VA tape

 BCMS arranges lots of rotations at the nearby VA hospital so we had to go thru the federal background check, fingerprinting etc for access. It was a pain in the *#a.  Last year, I had 5 ppd skin tests, 3 background checks (in which I needed to list ALL of my lifetime addresses & local (to said addresses) people to vouch for my existence there, and two fingerprinting sessions.  The extent of my civil disobedience consists of 3 parking tickets that I accumulated a decade ago by parking in the staff lot at a local community college. I can't imagine how much worse it would have been if I were a naughtier person.

I've lived in 7 states. I had to dig through old letters that I saved to find all my former addresses (15 of them that I could recall- I'm sure I missed one or two..). Then I had to supply references for a) places that I had lived and b) places that I had worked.  I actually used myself as a reference a couple of times.  I laughed when I received the letters "Can you confirm that 'Narrow Room' was a resident here between August 1997 and July 1998?". Why yes, yes I can.

Ironically, the med students who struggled more than me with this insane process were the few who were actually current members of the armed services (and already had partial clearance). The VA required additional paperwork from them. Insane.

But now I have a med school ID AND an official "get thru security at the airport quickly" government ID.  I'm so cool.

But in reflection, the VA sat on our application paperwork for 4 months. I received an email in December that all was in order for my background check. The class didn't get notification until last week, though, that all was in order with our application and we could go to the HR office to press our fingers to the confirmation screen and pose for our (dashing) ID photos. 

Then, two days after this notification, BCMS sent out an email that the background check/fingerprinting for the VA expired that weekend, leaving us just 2 days to get to HR before we would have to start the process all over.

I waited in line (the day before an exam, mind you) for three hours. Apparently, all the VAs in the US operate on two servers so the backup during busy times can be insane. Several of my fellow students did end up having to be re-fingerprinted thus delaying their "go straight thru security cards" by 3 months.

Now I ask: "Why did they have us submit our application, background check and fingerprint us on the same day leaving only 4 days for the processing completion?"  Wouldn't it have made more sense to process the application (the rate determining step), then do the background check?

And this is for (useless MS1s). I can only assume that all new VA staff, those who can actually help the backlog of over a million veterans, struggle with the same stupid delays.

I'm not even going to start on the old Commodore computers they still use....

Laziness and Loneliness

I'm lonely.

When I moved back from the west coast to my itty-bitty industrial town, my life changed completely. During the subsequent two years when my time was consumed with caring for my mother, my smart, stimulating and worldly friends across the continent dropped away. I just hadn't the time to nurture our relationships.

I'm trying to create new stimulating relationships but apparently I'm weird.

My nursing coworkers, the pinnacle of education in this working class town, are consumed entirely with creating and raising families, getting married or engaged. We're friendly enough at work but I so miss talking with people about things beyond our immediate sphere of family and work.

Those who read, read Twilight and the Hunger Games. They tease (not maliciously) me about the books that I bring in and I can't find any interest in the antics of Belle or Edward.

Growing up here, I was the lonely little girl in the tree with a book fantasizing about evading the trolls below. When I left at eighteen, I discovered a wonderful world full of fascinating curious people who read, traveled, explored cultures, food and art, fought for environmental preservation and human rights. They celebrated their own uniqueness and seemed to appreciate mine. I swore that I'd never return to this area.

Then dad got sick and mom got sick and I again was tethered.

I know that the end is in sight; I'll be leaving in a few months and re-entering a world of more curious people.

This last year has been brutal though. Those who have applied to medical school probably remember how demoralizing the process is. You basically rip your life and history apart, present the pieces to anonymous adcoms and wait for them to decide that you're lacking. With the deaths of my parents and my relocation thousands of miles and several time zones away from my friends, I lost all of my social and emotional support.

Every time that someone I work with asked why my applications were failing, I withered away a little more. Trying to explain the immense competition involved came across as just defensive and it showed in their expressions.

Emotionally, I'm hibernating now. The acceptance that I received validated me in a way that I could have never predicted. My intellectual loneliness isn't so severe now that I know that it's finite.

I don't feel defensive anymore when people insinuate that I'm lazy because I don't plan on working through medical school. I can just wait a few short, yet impossibly long, months and I'll be with folks who'll understand that I'm not lazy.

I'm grinning now in anticipation. I know that I'm leaving an intellectual desert to conquer an ocean of knowledge. It'll be hard, I know, but it'll never be as hard as the last few years of dehydration. It can't be.

The Catheter Interrogation

First thing this morning, a urologist came to place a supra pubic catheter bedside. The patient had been retaining crazy amounts of urine and neither his nurses nor his orthopedic surgeon could place a foley in him. So urology was consulted.

The doctor had called in a list of supplies that he'd need bedside by 0530. Apparently he was rather rude to the evening secretary about it, saying 'everything better be ready", in a 'you people always mess up' sort of way. But I know the evening secretary is something of a sensitive whiner, so I took her report with a grain of salt.

He arrived examined the patient and then decided to try his hand at placing the foley first, giving me and the patient's nurse a new list of supplies. We have coude catheters in different sizes and foley kits stocked on the floor so much of his list was immediately manageable. But he wanted Urojet (lidocaine) syringes too. We don't have them in our McKessen so it was a short process to get them up to the floor. He needed to write an order, I faxed it to pharmacy and then immediately ran down to pick them up.

He was NOT HAPPY.

Though it took 10 minutes tops to get them (5 of which were taken by him arguing about writing the stupid order), he was incredibly put out. I heard about how ridiculous we were, how he doesn't have time for this stupid delay.. etc, eye rolls and disdain galore.

Fortunately for the patient, he was able to successfully place the foley. Whew.

A few minutes later, I stopped in the room to check on the patient and I noticed that his collection bag had over a 1200 cc in it.

I remembered reading somewhere that draining the bladder too quickly can cause the patient major discomfort so I pointed it out to his nurse. She was busy doing her end of shift med pass and instructed me to ask the urologist if she should clamp the catheter.

So I did.

I thought he would attack me.

He completely lost his temper and flayed into me.

"That's the stupidest thing I've ever heard! Why do you think to clamp the catheter? Why?" and then he waited. It took me a moment to realize that it wasn't a rhetorical questions but that he actually wanted a response.

I tried told him that I had read somewhere that it could hurt the patient if the bladder emptied too quickly but as soon as I started talking he restarted his rampage.

I was mortified. I tried to explain that I was just an aide and the messenger for the nurse but he kept at me. I can't remember everything that he said; I was flustered and just trying to escape. I remember him saying that they don't teach nurses to be doctors and thrusting a new order at me, written in block letters as though I were in grade school, DO NOT CLAMP CATHETER. It was the only completely legible order he'd written thus far.

He ended up staying to yell at me for longer than it took him to place the foley.

So much for his valuable time....


I'm totally re-writing one of my evil book characters in his honor and he's (the character) is going to suffer.



.

Disaster

My area is under a state of emergency right now. I worked a 20 hour shift at the hospital yesterday and am looking into another long shift today. The region is devastated, without drinkable water and many homes without electricity. Emergency command centers and shelters have been set up throughout the county.

I'm amazed at how well everyone worked together these last couple of days. The folks who actually made it, driving hours in convoluted directions, without complaint buckled down to work and spirits were remarkably high. We didn't know how long we would be the only ones who would be able to work and so my manager set up a rotating schedule partway through the day so that we could get some sleep.

A rep whose presentation was canceled, dropped the food off on our floor and so we dined. Because we couldn't use the municipal water, our coffee dispenser was shut off (it is connected directly to the water line.) A neighbor of the hospital dropped off a couple of percolators so that we could refuel.

Another aide came in to relieve me around 4:00 this morning and I began my journey home. Only one bridge in the area is functional and so I have to drive 2 hours on a winding path in the opposite direction to get on the right side of the hill/river in order to get home.

I was the only car in the middle of nowhere when a red sports car wheeled in front of me and then over-corrected to go flying into the tree in someone's front yard.

Immediately stopped, I put my hazards on and called 9 1 1. Describing what happened to the operator, I got out of my car to approach the accident. As I'm walking up, the boy who had been driving, stumbled into the yard, turned to look at the car, said "oh shit!" and took off across the road into the woods.

And so I told the operator. She said someone would be out as soon as they can. Considering the area was in a state of emergency, that 'as soon as they can' was 2 hours and 15 minutes. After giving my statement, they let me go and I began the long trek home.

Chicken Pox

One of the new nurses on the unit has a moderate case of the chicken pox. Policy here is that anyone who had contact with the infected needs to demonstrate either a recent immunization or an adequate varicella titer.

When I was hired last year, my titer was low. When I was six, I had had a severe case of chicken pox; if you closely examine my cheek and shoulders, you can still see the pockmarks. Because I've read that those who actually have had the disease demonstrate lower measured titers than those who are vaccinated, I declined to get a booster shot when I went through orientation. The clinic was across town and I didn't want to take an entire afternoon to get a shot I didn't need.

I am now presented with a choice: either take 28 days of unpaid medical leave or get the booster shot. I, of course, am getting the vaccination - I would need to for school next year anyway. It's just one more irritating errand in my already insanely busy life.

The irony is that the new nurse's infection is due to a booster shot she received during her orientation.

Crying at Work

In Floating, I alluded to the reality that staff on my floor don't always do their jobs thoroughly. It's a major frustration; the onus of work usually falls on the shoulders of only a handful of people.

I get particularly fed up when our manager seems to coddle the biggest transgressors. He does have his favorites. Usually leaving before our shift starts, he's not much of a presence and I've always attributed his lack of enforcing job responsibility to his ignorance of what really happens during the evening.

When I first started, I really liked my manager. He was welcoming and warm and seemed to really try to create a happy work environment. As the first months past, he seemed really receptive to all of my little ideas for the unit, posting bed phone numbers over the information board in each room, changing the location of the linen carts to be more generally accessible etc. I reorganized the way that the medical teams, patients and nurses were listed on our charge board, color coding them to make the information much easier to read. You should have seen the way they did it before, it would take minutes to figure out who the doctor and lead nurse was for each patient! I was allowed to join the unit council (their first aide!) and I thought, despite my lowly status as a grunt, my thoughts, ideas and concerns were being heard. I took on all the training of new PCAs and attended workshops to improve my clinical mentoring skills.

Last month, another aide, ignoring an imminently dangerous situation for the patient, neglected to do something important. I stepped in and performed the required task, then followed the her to the nurses station. I confronted the aide and told her that she could not disregard those types of situations.

Well, she started to cry and complained that she was having a really bad day. Her brother was having oral surgery to have his wisdom teeth removed and she was so anxious about it. She became hysterical,(seriously!) and needed a twenty minute smoke break to regain her composure. Of course, I was rolling my mental eyes the entire time.

The next day, I was called into the NM's office and scolded. He informed me that it was not my place to police my coworkers(!) and that, and I quote, "not everyone has your work ethic". I told him that I was indeed having trouble adjusting to lack of my* work ethic in my coworkers and that my actions stemmed purely from my concern for the patient. He nodded sympathetically and asked me to work on my tolerance.

Of course, I've thought that maybe I was out of line or too harsh with the other aide. I talked it over with one of the nurses who had been present though. She reassured me that it happened as I remembered: 10 seconds of me getting the aide's attention, telling her to do her job and her becoming histrionic. She confessed that she too has been scolded for scolding someone else.

I'm currently looking for a new job** but I'm saddened and frustrated by the entire scenario. I absolutely love the work that my job entails (but not the poop part) and I hate that I'm leaving with such sourness. All that I've read about the evolution of healthcare shows that the culture is one of increasing openness to policing each other in the effort to generate fewer mistakes. To be slapped in the face with the very antithesis was shocking.


*my work ethic being that I actually do my job!
**I did call the 'anonymous' hotline two weeks later for an incident that I wasn't directly involved in. I haven't seen nor heard any outcomes but I hope that someone is looking into the mess that is my unit.

Nighttime Events

Yesterday, because of the construction, the census on U8 was low and I was expecting to get called off. Rather, another unit needed an aide so I floated down to the JD Rehab Center, a subacute care wing of the hospital.

I arrived to find Andrea, an ICU nurse, had been borrowed too. Andrea and I have worked together many times and have become friends. We laughed together as the night began because it was a vacation; most of her patients didn't even take medications and many of mine were independent.

Ironically, I wasn't allowed to do anything but task, no charting, testing glucose or vitals because I'm not a certified nursing assistant. So my responsibilities were minimal. After the last few months of juggling both the responsibilities of an aide and unit secretary, this was refreshing. Andrea teased incessantly, tickled by my certification limitations. She thought it was a riot and would demand proof that I was qualified to carry a dinner tray or empty linen carts.

The night dragged painfully though. After what would have been a double upstairs, the clock read only 3 hours into the shift on JDR.

Then the fall occurred. Apparently, the family of Grandma Smith* had unplugged her bed alarm while they were visiting. Its shrill beep was annoying to them. After they left without resetting it, 94yr Granny Smith decided to go to the bathroom to change. We found her crying for help in a pool of blood and vomit.

Andrea and I kicked into gear like Emil Fischer's lock and key enzymes. She checked vitals and stabilized her head while I went to the desk to call a rapid response team and the ED for a lift board, cervical collar and stretcher.

The nursing staff on JDR is amazing. They're friendly, good with patients and very good at their job. They don't have many medical emergencies there though and so seemed grateful to step back to let Andrea and I take control.

The residents, newly minted PGY1 and PGY2, examined her pupils, spoke with their attending and down we went to CT. I stayed at Gran's head, pushing the stretcher with one hand and holding the emesis basin with the other. When she would get sick, I would stop the stretcher, we would slowly angle the lift board and let her vomit on her side. Her wide eyes locked with mine and she held my hand tightly. I know that she was frightened by the fall and the rapid conversations flying over her head. I wasn't really needed in the medical part of the emergency other than as a strong back so I tried to keep a constant gentle flow of words to only her to give her something to focus on. I explained everything that they were doing before they did it and her breathing slowed and deepened.

We took her to CT, then XRAY and back to her room. She settled in quickly. Andrea dressed the wound on the back of her head and I swabbed her mouth out, washed the blood and vomit off her face and shoulders and changed her gown. She even laughed at some of my lame jokes. "What did one snowman say to the other?**" Then I stepped aside and let the CNA test her blood sugar.


*not Mrs. Smith real name. Also many details have been changed to protect her, or his?, identity and the identity of my medical institution.

**answer to really lame joke: "do you smell carrots?"

Cleaning

The hospital is undergoing renovations. Last night, the construction workers were on our unit. They taped up little tents and began asbestos cleaning under the ceiling tiles. They were being cautious. They had even put up double drop doors in their tents to prevent any contamination when they entered or left.

Partway through the effort, I walked into the little kitchenette where we keep snacks/ice/drinks for the patients only to find one of the workers rinsing his vacuum canister in the sink. Dude.

He totally bypassed the closed/locked door with the sign on the front saying U8 staff only. (They have a master key to access all the rooms.) He was washing a disgusting greasy dusty cylinder in what was obviously a kitchen sink. I was horrified. I asked him what he was doing and then kicked him out of the kitchenette.

He claimed that he couldn't find another sink. I pointed to four sinks in the hallway and directed him to two different bathrooms, all closer to the work area than the kitchenette. Seriously, you couldn't have asked? *facepalm*

Juggling Thoughts

We have a nurse on our unit. John* is incredible with the patients and acutely intuitive about their well-being. He's saved several lives by noticing that a patient is 'off' and calling the appropriate people to take care of it.

He sucks at multitasking though. His medicines are always administered late and he can't give a decent concise report during shift change. We all, nurses and aides alike, dread following his group. There's always information missing and tons of catch-up to do before we can start our own assignments.

I recently read Dr. Ofri's Lancet contribution and thought about John and then about my own future as a physician. My experience thus far has been relatively painless. There's a certain triage that people use when they multitask. Providing orange juice for a glucose reading of 56 trumps the coffee for a visitor in room 654. Occasionally, When I'm juggling 10-15 requests, I'll sometimes overlook one.

It scares me that I may forget something vital when I'm a physician. Will I remember to order a CBC on a patient with a GI bleed? How can I be smart enough to manage the care of so many patients when I can forget to bring someone a ginger ale?

Dr. Ofri's editorial has relived my mind (somewhat) in that I won't be the only doctor with these fears.

Fragile Flower Syndrome

My grandmother has what she has denominated 'FFS'. It's a delicate balance to treat her hypertension, hyponatremia and Meniere's disease (for which she takes hydrochlorothiazide, a diuretic) and she'll often call me over to check her blood pressure.

The heat wave has hit her hard but she giggled today when I told her as I wrapped her arm with the cuff that she looked like a wilted daisy with her white hair and dark eyes.

The Fountain

People often ask me at work why I want to go into medicine instead of nursing. I often say in partial jest that I don't like poop. The other, non-jesting half raised it's head last night.

An elderly patient was admitted with a broken hip from a local nursing home yesterday morning. Throughout the day, XRAYs were taken, EKGs performed and Ike* was medically and cardiology cleared for surgery on Monday. It was an arduous exhausting day for the poor, confused man.

As the evening progressed, Ike began to become more confused. Sundowners syndrome is a common phenomenon with some disoriented elderly people. In Ike's case, he became spatially disoriented and lost control of his bowels.

His nurse, Tina and I noticed his incontinence and gathered the supplies needed to clean him up; washcloths and towels, bedclothes, a new gown and Proshield, a skin protectant. We rolled him to his unfractured side and I began the cleaning process.

Afraid that he was going to fall, Ike began howling and let his bowels loose. It was Old Faithful. For several long moments the stool shot up into the air, splattering the sheets, the bed rail and my shoes. I quickly grabbed the clean towel and, in a futile attempt to dike the flow, placed it against his backside.

After the fountain tapered off, I gingerly took the towel away and resumed my wiping. Whoosh, the geyser erupted again spraying the front of my shirt. I snatched the bedpad and all the washcloths and again tried to dampen the flying stool.

This cycled continued for at least 20 minutes, all the while Ike was howling, Tina was trying to reassure him and I was trying to trench the lake of poop. It was awful. Tina was rubbing his back, whispering to him and avoiding my eyes. She snickered a couple of times but for the most part, stalwartly restrained her laughter. I'm sure that I was a sight; covered from shoulder to toes in poop and frantically using anything handy to stop the pool from cascading to the floor.

Later, as I wiped the streak on my cheek away in the staff room shower, I couldn't think of any of my more noble reasons for preferring medicine to nursing.

*all names and details have been changed to protect the identities of anyone who may be totally embarrassed by the occurrences that I described.

Ethics of Eating

There's a patient on the unit, a friendly undemanding young woman. Except for her diabetes and the cellulitis that brought her in, she has no other major medical issues. Which is surprising because she's beddridden due to obesity. She would need to lose over a hundred pounds to reach a BMI of 100. She's too heavy for any of our bariatric lift equipment and, though she rolls well in bed, two of our nursing staff have been hurt cleaning up her incontinence.

In his very first order set, the hospitalist requested Physical Therapy and Occupational Therapy to work with her 3x daily. The amazing strong gentlemen of our PT department were able to bring her to the edge of the bed (not an easy task for anyone on an airbed!) and do some ROM exercises with weights! We were so happy and proud of *Dolores. Then...

She refused. Every time someone would try to help her to the edge of the bed for meals, encourage her to use her little hand weights or ask her to try any form of exercise, she would become angry and uncooperative. She would throw the weights onto the floor and become unresponsive.

*Dolores is not this patient's name. All details have been modified to protect identities of both the patient and the hospital staff.

It's been six weeks since she arrived at the hospital. Her infection has cleared and she's medically well. The nursing home she came from no longer has a bed and other nursing homes/rehab centers won't accept her until she demonstrates some willingness to work on regaining functionality.

Our dietary service limits the concentrated sugars and carbohydrates she's served but her mother keeps her well supplied with candies and soda pop despite our requests that she not.

Every time I work with Dolores, I'm frustrated. As an aide, I have little autonomy in my work with her. I cannot refuse or limit her HS snack without a calorie restriction order. I cannot force her to use her weights or incentive spirometry. I cannot search through her mother's tote to prevent the mars bars or cherry coke from entering the room and Dolores' digestive system.

I've always adhered to Kant's categorical imperative (the second formulation). Shadows come though, as Kierkegaard predicted, because people are freakin' LAZY. Unchecked, people don't behave rationally. Dolores' laziness has become pathological.

Do we have a responsibility as healthcare givers, to set limits and enforce regimens on those who refuse to adhere? It becomes a catch-22 when someone refuses care but is too weak/ill to go home. What do we do when they're refusing care and refusing to leave?

Do we have the right to become enforcers, trumping their free will in these situations?

Floating

I'm glad to be off my unit today. Lately, I've had a hard time tolerating the young and, well, just young, attitudes/behaviors of my co-workers. The nurses are, for the most part, friendly but they can be callous and selfish in a way that only reflects their immaturity.

With more experience, most of them will probably develop into compassionate and wonderful caregivers but for now it's frustrating. With the patients, they can be dismissive of pain and fears, only noticing that the patient is inconveniencing them with 'petty stuff'.

Their own lives oscillate between two points: either everything is wonderful or it's awful. Calling in sick because their best friend's grandma had a heart attack, their parents' cat died or there's a power outage in their neighborhood is routine. In the last month, we've only had two shifts proceed without a call-in.

Today, I'm working on a telemetry floor. The staff is older and the shift is virtually tranquil despite the higher acuity. People are doing their jobs without histrionics or (much) complaining.

I can't help but wonder if the hospitalists realize how the differences in unit culture can impact the patient experiences and subsequently the HCAHPS and Press Ganey scores. Because of the future changes in insurance reimbursement policies, it's something that could really impact their livelihood.

*sigh*

My Narrow Room

In his sonnet, Nuns Fret Not at Their Convent's Narrow Room, Wordsworth describes the paradoxical liberation of having limits. The cells of a nun, though tiny, can still admit God just as the restrictive form of the sonnet can still accommodate the greatest imagination.

Likewise, my life started out at Versailles. I was overwhelmed with the need to open every door and look through every window. I traveled, wrote, acted, explored different careers and places to live. I studied poetry, literature, history, people and science. As I grew up, I gained the freedom to close doors behind me. I meandered through the palace, enjoying beautiful views and then fastening the windows.

I find myself at the end of a long winding corridor, looking into a small room. Of all the choices, careers and life paths, I chose medicine. This narrow chamber shines with light from a beautiful window and is large enough to fit and small enough to focus all the passion, curiosity and adventure I've found in life. I'm coming home to my narrow room and this blog is a chronicle of that journey.