Sunday, October 04, 2015

"Why don't we ask the patient?"

Marcie and I had One Of Those Days a couple of weeks ago. Dr. Vizzini had to go do something neurological halfway through the day, so The Golden Boy took over for him in the afternoon. He gathered his residents like ducklings and re-rounded on all of the patients in the unit.

Marcie had a guy getting ready to go home. He'd had a very minor stroke in a very minor place, and was essentially without any aftereffects. He also had Stage IV cancer of the something-or-other--I don't remember what; I was busy myself--and was on so many anticoagulants it was ridiculous. (Cancer can make a person more prone to blood clots.) The fact that he'd stroked while on an injectable anticoagulant and a couple of oral ones was weird, but not unheard of.

So Mister Man was getting ready to blow that popsicle stand when The Golden Boy decided that he needed umpteen more blood tests, a couple of fairly-invasive scans, another MRI, and some other tests run. To see, you understand, what exactly could be causing him to clot. The answer to which conundrum was "metastatic cancer, DUH," but TGB wanted an exact answer. Like, down to the molecular derangement level.

And Marcie, being the sensible person she is, argued. She pointed out that we had at least a general idea of what the problem was (metastatic cancer, DUH), the patient had a limited amount of time to be futzing around with, and nothing we did at this point was going to make a damn bit of difference. There was, after all, no change we could make to his already-maxed-out medications to lower his risk of stroking again. More tests would mean at least two more days in the hospital, more discomfort, possible complications, and added cost.

Golden Boy argued back that it was incumbent upon him as a doctor to get to the bottom of the problem, and that doing less than that wasn't ethical. He had a couple of other arguments, but by that time, both my hair and my pants were on fire and I wasn't really listening.

Marcie and TGB argued politely back and forth for a few minutes, and then Marcie said something that you never, ever, ever hear somebody in a hospital say:

"Why don't we ask this guy what he wants to do?"

The Golden Boy was taken aback, but he did it. Our patient decided to head home and follow up with his oncologist as an outpatient. And just like that, problem solved.

It's interesting that a doctor would be shocked by another member of the care team wanting a patient's input into what happens to the patient. I mean, we do it all the time for big decisions like end-of-life care, but not as often when we're doing normal everyday stuff. Why not, I wonder? I mean, it's not like being in the hospital automatically robs you of the ability to make good decisions about your own health. It's more like being in the hospital sends you back in time to a more paternalistic day, when Doctor Knew Best (except for when you have a medical directive, and sometimes even then).

It's so simple, really. Ask the patient what they want to do. Just ask.

Saturday, October 03, 2015

People who love my hair and people who do not.

I just ran the clippers through my hair. It's my every-two-week routine: pass a pair of clippers with a #3 guard over my head, then fade out the sides and back with a #2. Then, carefully, measure out an ounce each of color and developer and apply it to the stubble on my head and let it rest for twenty-five minutes. When I remember, I dye my eyebrows as well. My eyebrows have gone white, as has the hair at my temples and the nape of my neck, and it's nice to have at least an outline to pencil in in the mornings.

Here are the people who love my hair:

1. Black women of any age. "Rockin' that 'fro, Boo" is what I hear from Friend Lisa at work, and I hear its equivalent from other Black women of varying ages, all day long.

2. Black men in their 60's. On Sundays when everybody comes to visit their fellow parishioners in the hospital, Black men Of A Certain Age are complimentary of my buzzcut.

3. World War 2 veterans of any ethnicity. It's surprising how many centenarians and men in their 90's comment favorably on a woman with really, really short hair.

4. Punks, people with excessive numbers of tattoos, and people with piercings in places you wouldn't necessarily want piercings. The fact that I have no hair breaks down barriers.

5. White women who've had cancer and who miss the ease of a buzz, but who hate the psychological implications of no hair. I can totally understand that. After my surgery, I grew out my hair to prove to myself I could, then cut it off on my 43rd birthday because I hated having to keep up with it.

And here is a comprehensive list of those people who hate my hair:

1. My dad. Bless his heart, I don't think he'll ever imagine me with anything but the curly, wild, shoulder-length red hair that I had in my early 20's. I feel bad for him. Not only is curly, wild, red hair a distraction and a pain in the ass to take care of, it's just. Not. Me.

Sometimes I wish I could go back to the days when Beloved Sister took a picture of me, all hair blown by the wind, on the beach near San Francisco. What that picture doesn't show, though, is the stress and horror of being in California when I didn't want to be, the stink that came from my hair not reacting well to California water, and the exhaustion of trying to keep together a marriage that was coming apart.

Mom is undecided. I think she thinks something chin-length with waves might be more flattering, but she understands the discipline of long hair and why I can't deal with it.

Saturday, September 19, 2015

Here is why I love my town.

If you were to look at a map of Texas, you probably wouldn't notice Littleton at all. It's not one of those places where a river runs through downtown, free to everyone, or where huge concerts take place or where there's even a top-ranked university. It's just a small town, kind of stuck on the outskirts of a big city, but emphatically not a suburb. It's its own place.

That's why I love Littleton. The rents are cheap and there's a big airport nearby, yes, and the air is clean and coyotes and foxes and various other small animals roam through downtown (somebody found a litter of bobcat kittens behind a bar a few weeks ago and turned 'em into animal control, who is rehabbing them and re-wilding them), and it's peaceful and bucolic. And it's determinedly independent.

There are trains that run through the middle of town, just two blocks from the courthouse, every night. And every night, pretty much, you can hear the train horns blowing in some new and interesting signature way that the guys who drive them have developed. Yes, it's policy that they blow a short-short-long prior to reaching a level crossing, but the engineers have ditched the computer-programmed horns for Littleton and do their own thing. At Christmas, they blow "Jingle Bells" and "Rudolph The Red-Nosed Reindeer" rather than the usual signals.

The H.E.B. here (that's a local grocery chain) plays KISS and Ingrid Michaelson and the Bee-Gees over the speakers in the store. Rather than the usual boring "come get our chicken it's fresh between eleven and four and only a dollar ninety-nine" announcements, the staff say things over the PA like, "Is your life missing something? Do you feel empty inside? Try some CHICKEN! Fried or baked, it can bring new meaning to your existence!"

The Boyfiend's lawnmower was stolen last week and returned within three hours, thanks to the efforts of the local PD. Though they have pursuit cars and a bomb squad and a mobile emergency management truck, the officer still responded with "That sounds like Steve. Dammit. Steve needs to stop stealing lawnmowers" when he took the report. Despite technology, our PD is still small-town enough to be exasperated with the one crazy guy who makes a habit of liberating lawn equipment.

The city fathers decided to lock up the free public electrical outlets around the courthouse, but only after people started pitching tents there and setting up full-sized refrigerators that ran off the city's electricity.

We get the traffic from South By Southwest, but none of the other headaches. Bars that have live bands put up signs that say "OH MY GOD BECKY LOOK AT HER BOOKING" for that week. Gas is cheaper here, and the gas station is likely to have Mexican, Indian, or Korean home-cooked food for sale. The place I buy my beer smells of incense and kimchee.

There are four terrifying barbecue places where the meat melts off the bone and you're not advised to ask about preparation, and three terrifying Mexican places that have excellent strange salsas you've never tried before. Oh, and that little Japanese restaurant that will serve you amazing sushi if you shrug and say, "Whatever the chef wants; I'm not particular."

Soul food is cheap here. Grits are an option with everything. You can be literally thrown out of a bar, onto the street, on your ass, if you misbehave. Yet the patrons of the local gay bar will leave you alone if all you want is a beer and a book. There's a running club that meets at a local bar, three bike clubs (road, mountain, and casual), and a bird-watching group. There are two breweries and a dude who bottles home-made ginger ale and flavored seltzers. There's a soap company, two of those places that will sell you boxes of vegetables every month, and some guy who runs a barber shop out of his pickup truck and specializes in beards. Drag queens are an everyday sight. Nobody turns a hair at people of different/the same ethnicities/sexes holding hands in public. The library is one of the finest I have ever seen, and is enthusiastically supported by the locals. The city council is made up of a lawyer, a stay-at-home mom, a guy who runs the vegan restaurant, a history professor from one of Bigton's universities, some woman with oil and gas ties who is retiring this year thank God, and a couple of random business owners who want to legalize pot and skateboarding.

I was shopping today and had to do the excuse-me-I'm-in-your-way dance with a seventy-ish man in the soup aisle. It turned into a full-on dance-off and ended in a tango.

I love my town.

Wednesday, September 09, 2015

Happy Lumpiversary and 'Bye, Felicia.

Five years ago I was sitting in my dentist's chair when his hygienist found a lump on my hard palate. The lump, known as Cap'n Lumpy after that, turned out to be a rare-ish form of minor salivary gland cancer called polymorphous low-grade adenocarcinoma.

It started a year-long freakout on my part, most of which is documented on this here blog, that culminated in my wearing a cool plastic-and-metal prosthetic to replace the chunk of my mouth that a surgeon removed.

I'm not sure how I feel about this, so I'm gonna just mark this lumpiversary and leave it be. I have the latest set of scans (CT and MRI) coming up week after next. I'm not sure how I feel about that, either. Maybe it'll be easier once I transition to once-a-year rather than once-every-six-months scanning; maybe it'll be a whole new kind of hell. We'll see.

In other news, Keith is gone. I don't know the details, having been on vacation this last two weeks, but he's been relieved of his duties at Sunnydale and has gone back to the pit that spawned him. It probably had something to do with a patient decompensating to the point that she had to be intubated on his watch, with nobody but him being aware of it. I don't know. All I know for sure is that I can work now without having to worry about somebody else's patients as well as my own.

So. One okay thing, one good thing. Not a bad way to start off the new year.

Sunday, September 06, 2015

The best new nursing blog out there is "Florence Is Dead."

If you want smart, funny, badass commentary on the nature of nursing today, go read Florence Is Dead. It's a brand-new blog, but already it's creating waves. The Diet Coke Incident has some of the most bloviating ridiculousness in the comments section that I've ever seen.

In case you couldn't guess, I agree with pretty much everything Dead Florence writes. The one place we differ is on the scrubs issue: she'd like to see professional dress for nurses, while I stand firmly on the side of scrubs. The primary reason for that, you understand, is that I cannot dress myself. Other than that one disagreement, though, I'm firmly in DF's camp.

Go check it out. I got very excited when I stumbled across it (can't remember for the life of me how that was, sadly). Give her some love in the comments section.

Friday, September 04, 2015

Let's talk a little about patient satisfaction, shall we?

About a year ago, after Eric Duncan died at Texas Health Presbyterian Hospital in Dallas and two nurses who cared for him were hospitalized with the same disease that killed him (Ebola), Texas Health Resources got an independent committee to review what went wrong. It was like a root cause analysis, but more so: these were outside doctors and one nurse, they weren't paid, and they were given access to everything that was charted and all the folks involved in the Presby debacle.

They came to a number of conclusions: first, that education was lacking--the staff wasn't aware of what exactly to do in case of a person with Ebola coming in; second, that communication was poor--the nurse who took Mr. Duncan's health history didn't communicate verbally to the doc that he'd come from an Ebola-affected area; and third, that the fear of poor patient satisfaction scores led the doctors and nurses to rush Mr. Duncan through the ED that first time, in order to keep other patients from waiting and getting mad.

The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

Read that again. The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.

I don't know what it's like in Dallas, but here in Bigton, every medium-sized hospital and most of the smaller ones have billboards touting how fast a person can be seen in their various EDs. Some of them even have big neon numbers that show the current wait times outside the hospital itself. A few even have those big neon numbers on billboards on the highways.

The entire focus of emergency-room care has become, at least in this area, about how fast you can be seen for belly pain. Or a broken arm. Or allergies. Yes, they advertise ED services for seasonal allergies. And it's all about the time it'll take for you to be seen. Come in with a head injury following a fall or a sore back that's been going on for a month? Doesn't matter--our goal is to have you back in a room in ten minutes or less and have you out the door in half an hour.

At the beginning of flu season here in Texas, that emphasis on speed, which is translated to patient satisfaction by administrators, contributed to already-stressed doctors and nurses missing a diagnosis that turned out to be fatal.

(There's a lot to be said on the communication front as well--why was the flag in the chart that the nurse filled out not enough to alert the doc? Was he, perhaps, rushed? Why the emphasis on verbally informing him of something, when the nurse might not actually see the doc face-to-face all shift because they're both busy? That'll have to wait, though.)

Let's take this down a notch. At Sunnydale General and Holy Kamole, there's a big push on to satisfy patients in every way possible. Press-Ganey cards are sent to each and every in- or out-patient within a week of their leaving the hospital or clinic, and the results are taken very seriously.

I work in a critical care unit. It's likely that the patients that I see will go on to spend a few weeks either on a floor or in rehab or both, and may or may not remember their time with me. Brain injuries tend to wipe out short-term memory. Even if they do remember the NCCU, they probably won't remember me by name. All this leads to a very minor chance that they'll be able to fill out a card that mentions me specifically.

Yet if I'm not mentioned by name by at least one patient in a year, preferably by two or three, I won't get a point on my employee review. It doesn't matter how many students or new nurses I precept, how many errors I catch, or how often my patients have good outcomes. What matters is that somebody who's stressed or ill, possibly without family support, remembers my name (perhaps weeks or months after seeing me for a day or two) and takes the time to mail back a postcard with my name on it. Missing that point can make the difference between a raise and no raise, or between a satisfactory or unsatisfactory review. It's weighted that heavily.

We no longer track how often certain nurses' patients get bedsores or UTIs or end up going back to the CCU. What we track now is how often they're praised by patients or family members.

As a result, I find myself doing all kinds of crazy shit to get people to remember me. We're not allowed to hand out the Press-Ganey cards or special-mention cards ourselves, so it's up to us to do everything possible to make ourselves stand out. Most of the time, for me, it's staying at the bedside a little longer to explain what's going on with the care plan, or the physiology of the disease we're dealing with, or why the patient is on a ventilator or has this or that tube.

Sometimes I have to sweeten family members or patients who are determined to be upset. I act as counsellor, waitress, and gofer. A lot of times, those patients or families take me away from jobs I ought to be doing just so I don't end up with a complaint--I didn't get them a cup of coffee, or something. If I have a patient I'm worried about because her neuro status is changing, I have to weigh the consequences of letting her go for another ten minutes versus the consequences of being seen as not "patient satisfaction oriented" enough.

The worst example of this happened after a patient, who was fully in command of all his faculties, took a swing at me. Only a complicated move reminiscent of the "Matrix" movies kept me from a broken skull. Afterwards, the assistant manager told me I had to go back and make nice with the guy. I told him no, that I would not, and further, that if he or any other patient ever tried to hit me again, I would be calling the cops and pressing assault charges, and maybe suing the hospital for making my work environment unsafe. I refused to reenter the room.

I got a note on my review that year that said "Jo is an excellent clinician but needs more work on her relationships with patients."

For all you folks who want to point out that service is part of nursing, and that serving is a holy and higher cause, you go right ahead. I serve every day that I work, from before the time that I punch in to whenever the job is done (whenever that is). Service to my fellow humans, though, does not mean martyrdom or risking personal injury. It certainly doesn't mean putting a patient's satisfaction scores ahead of their health or safety.

If you, Administration, want me to be a good nurse, then let me be a good nurse. Let me educate and comfort and calm. Let me commiserate and be compassionate and do all the things that I was trained to do, including catching med errors and fixing problems. Don't push the patient satisfaction side of the equation so hard that you forget what you hired me to be: the first, last, and best guardian of my patient's health and safety. Don't confuse happy people with good outcomes.

And for God's sake, and the sake of your patients, don't push my profession into waitress/hostess mode so hard that we all forget what nurses are here for.

Sunday, August 30, 2015

Thank you.

Twenty years ago, before I was a nurse--before I had even started nursing school--I was at a used bookstore. I saw a title that intrigued me: "The Man Who Mistook His Wife For A Hat."

It was my introduction to Oliver Sacks. It was the beginning of a relationship, however one-sided, that got me into nursing, got me into neuroscience, and has kept me there for more than a decade.

Oliver Sacks was a walking contradiction: he was on the Asperger's spectrum, as he diagnosed himself, yet he was able to interact with his patients in such a way as to humanize even the most disabled person. He was obsessive, by his own admission; yet, he translated his obsessions into ordinary-person-friendly tales of his life as a doctor and the lives of his patients. He was incredibly learned, but never resorted to jargon when simple English would do. He was shy, but he put himself out to the public in a series of books about his practice and his life that showed us as much about ourselves as it did him.

The one true regret I have--after divorce, after cancer, after lost friends and relatives--is that I never got to sit down and listen to him talk. Just ramble, or expound on one of his favorite subjects, whether it was music or the periodic table or his days as a weightlifter on Muscle Beach. It wouldn't have mattered; I felt that close to him through reading his work.

It's important to remember that Dr. Sacks made most of his diagnoses and discoveries in the days before functional MRI or good CT scanning. Many times, the only four tools in his toolkit were clinical observation, x-ray, surgical biopsy, and a technique of pumping air into the brain in order to determine if a large mass were taking up space somewhere.

Of those four, his clinical observations were the most precise and flexible. Dr. Sacks taught me, through reading his books, to ask questions that went beyond the normal, prescribed neurological exam. He showed me what it was to sit down with a patient, to see how they ate, how they walked, how they interacted with the world in a functional way, rather than in a formalized exam.

Most of all, he taught me to see my patients as people. First and last, no matter the pathology in the brain, it is a person that we treat. That person never completely disappears; she's never totally lost to the disease or accident that might have claimed speech or reasoning.

For that, I am immensely grateful. Thank you, Dr. Sacks, for getting me into this insane, messy, endlessly fascinating and entertaining business of working with the human brain. Thank you for showing me the way that the brain informs and interacts with the mind. And thank you for translating your experiences into stories that anyone could understand, could follow, and be immersed in.

I owe you a lot. Your patients owe you a lot. The field of neurology owes you an immeasurable debt.

May it be indigo forever, from here on out.

Oliver Sacks, 1933-2015