Every now and then I run across an old post that I'd completely forgotten about. And so. That inspired me to occasionally re-share a throwback post with you.
Funny I should run across this one today. I recently saw one of the nurses giving a doctor the thirty-second stare every time he said something. Which doesn't guarantee but could possibly mean that, well, the nurses hate him.
Just maybe.
Kind of made me reminisce about one of the most EPIC-ly failed commentaries I've ever heard an intern say to a nurse. It happened circa 1996 on a med/surg ward in Cleveland, Ohio after my friend (who shall remain nameless) punctuated his request to a surly senior RN with the following statement:
"That's an order -- not a suggestion."
Oooph.
This is really me as an intern in 1996 overhearing that.
Man. They hated his ass after that. Talk about a long few years. His final residency stats with the nurses:
Number of phone calls he got in the middle of night: Seven hundred and sixty two trillion
Number of times it was emergent: Two
Number of stool softener and tylenol orders that mysteriously fell off of medical admin record in the middle of the night or busy call: Nine hundred and seventy seven kabillion
Number of IVs that curiously fell out at three a.m.: four hundred fifty four gazillion
Number of attempts made by senior nurses when they heard it would help him: Zero
Number of eyerolls per hour when near any nurse on the unit: Too numerous to count
Number of cups of coffee and extremely cold Diet Cokes thrown away for being left at the nurses station: five point seven trizillion
Average number of seconds before said coffee or extremely cold Diet Coke was pitched in the trash "you know for OSHA reasons and Joint Commission rules" after being sat down on the nurses station: one point two nanoseconds.
Number of bagels, cookies, perfumed lotions, sticks of chewing gum or pieces of pizza offered in the rest of his entire residency: Negative four.
He should have read this. But then again by the time a person sees these signs it's probably too late to be saved.
************ February 10, 2011
Top ten ways to know that the nurses hate you (especially ICU, ER and inpatient nurses):
They scowl and answer every single one of your questions with, "Wh-aat?"
Way #9
They
don't save you when you're getting ready to majorly screw up in front
of the attending (unless of course it involves a patient's safety.)
Otherwise, you're on your own. Oh yeah, and if they really hate you,
they ask a question on rounds in front of the attending that they know
100% for sure that you don't have the foggiest notion how to answer.
(Note: Usually involves dropped balls or screw ups on your part.)
Way #8
They page you every hour on the hour between the hours of midnight at six A.M.
Way #7
They don't offer you any of their food. (The nurses always have the best food--especially ICU nurses!)
Way #6
They approach the attending or the fellow with all of their questions or suggestions instead of talking to you.
Way #5
They approach the medical student with all of their questions and suggestions instead of talking to you.
Way #4
They start off all conversations with you by saying the words, "Look, I'm not sure if you realize it, but. . . "
Way #3
The nurses lounge gets quiet every time you enter.
Way #2
The nurse stands there staring at your for thirty seconds after everything you say, kind of like you're stupid.
and . . .drum roll please. . . . the #1 way to know for sure that the nurses hate you. . . . . .
They tell you.
***
Pearl of wisdom from a doctor who has usually made good with the nurses:
Love thy nurses. Why? Because NURSE = butt-saver,
hands-on-deck, extra-brain, person-who-remembers-next-step-in-a-code,
shoulder-to-cry-on, cheerer-upper, differential-diagnosis-suggester,
back-into-reality-smacker, team-mate-extraordinaire,
knower-of-fine-details, wind-beneath-tired-wing, wingman-or-wingwoman,
explainer-of-drips-that-you-are-clueless-about, teacher, and best of
all, friend.
So here's to all the nurses. .
. . . .and to those of us who work with them. May they always share
their food with you and never hate your guts!
***
Happy Monday. Feel free to anonymously share this with someone who hasn't gotten the memo that we need our nurses to survive.
I told her she wins "best hairstyle of the entire week." That made her laugh out loud in between passing meds and caring for her patients. I also told her that she probably brightens up her patients' days when they see that she will be their nurse. Thinking that the same love and meticulousness that went into that perfectly round afro will go into them, too.
And you know what? It does. I've worked with her and know for sure that it does.
Now this? This, too, is Grady.
***
Happy Sunday.
Now playing on my mental iPod. . . .with love for the nurses who put love into everything they do.
When I was a brand-spanking-new intern, I remember taking a call that was so scary that it nearly caused me PTSD. This fearless senior resident was supervising me and thank God she was because the way people were coding all over the place felt exactly like stepping on landmines. My senior resident was the "Black Hawk Down"/Army Ranger of residents; she had already secured a spot in a Pulmonary/Critical Care fellowship, and was virtually like a mini-ICU attending. To that, all I can say is hallelujah.
Hallelujah, because the ICU scared me. Every single page that came through was about something really, really serious. No "can you write for a stool softener, please?" or "can I get a verbal for some pain medicine?" calls. Nope. Every beep was for the hell that was breaking loose in some part of the unit--and let me tell you--hell was sho' nuff breaking all the way loose. I am so glad that I was being covered by someone who knew what the hell to do.
As I already mentioned. . . .since this was the intensive care unit, for the most part, all calls were "real calls." ICU nurses are, by definition, "bad ass" and generally don't go bothering folks with simple things (unless of course they hate you.) These nurses were not only knowledgeable, but excellent teachers for new interns. So, despite my panic, between the unit nurses and my hard core resident, I had great support.
Hell kept breaking loose for most of the night and eventually slowed down some. The unit was full, and my resident told me that this "was a good thing because now we couldn't get anyone new." I decided to believe her, relaxing my new-kid-in-school expression and even laughing at a few jokes.
I guess I got a little too relaxed.
All that easygoing laughter must have made me look more confident than I was. That's the only explanation for what could have possibly given my mini-ICU attending/senior the unwarranted faith in me to nonchalantly shrug her shoulders and say to me, "I'm gonna go and get me a few winks since I have clinic tomorrow. I'll be back in two hours and then you can go get a couple of hours before rounds. You hold down the fort, okay?"
Say whaaaat?
Dude. It was 2 a.m.! That meant I had at least five hours of potential hell-breaking-loose-ness remaining!
Awww hell naww!
This resident was responsible and hard working, and I know that she would have NEVER left me if she didn't think I'd be able to manage things. But the thing is, I didn't agree with her. I was NOT ready for prime time. And being alone in the ICU at 2 a.m. was sho' nuff prime time. I offered her a sick smile but tried my hardest to look easy-breezy. Behind the cool expression was somebody screaming and waving her hands like a wild woman, "MAMA! DON'T LEAVE ME MAMA! I DON'T KNOW NOTHIN' 'BOUT BIRTHIN' NO BABIES!!" (Well, not exactly that but you get the picture.) She didn't catch on. "Call if you need me, okay?"And before I could say a single word, she had disappeared through the automatic doors. Just like that.
(This is really a picture of me circa 1996.)
Lawd. Lawd. Lawd.
I remember standing in one place, kind of like some city dweller plopped in the middle of the Amazonian rain forest at night. That, or that terrified kid who video taped himself in that creepy Blair Witch Project movie. I was scared to move, speak, or breathe. All I did was pray in my head, "Please let nothing happen, please let nothing happen." I felt my stomach rumbling and my pulse quickening. I repeated my pleading prayer. "Lord, please let nothing happen. Please let me not hurt anybody. Please let nothing happen."
(This is really an ICU intern.)
And for like ten minutes, nothing happened.
I sat in the nearest chair gripping my sign out cards. I jumped every time I heard a beep or an alarm on one of the vents. For a little while, I even held my breath. And eventually decided to put my head down on the nurses' station. Exactly one second after I laid my head down my pager went off. Before I could even dial the number, I overheard Ida, one of the ICU nurses, yelling for me to come.
"Doc! Doc! Are any of you guys still over there?"
The urgency in her voice made me feel sick. I knew this was going to be something and not nothing. I wanted so bad for it to be nothing. So bad.
I scuttled over to Ida and, in my most confident voice, asked what was going on. To answer me, she handed me a strip of paper with an EKG tracing on it. Intermittent runs of ventricular tachycardia---the kind of heart rhythm that precedes a cardiac arrest. I sifted through my brain for a logical approach to what was surely about to be a problem.
Mr. Jones was the 71 year old patient in question, and had just turned the corner after a near-death experience with multilobar pneumonia. He'd been intubated for nearly a week, and had just been extubated earlier that day. According to my sign out notes, he was now in a step down bed and was "doing just fine with nothing to do." Nobody said anything about V. Tach.
Damn.
My brand-spanking-new intern brain wasn't on auto pilot yet. I took a deep breath and thought for a second. Electrolyte abnormalities? Was his potassium high or his calcium low or his magnesium low? Was he hypoxic? Were his medications some how screwed up?
Ida must have read my mind. She'd been an ICU nurse for waaaay longer than I'd been an anything so before I could say a word, she rattled off answers my short list of thoughts.
"Lytes are all normal--potassium is 4.1, calcium and mag are stone cold normal. Tolerating the 40% ventimask just fine and oxygenating at 95%. Renal function is also fine." I swallowed hard as I listened to all of that. Shit! Now what? Ida went on. "We were going to transfer him to the floor earlier today, but the attending decided to just watch him overnight to be safe since he'd had such a tenuous course. That was a pretty nasty pneumonia he had, you know?"
I nodded while staring at Mr. Jones. He didn't look good. His face had a grayish cast over it and his brow was covered with sweat. The whites of his eyes looked unusually white, enhancing what I am sure was an expression of fear. A sinking feeling rooted in my stomach and suddenly I recognized something that my senior had been trying to teach me for the past few weeks--the sense of impending doom.
Impending doom. That gut feeling that tells you that things are not right. It's how you know who is sick and who is sick-sick. This man was sick-sick.
"Mr. Jones? Sir, are you okay?" I asked. Which was a dumb thing to ask because he obviously wasn't okay at all.
His response was a widening of his eyes and an anxious pant. I looked at Ida.
"Come on, buddy. We're okay." She tried to prop him up with some pillows and readjusted the pulse oximeter on his finger. She pushed a button to recycle his blood pressure. "Doc, I sent off some cardiac enzymes and checked a twelve lead EKG on him already. Other than a few premature beats it looked okay."
The cuff slowly deflated and eventually displayed an error sign across the LED screen. Ida grabbed a manual blood pressure cuff before I could register what that meant and began attempting to check his blood pressure. All of a sudden, she pulled her stethoscope out of her ears and growled, "Dammit! We don't have a pulse!"
Famous last words. We. Don't. Have. A. Pulse.
No. WE don't have a pulse. Nor do we have a spine. I am 100% sure that, had I had time to eat dinner that evening, I would have evacuated my bowels right then and there. This wasn't supposed to happen. I wasn't supposed to be the one leading a code on Mr. Jones. He was supposed to wait until my resident was awake to have his v. tach and his no pulse.
"We need some help in here!" Ida bellowed to her fellow nurses. They quickly ran to her side.
Things started moving fast all around me. Ida quickly let down the head of his bed so that his feet were elevated. This position, called the Trendelenburg, assured blood flow to the brain when patients became hypotensive. Before I knew it, the room was filled with ICU nurses, industriously positioning themselves to save Mr. Jones' life.
good ol' Trendelenburg.
But the problem was, there were no other doctors.
Crap. Crap. Crap.
See, here's the thing. The ICU nurses already knew what to do. They had paddles nearby and were assessing his cardiac rhythm. They were doing chest compressions. They were drawing up meds and handing me gloves. The respiratory therapist pushed a mask over the now somnolent patient's face and began bagging in oxygen. And me? I just stood there with my gloves on. Paralyzed with fear. Terrified to say or do the wrong thing.
Ida saw the terror in my eyes and whispered in my ear, "Come on, baby. You can do this. We got you, baby. Just think it through. We got you."
And you know what? They did have me. They really did. I carefully walked through the stepwise interventions in the Advanced Cardiac Life Support protocols as experienced nurses helped me through it. They gave me gentle suggestions and firm "uh uh, baby's" when things weren't going in the right direction. It was like walking a tight rope with pillows all around you.
Finally, we regained a rhythm for Mr. Jones and they Anesthesia team reintubated him. Shortly after, my resident came in and helped with the rest of his stabilization. We confirmed his ventilator settings with the respiratory therapists and reviewed the stat lab results that had just come back. After a few more tweaks, he had turned the corner. "Strong work, Kim!" my resident said while suturing down an arterial line in Mr. Jones' wrist. "You saved Mr. Jones' life."
I saved Mr. Jones' life? Uuuhh, I don't think so.
I glanced over at Ida who was now across the room giving report to the nurse on the next shift. She smiled and gave me a thumbs up. I tried to profusely thank her before she left that morning, but she disappeared before I could.
And so.
Mr. Jones' lived. The sun came up a few hours later. I gathered information on my patients for that upcoming morning. And rounds happened at 7 am.
That morning on rounds, my resident told our attending, "Kim saved Mr. Jones' life last night!"
To which I admitted, "The nurses were amazing. Especially Ida."
Because they were amazing. And, no, I can't exactly say that I saved Mr. Jones' life that night. We did. Together. . . .
Yeah.
As I remember it, that night an R.N. saved my life.
***
Shout out to all the nurses who save patients--and doctors--every single day. 'Preciate you.
Now playing on my mental iPod. . . . .(insert "RN" for "DJ"). . .
Aww, HELLS no! Did that 4-day-old intern just roll her eyes at me?
Ten Ways to Make the Nurses Hate (or at least Really Not Like) You:
1. Write all of your orders one at a time and twenty minutes apart. All. Day. Long.
2. Get an attitude and say some kind of condescending remark under your breath. (They can hear everything.) If that's not sufficient, roll your eyes behind their back. (They can see everything.)
3. Act like you are the only one who knows anything about the patient and his or her problem. Oh yeah. And refuse to listen to them or factor their opinion into anything whatsoever.
4. Sit in the Nurses' Lounge writing your notes when they are trying to give report or write new orders at change of shift.
5. Forget the fact that the nurse has been nursing since before you were born. Have the nerve to say something insulting like, "I'm not sure if you realize this, but in heart failure, we have to watch the salt and fluid intake."
6. Bark out orders like a drill sergeant. The say something crazy like what my dear friend, R.C., said to a nurse during our internship: "That's an order, not a suggestion!" (Not good.)
7. Work with the same nurses every day and refuse to learn their names. But expect them to know yours. Oh. And eat the snacks provided by the same nameless nurses every day.
8. Blame an adverse outcome on them when it was your fault. Or worse, get your ass saved by a nurse and take the credit for it on rounds. In front of the nurses.
9. Call in verbal orders when a patient is sick and needs your personal attention.
10. Start a medication that induces diarrhea two hours before change of shift. And then don't answer your pages.
When I was an intern doing my very first rotation on the Internal Medicine inpatient wards, I remember hearing my senior resident say to me with her thick Latin accent and a mouthful of bologna sandwich:
"Keem, if you don't learn naathing else this year, you need to learn one thing and one thing only. Seeck versus not-seeck. Period. It doesn't matter how smart you are or how many facts you can regurgitate. It's all crap if you don't know a seeck patient when you see one. Sometimes the smartest thing a doctor can know is when they need to run like-the-hell and get some help."
"But we're in the hospital," I replied, "Isn't everyone technically sick?"
"Oh no! Definitely no. A lot of the patients in the hospital are not seeck at all. I mean they are seeck, yes. But most are not seeck-seeck. So now as-I-think-of-it, Keem,"she added with her musical voice, "What you really need to know is seeckversus seeck-seeck." Oh Lord. Seeck-seeck? Nobody told me about that in med school.
"How do you learn it?" I really wanted to know. "I mean, is there something you suggest I read? Like maybe in the Washington Manual?" (In pre-internet-savvy 1996, that was the Internal Medicine intern's bible.)
She threw her head back and laughed. More of a cackle than a laugh. For a few minutes I thought she was mocking me. . . .but then she stopped abruptly. "Read?" She raised one eyebrow. "Oh no, Keem. You don't readnaathing to know this. You leesten. You watch."
Okay. I think I was catching on here. This was one of those "Art of Medicine" moments. I was always intrigued with these sorts of teachable moments. "The senior doctors? I should listen to and watch the senior doctors, you're saying?"
"Keem," she spoke carefully with an icy glare (yes, I still remember and am amused by how she pronounced my name),"Keem, you listen to and watch the patient. And then . . .you always, always listen to and watch the nurses. Always, Keem."
Ummm. Okay. I'd heard countless times even before finishing medical school of the importance of remaining in "good graces" with the nurses. Be nice to the nurses, some resident would tell us as students, They can make your life pretty miserable or pretty wonderful. But the advice was always to befriend them, be collegial with them, and depending upon your personality and level on the totem pole, even brown nose them. But listen to and watch them just for the sake of learning how not to be an assassin? This sounded like a new spin.
"I've heard that you should always get in good with the nurses."
"No, Keem. Not that. I'm talking about real patient care. Leesten and watch. The nurses always know who is seeck-seeck first. They always do. Sure, don't piss them off. But leesten. Watch. Especially the really good ones. They always know first."
"Even before the patient they know?"
My resident folded her hands behind her head and rocked on the chair's two hind legs while balancing with her crossed feet on the conference room table. For a split second I feared she'd fall back and need stitches on her head, but she looked so relaxed that I turned my focus back to our conversation. "Even before the patient gives you the clue?" I reemphasized.
She continued her treacherous rocking. "Oh. . . well that depends."
I wasn't sure what she meant. "Depends on what?"
Suddenly, she slammed the chair forward and back down on all four legs. With both hands, she gathered her long, dark hair into a tight chignon and secured it with a pencil sitting on the table. With a knowing smile she said, "It depends on how much experience you have and how much you know. With time you understand more of the subtleties of patients. But long before that and long after you have the nurses--don't forget that." Aaaah. The nurses. Claro que si.
***
Turns out that this sage moment with my resident included some of the best advice I've ever gotten in medicine. . . . .
. . . so today, I'm reflecting on the hospital nurses. . . . . and all of the times they've both figuratively (and literally) thumped me on my head to alert me that a patient was indeed not just sick but sick-sick. I'm reflecting on the one who told me early in the morning before rounds that my patient had refused a lab-draw but not because he was ornery like all the other days he refused but because he was "out-of-sorts". And I'm remembering how "out-of-sorts" ended up being the first sign of septic shock (also known as "seeck-seeck")-- and ended up leading to an early intervention that ultimately saved a man's life.
Now, I'm more experienced. That conversation was over a decade ago, so, yes, I do pick up more on hints from patients that would have previously flown over my intern head. I'll take pause on things like, for example, when this nineteen year old girl with a sickle cell anemia pain crisis in her leg asked me for a bed pan one day. A nineteen year old wants a bed pan? That's weird, I remember thinking. Weird was right. It ended up being severe osteomyelitis (a bone infection) instead. And less than twelve hours after she asked for that bed pan, we confirmed it as such--all because of a simple request that just didn't sound right.
But how does one get there? I'm sure time, experience and a few key physicians help. But, in my experience, Lord knows the nurses played a key role. Like Priscilla, the nurse who used to pound her fist on the wall that stood between my call room and the PICU when someone coded because it was faster than paging me. As tough as she was, I learned quickly that I'd get much further working for her respect than of her fondness. It was with Priscilla that I learned, while chatting with her over tepid coffee as she charted her patients, countless things about really sick (and really not sick) patients that could not be found in books. Like when she taught me that people who say they are really worried about "something being wrong" are often right--even when the tests say otherwise. Or like when she showed me goof-proof ways to start and secure IV lines and when she taught me pearls like drawing blood too close to the IV line can screw up all your lab values or not checking the equipment (like unplugged O2) can make you worry for no reason. Sick versus sick-sick. Experience? Uhh, maybe. Nurses? Sho' nuff.
It's funny. Now that I think about that young woman with sickle cell anemia, I am reminded of what her nurse, Mrs. Nix, said that day after we'd gotten her down to the MRI scanner for her leg imaging:
"Dr. Manning, as soon as I saw that baby, I just knew something wasn't right. Nope. I was thinking during intake, This ain't just a pain crisis. Mmm mmm, no. That baby just wasn't right."
But of course. The nurses always know first. :)
***
"Art of Medicine" Teachable Moment for New Interns and Medical Students:
Sick vs. sick-sick? That's easy. Follow these simple steps:
1. Listen to and watch the patients. (Duh.)
2. Get some experience. (Double duh.)
3. Get enough experience to know well enough to never, ever overlook the warriors on the frontline--the nurses. (They'll save you and the patients from stepping on a land mine.)
4. The good news is that when you listen to the nurses, they'll generally like you -- no brown-nosing required.
****
With respect, gratitude and admiration for all of my favorite nurses and all they've taught me . . . . .and for being there long before and long after I had a clue. . .
(I started to list your names, but realized it would be too many to list)~
Thanks for being the wind beneath our wings
(and the thumps upon our foreheads.)
Claro que si!
Wisdom from "Mother" Nix -- one of the best nurses I know. . . .
Honestly? I write this blog to share the human aspects of medicine + teaching + work/life balance with others and myself -- and to honor the public hospital and her patients--but never at the expense of patient privacy or dignity.
Thanks for stopping by! :)
"One writes out of one thing only--one's own experience. Everything depends of how relentlessly one forces from this experience the last drop, sweet or bitter, it can possibly give."
~ James Baldwin (1924 - 1987)
"Do it for the story." ~ Antoinette Nguyen, MD, MPH
Details, names, time frames, etc. are always changed to protect anonymity. This may or may not be an amalgamation of true,quasi-true, or completely fictional events. But the lessons? They are always real and never, ever fictional. Got that?
