Tangled Web

Sometimes there is a thin line between perception and reality. Between what someone tells themselves is happening and what is really happening. Our ability to deceive ourselves and even our own bodies makes understanding and believing others, and even ourselves, harder than it should be.

She was brought in by ambulance, and she was thrashing and weeping and screaming as they transferred her to our gurney. Her back would arch and her body jerk side to side as tears streamed down her face. She would make eye contact with me and then with her husband who stood helplessly and awkwardly at her bedside. Her admitting complaint was "seizure" and her husband reported that she had a history of these "seizures".

If you know anything about seizures, you may know that they involve more than uncontrolled jerking of the body. The person is not conscious during a seizure, will often lose control of bowel and bladder, and afterward has a period of confusion, we call being "post ictal". A person in the midst of a true seizure will not be crying or screaming and most certainly cannot make eye contact.

"Can't you do something to help her??" Her husband looked at me and back at his wailing wife with a mixture of concern and uncertainty.

I shifted uncomfortably. I was still fairly new to the ER and no Neurologist, but I was pretty certain whatever was happening to his wife would fit more appropriately under the "mind" than "body" category. But you can't really tell someone's worried spouse, "You know it's probably all in her head..."

We gave her Ativan (helps seizures and agitation), tested her blood and scanned her head. As expected, everything was normal. "What do you think is going on?" Her husband asked me later. I explained carefully that the symptoms she exhibited varied largely from a classic seizure, but it didn't feel right to express to him that it might be a psychological issue. I saw the glimmer of doubt in his eyes as he stood there.

I've wondered many times since about this woman, hypothesizing about what goes on in her head when she has these "episodes". Does an increasingly aloof and distant husband suddenly become attentive and concerned as he leans over her bedside in the hospital? Does it give her temporary respite from stress and responsibilities? Has it become her back door, her excuse, her crutch? A fake seizure is much further down the line than faking a headache to get out of school, or over-exaggerating an injury for the attention it brings, but isn't the root the same? I'm willing to bet she doesn't even admit to herself that there isn't something physically wrong. Because it's amazing how adept we can be at deceiving ourselves right along with deceiving others.

Helpless on the Holidays

It happens every major holiday. Families pop in to visit Grandma or Grandpa for the first time in Lord knows when, and find them dead, mostly dead, or broken and bruised alone in their house.

This was the story of my first patient Thanksgiving morning a few years back. She was in her 80s and had slipped in the bathroom, injuring her hip. She couldn't get up and was stuck there on the floor in a puddle of water for three days. Family tried to call that morning for the holiday, and when she didn't answer got their first clue that something was wrong.

She was unconscious and her skin was cold with a bluish hue. Her core temperature was 88 degrees Farneheit from lying naked in cool water for so long, and she had several areas of obvious skin breakdown. Our first goal after the first round of assessments was to warm her up. This cold she was far beyond the therapeutic abilities of our blanket warmer.

"How about the Arctic Sun?" Someone offered.

The Arctic Sun is one of our favorite little pieces of cutting edge technology. Consisting of large gel pads that connect to a machine that circulates water through them, we normally use it to induce hypothermia in patients post cardiac arrest to help preserve brain function. But since you can control the goal temperature, you could hypothetically use it to warm someone up. We ER nurses are very much fans of trying new things, and it seemed like it was worth a try.

So we placed the temperature probe by her breathing tube to record accurate core temperature, fitted the various gel pads to cover the majority of her body surface, and set the temp goal for a more comfortable 96. As I set her up for her transfer to ICU, I knew her odds were dismal. It's not very often that an elderly patient who is brought in critical condition walks back out again. In my subconscious, I assumed in a couple of days she would most likely be gone.

At work a month or so later, I was busy at the nurses' station with some paper work when one of my colleagues came up to me.

"Hey remember that Hypothermia patient we had on Thanksgiving? She's in room 5 for something minor, but she's doing great! She's totally with it!"

I'll count that one as a Holiday miracle.

Moral of the story:

Don't let your mom, dad, grandma, grandpa, uncle, aunt, etc be one of our annual sad holiday stories, because no one pays them attention except on special occasions. On that note -

Happy Thanksgiving!

Nurses versus Docs

The first time I saw this, I'll admit, I chuckled a bit. And then I thought, 'man, if I was a doctor, jokes like that would really irk me.' Then I started thinking about this on going battle between nurses and doctors. And in a lot of ways, I'm thinking it's time that bugle went silent.

It all started in nursing school. Before then, I always thought of doctors as respectable people who want to help others. But somewhere, subtlety and almost subliminally, in the process of nursing school I learned that 1. doctors do not care about their patients as much as the nurses, 2. nurses will often have to save their patients from the doctors 3. doctors are jerks 4. doctors resent the increasing skill level of nursing.

It reminds me a little bit of the feminist movement. There were real injustices against women and real inequality, and I'm thankful to live on this side of the movement. But we have a hard time keeping that pendulum from swinging too far. For example, what TV family can you think of where the man isn't lovable but largely idiotic and married to a competent and capable woman who rolls her eyes and holds the family together? Women have been victims of injustice and inequality and violence at the hands of some men. That doesn't mean that all men should be disrespected and demeaned by women.

In the medical field there's been real issues with doctors being mean and even verbally abusive to nurses and I know there's been a real turf battle, but lets not let the pendulum swing too far. We've been taught a lot about being advocates for our patients, which usually implies standing up to doctors when we think something isn't right. And I'm not saying that isn't necessary sometimes. I just think we need to remember that nurses can kill patients too. By negligence, distraction, and error just as easily as doctors. I've met as many nurses that have lost concern and compassion for patients as I have doctors. Nursing has grown in its scope and skill set but that doesn't mean we should stop respecting our doctors, or start thinking we are immune to the same vices we like to stereotype them with.

The human condition is not unique to certain professions. We all deal with our pride, with losing our vision and ideals for working in healthcare, with being unfair or unkind to the people around us. None of us like being challenged in our decisions. If I had four more years of education and x number of years more experience than someone, I would have a hard time not being angry or defensive if they questioned my decisions, overtly or subtlety. That doesn't mean there isn't a time or a place for that, it just means it would be helpful if we communicated respect to our doctors when we ask questions or bring up concerns. And to remember, as much as it stings, they really do know more than us. Usually. ;)

It's a rule of human behavior. It's a lot easier to show respect for people who respect you. Respecting someone doesn't mean becoming subservient and mindlessly compliant. It's recognition of position and skill set and knowledge base combined with the gracious communication we should give to any human being.

Don't assume from this diatribe that I am not guilty in taking sides in the nurse v. doc war. But I am trying to stop myself and think about it more and try to be more deliberate in respecting the doctors I work with. Because I do work with some pretty fabulous doctors and I want them to feel the support of the nurses that work with them. And let's face it, everyone fares better (especially our patients) when nurses and doctors play nice. We want our doctors to respect us and treat us well, let's start by living that Golden Rule ourselves.

Triage is Tricky

Definitely one of the hardest jobs in the Emergency Department is Triage. "Triage" comes from an old army term meaning "to sort". It's the triage nurses' job to determine who needs treatment the quickest and who is ok to wait. On a busy day you may be eyeballing a line up of people at the check in desk, and plucking out the ones who looks like they're about to drop to get them help right away. It's the psychological pressure and potential for disaster that really makes the job stressful. If there are not a lot of people checking in and there are plenty of open rooms, the job is a snap. But when the tidal wave comes and there are no rooms and a line out the door, a lot depends on your critical thinking skills and clinical judgement.

There are plenty of scary stories from ERs around the nation of triages gone wrong. The nurse that didn't have mom and dad take their baby out of the car seat to check him properly, and by the time they got to a room the baby was almost dead. There are plenty of extreme, news making cases out there, but the ones that scare you most are the easy misses. A benign seeming headache that turns out to be bleeding in the brain. The shoulder pain that turns out to be a massive heart attack.

Even aside from the fear of missing something deadly, there are the daily stresses of making good decisions for the patients, the other staff, and the general flow of the department. In our department the triage nurse decides to start IVs, order basic blood tests and radiology studies in order to help decrease the length of stay for the patient. Some cases are clear cut and decisions are easy, others you feel like could go either way depending on which doctor ends up treating them. Younger doctors tend to order as much as they can, older doctors tend to be more minimalistic. Some order based on what could potentially get them sued (CYA philosophy), others based on what they think the patient really needs.

For example I check in a guy in his 30s, low risk factors (nothing that particularly predisposes him to a heart attack), who experienced 5 seconds of palpitations (extra heart beats) and felt his left arm "tingle" while he was driving. Um... ok. We do an EKG - perfectly fantastically normal. So I have a few choices, each with different consequences. What I know (pretty much) is that he is not really having any heart problems whatsoever, maybe he had an energy drink, and it's really unfortunate that the tingle event had to be his left arm, because that's the one classically associated with heart attack. I can do what would be most helpful for the nurse that will inherit him and start the IV and send off labs to check his heart status, because most doctors do operate under the CYA philosophy (why take the risk??), and he'll probably get a full meal deal work up, even though we all know he's fine. Or, I can wait until a doctor sees him because I know we have a few minimalists on today who might actually save him the 500$ IV start and 1000+$ work up (hope you have insurance!) that a cardiac rule out would involve. I chose to wait. Wrong decision! He got the whole work up, and his nurse was annoyed that I hadn't started anything because let's face it - you can be the healthiest young person on the planet, but if you say anything about your heart and your left arm together in the ER - you will get a big, costly work up.

This little rant is all to say that a job where a lot rests on your decision making, and where sometimes the right decision can be pretty hard to know, can be a little bit stressful. My triage days start with a lot of prayer for wisdom and protection (for me ( there are crazies out there!) and for the patients) and I have a lot of reassurance knowing that I have a God who watches over (and out) for me. In all of life's tricky situations.

Priorities

Knowing how to prioritize is one of the most important skills an ER nurse can have. On a busy day, guaranteed, there will be a lot of people who need a lot of things and they'll need it all at once. And since we can still only be in one place at one time (come on Scientists!) - you have to prioritize. Who is most likely to die? Who can wait, whether they are happy about it or not, and who will actually deteriorate if they don't get what they need this instance? What needs to be done right now (CPR)?, what can wait until later (peeing)? Not having this skill results in more stress for you (and your coworkers) on the lesser end and actual harm to patients on the extreme end. So needless to say - its a big one. As my years of nursing have added up (5! Woohoo!), I finally feel like I've grown into the ability to prioritize fairly effectively. I can balance my load and nobody dies. (Usually;) )

So why can't I prioritize in my other life?? I know this is where you might expect me to launch into an exciting story of priorities gone wrong during a hectic day in the emergency room. But no. I'm going to talk about the other side of my life. The domestic, cleaning, cooking, laundering, toddler wrangling side of my life. It might not have it's own blog - but its a pretty big side. No come on, keep on reading!

Anyways - if you're still with me... Priorities obviously matter in every faucet of life, and the way we manage them often determines the quality of our lives and our relationships. In my head my priorities go like this:

1. God
2. Family (husband and aforementioned toddlers)
3.Friends
4.Work (be it house work or emergency work)
5.Volunteer shiz
6.Random hobbies (like this blog)

In reality they go something like this:

1. Family (and only because my children refuse to sit quietly in the background, unless I lock them in a closet. Which I've never done - but maybe have in a moment of weakness and stress considered. Maybe.)
2. Work (have you seen what toddlers can do to a house in an hour??)
3. Volunteer shiz (gotta keep up the image!)
4. Friends
5. Random hobbies (if it didn't take constant vigilance to keep my son from seriously harming himself, it might jump up to 1. )
6. God (oh, yeah....)

And it's not until my world suddenly seems to want to crumble down around me that I realize - huh. My priorities are all out of whack. Like this week. Remember how I said I'm not a crier? I've cried three times this week. Three. And not little sniffles. Big ugly cries. I know. Feel bad for me.
But don't really, because the answer has been in front of me all along. I just have a really hard time believing it.

Jesus said, "Seek first the Kingdom of God and his righteousness, and all things things will be added to you as well." All these things? Do you mean if I take time to pray and study my Bible an angel will show up to clean my house and prep dinner?

He also told one of his followers named Martha, "You are anxious and concerned about many things, but only one thing matters." That's me in a nutshell. I'm trying to do everything in my own strength, while God is trying to tell me to rest in His. I'm trying to pretend I don't have weaknesses, while God is trying to remind me that yes I do - but in my weakness He shows Himself strong. And if I'll remember what really matters in the grand scheme of eternity and pursue that first of all - God has a funny way of working out the littler things too. Even without an angel to do my housework. Although that would be awesome.