others. The boyfriend who never gets a job and you continued to support. The addict who keeps going to the hospital and nothing is wrong with them but they get lots of pain meds and a million dollar work up. People who fake a disability. They all have one thing in common. No conscience. They have figured out how to get whatever want. A free ride, drugs, attention, power.

1 in 25. That's a lot of people.

Labeling IV bags

Why? Someone explain why I have to label a bag of normal saline with a sticker that says it's normal saline when the bag already had normal saline printed on the side?

It drives me nuts.

I didn't add anything to the bag of normal saline. What nurse does that anymore?

The last time I added a drug to a an IV bag was when we used to heparinize flush bags for art lines. I understand labeling that IV bag.

I don't get labeling a bag of NS with another label, covering the original label with my label.

Welcome to the department of redundancy department.

Interview rash

You probably can't tell very well from the photo of the crook of my arm but there is a little red prickly rash there. I call it my interview rash. It actually was way worse but has been getting better by the minute.

My big job interview was today. And my friendly little outward expression of anxiety and stress showed up behind my knees a few days ago. It progressed to my arms yesterday. Itchy. Red. Not good. No Bueno.

The interview went well. I should call it "the inquisition" (and I have). Only because it's two hours long. And with two different panels of interviewers. Torture.

I think I nailed it. I owe some of that perceived success to my sister-in-law. She told me "It's a game. You have all the answers because they are YOUR answers. There is no wrong answer because they are YOUR answers." I also owe some of my confidence to my sister who shared her experiences of interviewers whose goal it was to make you cry. I chanted in my head as I walked down the hall toward the room to the interview. "they are my answers, my answers, none of them are wrong, they're all right, it's a game, it's a game, just smile and give my answer, I can do this!"

I think it might have worked. I'll let you know if I get the job.

Yes

Ahhhhhhh. Do I need to say more?

A nurse's nightmare

When I went to bed last night I didn’t know I would bespending the night enduring the worst nursing shift of my life.

But I did, well sort of, I did it in my dreams.  I dreamt I was running around trying totake care of my patients and getting nowhere.  

First, I received a new admit and a patient from PACU, bothat the same time and I couldn’t find anone to help me get them into bed.  My new admit was a very old man in his 80’s or 90’s.  He was covered in urine.  His foley catheter was overflowing andthere was so much urine under him it looked like he was laying in a kiddy poolfilled with urine.  It sloshedaround when I moved the gurney across the room.  The room was full of furniture and supplies, none of whichwere useful to me and all of which were in the way.  I couldn’t even find his bed.  I couldn’t find a new foley catheter.  He had a dozen family members crammedinto the room surrounding his gurney and they were all watching me, waiting forme to get him off the gurney, into bed and cleaned up.  But I had no help, couldn’t findsupplies and the room was a disaster! 

I started running around the unit looking for supplies andlooking for someone who could help me. Supplies were everywhere, in bins similar to products at Ikea, and noneof them was what I needed.  Therewere miles and miles of hallway too, just like Ikea.  There were nurses everywhere, all of them unavailable tohelp me.  There were managers andcharge nurses having meetings in the hallway, and they all looked at me as if Iwas nuts for asking for their help. I started to cry.  I bawled even, as I ran around the unit looking for suppliesand help. 

Finally a few nurses took me seriously.  I frantically explained that I neededhelp and they followed me to the room of the old man laying in the urine filledkiddie pool.  Then, one afteranother, nurses kept filing into the room, each washing their hands with pilesof soap and each one using the isolation gowns, (did I mention this patient wason isolation?)  They just stoodthere not knowing what to do for me and clogging up my room.  This apparently seemed like a good timeto put a  new foley catheterin. 

With my manager and the educator and all my peers standingthere watching me, I kept dropping the foley catheters on the floor and wouldhave to get a new one.  Thensomehow the new ones were full of urine already.  The scene bounces between the foley catheters, the mounds ofsoap the nurses were using, my patient in a kiddie pool of urine and mecrying.  

I start to direct peopleto move the furniture out of the way so we can get the patient off the gurneyon into bed and realize I have to ask the dozen family members to leave.  I can tellthey don’t want to go but I ask if all can leave but one so that we can havesome room to arrange the patient comfortably.  They start to file out of the room, as I escort them to thedoor there is a little young lady in scrubs yelling at me at the doorway.  Like I had done something wrong.  

I’m pretty sure she was a nurses aideand I think she was mad that I needed so much help.  I was crying and yelled at her about how bad my day was andhow little help I had and if she knew what I’d been through she wouldn’t beyelling at me.  

I went back to theroom and started directing people on moving pieces of furniture.  There were tables, and chairs.  Big ones and little ones and abassinette and little rocking chairs and a sofa.  The patient's bed was on the opposite side of the room fromwhere it needed to be.  Of course,everyone is washing their hands after each piece of equipment they touch, andwith copious amounts of soap, then getting on new gowns and gloves.  I got exasperated with the isolationgown at one point and threw it and my gloves off saying “I just don’t careanymore”.  Immediately after, I gotsome nasty bodily fluids on my hands. Looking down I realized I had a big cut on my left palm that was nowcontaminated with bodily fluids. So I began washing with lots of soap and water.

Eventually Igot the help I needed.  The roomwas arranged.  The bed was where isshould be and the multiple chairs were lined up out of the way for the familymembers.  I had a clean foleycatheter to insert and I wasn’t crying anymore.

This was the most vivid nursing dream I have ever had.  What does it mean?  Is it a metaphor for the nursing profession?

Being surrounded by supplies and unable to find what youneed.  Two patients needing you at the same time.  Fellow nurses unavailable to help.

Family members with expectations far beyond what one humancan actually deliver.  Not a single doctor in sight.  Managers and charge nurses who appear to do nothing but clogthe hallways.  CNA’s with attitude.  Family members in the way.  And apparently nurse co-workers who are obsessed with soap, and isolation gowns.  Cluttered rooms.  The crying.  Taking shortcuts that get you in trouble.

UGH!  I hope that's not what nursing is.

Applying for a job

About 6 months ago I applied for the nurse manager job in my critical care unit. I didn't get it. An ER nurse got the job. I was upset. I felt that one of the applicants from the ICU should have gotten it. After all, the three of us from the ICU that had applied for it had devoted years to the care of critical patients. She was an ER nurse.

Turned out that this ER nurse is really good. I like her a lot. And I like how she manages the unit. I probably would not do as good a job as her. In fact, I'm sure of it.

A few weeks ago I heard an educator was leaving her position. I was so excited! Then so deflated as I heard they weren't going to replace her. Hence, I have spent the last few weeks in a funk. The ICU was full of really sick and hopeless, heartbreaking cases. I was sick with a headache almost every day. Surely a brain tumor misdiagnosed as chronic sinusitis. And I felt that I would never get a chance to advance my career. My attitude was poor. Every little annoyance at work bothered me.

Don't get me wrong. I love being an ICU nurse. I love taking good care of my patients. But I know I have so much more to contribute. I would have applied for the hospital President's job if I didn't think they'd laugh at me. Unit Based Educator is a perfect job for me but it was gone. A casualty of the recession. Or so I thought.

As I checked the job openings there it was. The Unit Based Educator job that I wanted. So I applied. And I am hopeful again. I am already looking for an interview outfit. Let's hope no one noticed my bad attitude these last few weeks. And let's hope my vocal nature won't hurt my chances.

The Slug

Have you ever cared for that patient referred to as a "slug"?  I first heard that reference in coronary care.  It referred to a post open heart patient that you had to pry out of bed, they didn't want to do anything to get better, they didn't want to eat, didn't want to walk, didn't want a shower.  They exist in all areas of health care.  Nursing homes, hospitals, clinics.  People get tired, get depressed, get demoralized, and give up.  They don't believe they can get better anymore.  They stop making any effort.

Sometimes the slug needs Nurse Ratchett.  The mean nurse that says "It's time to get up".  "No, you're not going back to bed, we're going to the shower."  "Do you want to sit in the chair or go for a walk?"  This is the patient that you need to come to a shared understanding with.  "Choosing to lay in bed is choosing to die.  Today, there is no reason you can't get up to a chair for every meal.  And after every meal we are going to walk one lap around the unit."

I had to be the mean nurse.  It wasn't fun.  The patient hated me.  And there were moments that I felt bad.  But I knew I was doing the right thing.

She wanted a bedpan when I had just seen her walk around the unit earlier that day.  Why in the world would you need a bedpan if you can walk?  "The commode is uncomfortable!" she exclaimed.  "Let's go into the bathroom then"  I insisted.  We went.  She did fine.  But she wouldn't look me in the eye.  She scowled the whole time, and rolled her eyes like a teenager.  It's not that she was incapable.  She got out of bed slowly but without any help from me.  She didn't need help.  I just stood by.  Just in case.  But she was strong enough and there was no reason for a bedpan.

I was with her for three days total.  Day one, I was nice nurse.  Day two and three I had figured her out and I had to become Nurse Ratchett.  She hated me.  She scowled at me.  Made statements like "There's no use arguing with you."  "This is some kind of power struggle."  "I have no say in what happens."

I gave her choices.  She had a pressure ulcer developing on her back.  I asked her to stay off of it.  She was independent with her bed mobility.  But even though I would get her on her side when in bed I would find her on her back a little while later.  On my second day with her, after making her take a shower, I asked her what she was going to do about the pressure ulcer on her back.  I made her own it.  After that, she stayed on her sides when in bed.  The next day, the pressure ulcer was starting to look better.  I let her decide left side or right, walk before the meal or after.

By day three she was up to a chair for every meal and she walked the unit before going back to bed each time.  At the end of my shift I told her I expected her to continue this plan while I was gone for the next four days.  Hopefully, her nurses won't be fooled, and will insist that she do what she is capable of.

The student I had with me put it well.  He said, "Our job isn't to make you happy, it's to make you well".  I was so proud.  This was actually a big lesson for him.  A young man who comes to nursing from a service industry job.  While, as nurses, we do need to be mindful of our "customer" and give them as good an experience as we can.  The goal is to get better.  Our job is to help them get better.  Even when they don't want to help themselves.

muddy shoes

Do not enter my hospital with muddy shoes.  Especially if you're gonna try to get pissy about the spot of blood on your moms sheet.  You are moms caregiver and that mud you just tracked through my hospital tells me this is probably the cleanest your mom has been in a long time.  Have some respect. Do I need to say more?

Bob Ross

That guy with the Afro who painted on TV? Yeah him. The one, that hippie guy on PBS, that embraced his "happy little accidents"...he knew what he was talking about.

I recently took up a hobby. Making quilts. I have some sewing experience but last time I tried quilting it was a complete failure.

This time I read blogs to learn some basic techniques. And I made a small practice quilt that is a hodgepodge of all the stuff I learned.

It was very satisfying to create something again.

I used to paint. I was artsy. Then I became a control-freak-perfectionist-nurse. That's not a fun job. Satisfying in many ways. But not fun.

While working on my quilt I was about to rip out some mistakes. Then, somehow, I channelled Bob Ross. He told me they were only mistakes If I wanted them to be. That I could choose to let them be "happy little accidents". That I should let it go. Be free and happy. Enjoy and trust the process.

I am so happy I listened. Letting go of that perfectionist attitude allowed me to have fun. Allowed me to experience some real joy. Allowed me to be more creative.

Thanks Bob. But now what do I do about this new obsession?! All I can think about is my next quilt!

I guess there is more to life than just nursing.

That did not take long...

Unfortunately, I was only one imperfect RN today with enough work for at least 3 perfect RN's to complete in 12 hours. (I will go read my last post so I can remember a good day.)

I know some poor night shift RN out on the medical floor (where I transferred a patient) is happily writing me up for holding that dose of methadone and doing a blood sugar late because the patient was sleeping. Which may have had something to do with the vitamin A he needed and I gladly gave.

I can only hope the night shift ICU nurse I gave report to, "Hoover", has as busy an assignment as mine was and won't have time to write me up for missing that 1600 H/H.

I did have my perfect moments. Like when I wrestled an Ativan order out of a pulmonologist for my patient I was sure has been in benzodiazepine withdrawal.

I realized last night in my sleep that his tox screen was positive for benzodiazepines on admit, and all we kept giving him was fentanyl for pain. Which maybe, sometimes, lasted an hour. Then he was fidgeting and pulling and moaning and grabbing and yelling "help me!" in his frail little pitiful voice over and over.

One dose of Ativan 0.5 mg IV and he was calm, slept well, wasn't oversedated. No narcs for most of the day. I did try the new order for dilaudid once and it didn't do much to him. Maybe slowed him down a little but he was still miserable.

Ativan. Vitamin A. Thank you big pharma for this. (I take back all the bad things I've said about you)

I also knew the answer to the pulmonologist's pop quiz question. (maybe that's why he agreed to write for the Ativan). He asked me, "Why would I not want to give the patient blood until his Hgb was less than 7? I answered, without hesitation, "Because studies have shown that patients die when we do". He was impressed.

I failed the follow up question: "Why does it kill them?". I couldn't remember. It is because of infection related to the immuno-suppressive effects of the transfusion. Or so he says. I bet it's more than that.

I happen to think we kill people every day with over treatment.

I did one more perfect thing. I made a patient get out of bed, take a shower (the completion of which was an incredible feat in itself), and let his wife go home. That doesn't sound like much. But it is everything.

He wasn't at risk of dying from his knee infection anymore. His biggest risk was now a secondary infection...from being filthy (refusing nursing care and expecting his wife do it all); or pneumonia from not getting out of bed; or from a DVT due to his immobility.

He was IRATE with me. He almost fired me. Right then his doc showed up and I asked him to reinforce what I told the patient. He did. And the patient did what I said. Even though at one point he told me he'd be doing better if I'd stop talking. Ha ha!

Whatever dude! You may not know it. But I saved your life today. And I'm transferring you to the Ortho floor where I know they'll make you get out of bed!

Then I had the 5 hour admit and it all went to $hit. Yes. 5 hours, a PA (useless), and 3 doctors later I finally had the chart. It was now change of shift.

I missed the blood draw in the other room. I let the first guy sleep through his methadone dose and blood sugar until I was transferring him to the floor at which time I did the blood sugar.

I will be written up for something. I was so tired by the end that I could hardly walk to the car. And I called from the car to tell the night nurse one more important thing.

Oh! And I told the doc that the PA had no business seeing our patients. She needs to stay over on the medical floor. That was pretty perfect too.

This is nursing.

PS. To that night shifter writing me up: I hope the computer freezes.

Today I was perfect.

It's the end of a shift and I'm not running around like a crazy person trying to get everything done. In fact, today, I ate when I was hungry, I peed when I needed to, I provided thorough and excellent patient and family education, and even printed materials for them on their meds and disease process. I answered questions, and charted the care I provided. I crossed all my T's and dotted all my I's.

I feel really good about the care I provided today. Every patient deserves a day like today. Every nurse deserves a day like today. This was how it should be but it never is.

I had two easy PCU patients today, all day. I'm blogging this fact so that you can point it out to me when I complain that I am overworked and had a crazy (usual) day. Perhaps i should have organized my nurse tote (security blanket).

Today was perfect. Today I was perfect. Mark the calendar lest I forget.

Trying blogger app on my iPhone

Hmm. Not sure I know how to do this. This is JV. One of my nursing buddies.

We're all gonna die.

I'm pretty sure that people in the 1800's and early 1900's didn't have living wills.  Why would they?  Back then, dying was dying and living was living.  There was no grey area.  If someone survived pneumonia it was a miracle.  Survival, that was the surprise, not death.  Death was expected.  Death was understood to be inevitable.

Now-a-days, we are surprised when someone dies, for any reason.  But if you ask most people they will tell you they don't want to be kept alive artificially, they don't want to be Terri Shiavo, they don't want to be a vegetable, or a paraplegic, or on a ventilator, or... you name it. No one wants a chronic, painful, debilitating disease that makes their quality of life unbearable.  My husband says "If I can't swing a golf club honey, pull the plug."  Not being able to swing a club would make his quality of life unbearable.  (duly noted honey)

I am there when the time has come to face these life or death decisions.  No, let me change that.  I am there when you should decide to stop torturing a dying person with invasive procedures and treatments that will only serve to prolong the inevitable. Time and time again I see how what we would choose for ourselves is not what we choose for our loved ones.

Where the heck did this grey area between life and death come from?  Technology.  Medical "advances".  Changes in societal expectations. There are worse things than death.  Ask any ICU nurse.

Lonely Nurse

dear miss nightingale,

I am working on a hospital committee that is tasked with decreasing our 30 day readmission rate for heart failure patients.  The group has developed a "clinical pathway" for the heart failure patient.  It is a multidisciplinary document that includes all the care that we (MD, RN, nutrition, PT/OT, etc.) provide for a patient with the diagnosis of heart failure.

I am a critical care nurse with 15 years of nursing experience.  This last year I was part of an interdisciplinary team that developed the care plan content that will be used in our future EMR.  Currently, I am working as a subject matter expert for the EMR implementation team.

This is my problem:  I have experienced a paradigm shift in my thinking about care planning and documentation in an EMR environment and I don't know how to share this epiphany with others.  I don't have all the words I need and I don't have the positional authority to be heard if I did.

NOTE: When words are found to describe this epiphany I will insert them here.


I feel as though I have trekked through a long dark maze of unexpected twists and turns and murky waters, with weeds tangling my feet and cobwebs sticking in my hair and I've left my peers at the other side.  The injuries I sustained on this journey have healed so no one can tell what I went through.

Now I can see the path as clear as day inside my head.  I want to tell them how to get through the maze but why would they listen to me?  Who am I to tell them?  And if they would listen, I don't know that I would have the right words.  What if I lose most of them along the way?  It is very lonely on this side.

Sincerely,

One a-Maze-ing Nurse

Snot

Very little gosses me out.  My husband, on the other hand, can't even listen to the music associated with medical shows if he is eating.  It gosses him out that much.  Nurses don't have that luxury.

Most nurses I know have a thing.  The one thing that they can't do.  Mine is snot. 

There is a lot of snot in the ICU.  We wipe it, suction it, collect it, document the color, consistency and frequency of it.  Seriously.  We call it sputum (spew-tum), that's the correct terminology.  "Frequent cough with copious amounts of green-grey, blood tinged, tenacious sputum."  I've charted it.  Patients save it for us in little tissues.  "Look at what I coughed up."  I bet most people will never hear that statement in their entire career, I hear it on a weekly basis.  Just be happy I'm not posting a photo of sputum.  Maybe I'll do that the next time a patient saves a tissue full for me.

Sometimes you just forget to work, and life goes on.

Today, this dumb nurse just decided not to go to work.  The charge nurse had to scramble to get a night shifter to stay over a few hours until she could figure out staffing for the day.  To make matters worse we were already short a monitor tech and had one from nights staying over.  Several calls were made to the offending nurse.  The house supervisor and the charge nurse called her home phone and her cell and left messages.  They even considered calling the police to see if she was okay.

What really sux?  That dumb nurse was me!

I really didn't think I worked today.  It wasn't on my calendar.  I must have transferred the info from the schedule into my calendar wrong.  I work three 12 hour shifts a week.  That's 36 hours people, so it's almost full time.  (don't act like I work part time now)

But damn I look like an idiot.  If only it was the first time I'd made a mistake like this, though it was the first time I'd just not shown up.  I showed up for work on a day I wasn't scheduled but they don't give bonus points for that.

They could use this mistake to get rid of me.  This could be a huge deal with meetings and performance improvement plans and the works.  There is really very little I can do about it.  If they don't like you they will find a way to get rid of you.  Well, here's your opportunity...(waiting for my phone to ring...nope, what's it take to get fired around here?)

Thankfully my charge nurse is pretty forgiving, as was the night shifter who stayed over.  The overtime pay must have softened the blow. I am lucky the boss is on vacation this week and hopefully no one will point out my mistake to her when she gets back.

This is one of the (2 billion) great things about nurses.  We make it work.  No matter what the problem, no matter what the obstacle, we get things done.  We know how to prioritize, plan, execute and move on.  We know God is laughing at our plans so when things change we alter the plan and move on.

There is no time for dwelling.  We do that after the fact, long after, when we have coffee with friends or vent to our husbands or in a weak moment pull the manager off to the side and tell her about the obstacles that kept us from providing the best care.

This isn't to say it's not stressful.  It's very stressful!  There are a million things to do and never enough time or resources to do it with.  It's a constant battle to get it all done.  Sometimes I feel like a soldier dodging bullets, crawling through the muck, losing fellow fighters, dodging friendly fire, and making sacrifices to take the hill.

And no one notices.  I have post traumatic stress disorder (PTSD) from some of my shifts.  That's funny but the truth usually is.  Every once in a while someone notices and it feels real good.  Don't expect that to show up on your eval though.

We are martyrs, most of us.  Though we'll deny it.  We all like to save the day.  We want to be the one that worked hardest or charted best or knew the most.  And we love to be thanked, though we'll say "that's my job".  We're not good at accepting the thanks.

Next time someone says thank you for what you do I want you to respond with "thank you for noticing, I really appreciate it" okay?!  And the next time one of your co-workers forgets to come to work...be forgiving, we can't be perfect every day.