Patients

 

I decided to start this series in honor of the patients I work with. While working on my degree in psychology we talked about the local abandoned mental hospital and all the nameless graves that lie there. All the stones marked with "unknown" or meaningless numbers. All the lives that meant something, but were left with nothing. The Greeks have many words for different types of love and it is true to me that each of the patients I work with I love. Agape - enormous empathy, selfless, unconditional love. For them I write these pieces as a marker of their impact on me. These people mean something, something beyond their mental illness, something much deeper. It is my hope that their stories, while anonymous, will resonate with someone deeply. That through these stories they will have a purpose they themselves may not recognize. 

Patient Zero - patient zero was the first patient I wrote about. He was chronically ill with lung cancer among other diagnoses, including drug-induced schizophrenia. 

Yellow is meant to be the happiest color

It surrounds him -

the notepad,

the stethoscope, 

the isolation gowns,

the color of his sputum.

The nurse's pager beeps and he asks

If his wife is calling

A wife who never existed at all.

He asks me about teaching a blind fish to swim,

points to my eyes like he sees them in there.

He says he is sick of the howling dogs.

On my way home I hit seek on the radio

The coarse static reminds me of his cough

The sound you hear when you are hoping for

a good song to come through clear.

A good song is not coming.

Patient One

I hate meth

It stole the spirit of someone I loved

& as I sit here watching CPS whisper

around the incubator of a four pound baby girl

I can picture her mother upstairs

trembling, 

vomit dribbling down her chin

as the grips of withdrawal hold her - 

they whisper that she should be holding her,

that the baby deserves better

but someones should be holding mom too

Patient Two

It takes an 819mg vial every three months

to keep the roaches at bay

She calls them "the wigs"

And the nurses laugh behind their masks at the concept.

She tells us there are thousands of roaches

each wearing a George Washington wig

And it is easy to laugh without knowing.

The concept itself is amusing.

But they do not know about the George Washington portrait

that loomed above her in her father's office,

watching her

as he touched her in ways that unwired her brain, 

clipping circuitry that is intact in ours.

Or the cockroach infestation her father couldn't afford to fix

that drove her mother away

"the wigs carried her off one day in July and she never came back."

It seems funny 

until it isn't. 

All My Patients

I am a real nurse now and this idea weighs heavily on my conscience. I am responsible for each life that I come into contact with at work, which ranges somewhere between 10-30 lives a day, having opted to work in the emergency room. 

Some I spend only an accumulative ten minutes with. Others hours. For the unlucky overnighters they may see me two days in a row. I bring them warm blankets and water. For those with less functional abilities I wipe them clean and they look at me with shame in their eyes, apologizing for the mess.

I hear some nurses scoff about these patients. Some hide their gags with a cough. Others let them sit in their mess for as long as possible. 

Some days it is these patients I love the most. We call the adult-sized diapers "briefs" in the healthcare community. One patient, who asked me to change his brief, asked why we didn't just call them what they were. I explained that it was to uphold patient dignity. He replied, frankly, that he was "too damned old for dignity." 

I wholeheartedly disagree with him, but I also don't think that the word we use is what provides the dignity. I hum as I work. I think about my grandparents, my parents, my sister. I pretend it is them in that bed. I think of my own mother wiping my fat baby rolls. As I clean him I think of the tender moments his mother shared with him doing the same. Bathing and dressing him day in and day out. 

When I am done he thanks me and I thank him. Thank you for letting me share these vulnerable moments with you. Thank you for trusting me blindly. 

Jaded

Most of the nurses I know are jaded. Many weekend mornings the emergency room fills at the earliest hours with mothers and their children. My friend explains that many of these mothers could easily remedy their little one's cough with over the counter medicines, but if they come here these medicines will be free. Our prescriptions allow insurance to cover them. Another nurse calls these mothers and their children a "waste of resources" and my stomach churns at this phrase. I hear it every day. Productivity, efficiency, resources, cost of supply. The minimizing of human lives to a business transaction. The disgusting dehumanization of impoverished families and the lengths they must go to survive the day. I wonder if my coworkers think that these mothers want to hear their child scream when we hook them to our monitors. I wonder if they can hear the trauma the child endures echoing in our stethoscopes as their tiny beating hearts accelerate with fear. Our system traumatizes not only the child, but the parent. The exorbitant bills they expect to receive after their visit and the subsequent filing of endless paperwork to bring that bill down looms over them. Yet they rely on us and here are my coworkers, many of whom I consider friends, shaming their parenting. Shaming a narrative they could never understand through the layers of privilege that separate us from them. I wonder if they've considered that the "weekend morning" phenomenon" exists because these mothers have been working double shifts all week to have these days off with their child.

Unfortunately, I am a product of the system. I work for, and can understand, both sides. A minimally ill child in a room takes away from a maximally ill patient in the waiting room. I understand the desire to educate patients on urgent care needs versus emergent care needs. More than that though, I understand the broken system I have contracted into. 

Today, a little boy in light-up Spiderman shoes stomps his feet in a panic when I enter the room. To this child I am terrifying. I will make him drink disgusting concoctions, poke him with big, scary needles, and behind my mask I might have fangs or fur a gaping black pit of doom. 

For twenty years the Gallup Honesty & Ethics Poll has voted nursing as the most trusting profession. I find irony in this as the healthcare system continuously fails the lower socioeconomic class, people of color, immigrants, and the LGBTQ+ community. The inequity statistics are overwhelming and largely sequestered as the Gallup poll is conducted by cell phone. What about those who have no cell phones? The irony of only 20% of the population in 2019 having high trust in the ethics of state governors and 12% in members of congress is laughable, for they are the individuals who regulate our healthcare laws.

I do not blame this child for not trusting me. I haven't done anything to earn it. Before putting on his oxygen probe, I put one on his mom. I show him that his is a sticker with balloons and this soothes his feverish body from a wail to a whine. He has been throwing up for three days. His mom tells me he was sent home from daycare yesterday and that in the past month several other children have been sent home too. She tells me she had to call into work yesterday and that she needs a note for work. It annoys me that she has to waste energy to prove her whereabouts to a boss that probably preaches about productivity as much as mine. She asked me if we have any snacks - she didn't have time to make her son breakfast. 

I've heard other nurses tell patients we don't have any snacks. I've heard some say that patients see us as a free meal. I say that if I was taking a trip to the emergency room where my bill is expected to be upwards of $500 and I'm feeling like absolute hot garbage, I'd want some snacks too. I wouldn't ask for them out of sheer embarrassment of bothering my nurse, but I also have a house full of snacks to go home to. Maybe this family does too. Maybe they don't. Either way, the idea that these requests are an act of "entitlement" irks me to my core. Good for them for being brave enough to ask for what they want. Or maybe this is an act of survival.

We live in a system that is designed to force poor families to beg for what they need (check out the laundry list of paperwork needed to prove your eligibility for WIC programs, subsidized housing, etc.) and then shame them when they use the programs we offer. My father recently sent me a copy of "Maid" by Stephanie Land which outlines these processes and the ass-backwards way our society gives and takes and perpetuates the cycle of poverty to keep the lower class stagnant. You make a little more money, they take away your supplement, you end up right back where you were. 

So to all the mothers and fathers who ask me for snacks for their children: Thank you for wanting to feed your child. I have graham crackers, saltines, Cheezits, shortbread cookies, three types of juice, and maybe even a sandwich. If the hot meal cart rolls through, I'm grabbing you one of those too. GoodRx is your best friend and there is an app for that. If you don't have a phone, there are little cards you can use at most pharmacies. Ask us about generic medication options. You can ask us for estimated costs, we have a cheat sheet for that somewhere. If we bill you for more, you can challenge it. Always call about your bill, it can be reduced. Ask about our financial assistance policy. 

And to that patient in particular, thank you for trusting me. Your shoes were cool. 

---

Toe Tags

The first time I prepared a body for the morgue, as we were taking off the cardiac monitoring stickers that had tracked the rhythm of his heart until the very last beat, my boyfriend texted me to ask what I wanted for dinner. I tell this story often, shocked at the fact that I still had an appetite at all. Shocked that I could think about a cabeza huarache while I prepared a now lifeless body for transport.

 I had been in the room when the monitor showed asystole and I had been awed by the fact that the line wasn't truly flat at all. I had watched the LUCAS compression system keep his heart pumping until his family saw the true nature of what it was taking to keep their beloved father and husband alive and ordered us to stop. When he arrived his teeth had been knocked loose from EMS intubation and his body was already cool to the touch. For over an hour we pushed medications, shocked, checked pulses. Even with the relentless beeping of our machines, no room is quieter than a room waiting for dual confirmation of pulselessness. Two times I thought I felt a pulse but it was my own blood pumping with adrenalin from the code.

As a gift, my college professor gave all of his health systems majors a copy of Atul Gawande's "Being Mortal," a gift I have cherished endlessly. This excerpt in particular helped to shape my practice as a nurse:

"Consider the fact that we care deeply about what happens to the world after we die. If self-interests were the primary source of meaning in life, then it wouldn’t matter to people if an hour after their death everyone they know were to be wiped from the face of the earth. Yet, it matters greatly to most people...In the end, people don’t view their life as merely the average of all of its moments, which after all is mostly nothing much, plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments; the ones where something happens. Measurements of people’s minute by minute levels of pleasure and pain miss this fundamental aspect of human existence."

As someone who has struggled with severe anxieties related to death and identity, I expected that my first hands-on experience with death would have a radical impact on me. I was shocked to find that it did not. What did have an impact on me happened after exiting the room where I had just put tags on a the toes of a body, tags that were the only remnants of this individuals identity as far as knew him, and faced the inexplicable grief of the family who had just watched us use brutal technological force to sustain a rhythm of life that could not possibly equal the depth of life of the individual they had known and loved. A son named for his father. A wife who had expected her husband to come home in an hour. A brother with identical freckles across his nose. A family standing at the nurse's station with no idea what to do next. Do they go home to the house where just this morning he'd dressed and walked out the door? Who designed the protocol for what to do when the world you know falls from beneath you? 

I wished, at first, that I had been more shaken by this experience. I felt heartless that my only concern was those left behind and not the body on the table.

 I had a few other experiences with death both personal and clinical. While doing rotation on the oncology unit I had established a relationship with a patient with end stage cancer. The words "Do Not Resuscitate" glared at me from her records. I brought her and her husband hot water for tea he had brought from home and we would talk about the books she was reading or I'd listen to her tease her husband as they played cards on the rolling table positioned between him in a chair and her in her hospital bed. When she died there was not a crowd of physicians and nurses in the room. Her husband's grief transpired in screams at the nurses for more pain medication. She'd had her last dose of morphine just a half hour earlier. It was quiet and the tears from her loved ones were silent. I walked past the room with my head down, afraid to see the empty shell that she left behind. 

I rode the elevator to leave the hospital that day with her best friend. 

"For ten years she fought this thing. Ten years and you would have never known she was sick at all. She was always scared of horses in this world, but she loved them. She always said she wanted to ride one. I bet that's what she's doing up there right now." I felt embarrassed that this woman who had known her all her life was smiling and I was standing there with tears streaming down my face.

"I feel lucky to have taken care of her."

I ran to my car and called my boyfriend crying. 

My father used to send me photos of dead people. Vintage black and whites bought at an antique store and repurposed as postcards where he'd write tidbits of advice and reminders like "P.S. I'm proud of you." The body on the table is meant to decay. Our bodies are designed to return to the soil that once sustained us. From there, we are repurposed, just like those photographs. It is the story coming to a close that causes pain. A riveting adventure's last sentence. A beloved character's final words. The Pulitzer book being closed for good. Yet the closing of the book doesn't take away the value of the contents. They'll continue to quote your story and relish in the memory of what a good book it was. 

I just only got to read the last chapter. My attachment to the story was fleeting. But I feel lucky to have read any of it all. 

Ram Dass described my feelings towards treating the dying and dead best. 

"Working with the dying is like being a midwife for this great rite of passage of death. Just as a midwife helps a being taking their first breath, you help a being take their last breath." 

I am so honored to walk your family home. 

RaDonda Vaught

A week ago my father sent me a link to an article about the RaDonda Vaught trial. The words "Could I be next" stare at me from my phone screen. As I scroll through the article I find myself critiquing Vaught's missteps and thinking that it couldn't be me. I would be more careful. I scan in my medications and double check my dosages. The six rights were drilled into my brain day in and day out in nursing school.

Right patient, right medication, verify indication, right dose, right time, right route. 

Two days later emergency medical services wheeled in an acute respiratory failure Jane Doe in need of emergent intubation. Before they even arrived I had overridden our medication system to retrieve an RSI (rapid sequence intubation). Just weeks before these kits had come in what looked like a medication tackle box, organized enough to get the job done. Now, these kits come in a bag more akin to a Ziploc. The unspoken consensus is that this was a cost saving measure by administration. 

Within this Ziploc bag is a collection of small glass bottles, mostly identical, aside from the names on the labels. Fentanyl, propofol, etomidate, ketamine, midazolam, vecuronium, rocuronium. High-risk drugs that paralyze and sedate jumbled together. All the bottles are dumped onto a surgical tray and we play "Where's Waldo" to find the appropriate medication as the doctor yells orders and dosages. Eight of us in the same room performing different tasks. One person starts an IV, another hooks the nameless patient to our monitors, respiratory therapy bags the patient, myself and another nurse pull up medications and repeat dosages back to the doctor for confirmation. 

The doctor calls out for Versed. The same medication RaDonda had meant to retrieve when she made the fatal mistake of administering vecuronium instead. What a layperson wouldn't know is that when a doctor asks for Versed they are actually asking for the medication from the bottle labelled with the generic name, "Midazolam." On our table, midazolam and vecuronium lay beside each other in the jumble.

My coworker under her breath says, "I can't find the fucking Versed." 

Having just read the Vaught article two days before I grab the midazolam and hand it to her.

She is successfully intubated and stabilized. Within the hour she will be transferred to the ICU and they will start an Ativan (lorazepam) drip to ensure she doesn't tear the tube out of her throat. For now she is drowsy, head lulling side to side from oxygen deprivation and medications. 

I know that in reality, I could be next.

I use the safeguards - scanning medications, using medication system removal appropriately, running through the six rights - until those safeguards are not possible. In situations like these there is no time for the doctor to walk back to his office and put in medication orders. I cannot scan a patient who is, thus far, nameless.

I was taught in my first week of clinical orientation that self-reporting medical errors is key to preventing future errors. Self-reporting is a tool for performing root cause analyses for preventing future, preventable errors. Approximately 41% of Americans have been involved in a medical error (Institute of Healthcare Improvement/NORC at the University of Chicago, 2017). The likelihood of medication errors is increased in new graduate nurses. Will we still feel safe reporting our errors?

Just weeks earlier a medication had been sent to me from our pharmacy - medications that have to be specially mixed or dosed are tubed to us from downstairs. I scanned the patient and the pharmacy label before administration and an error notification popped up on the screen. I peeled back the pharmacy label and found that the medication was not what it had been labelled as at all. Had I ignored the warning, I would have contributed to the 41%. 

A 2012 study found that about 40 wrong-site surgeries occur weekly (Cobb, 2012). In blog comments, nurses state that in these cases the surgeon often takes no punishment and the blame falls instead on the OR nurse. The individuals who have no malpractice insurance protecting them. Another nurse describes how she was attacked by a patient on the job and administration immediately launched an investigation into her employment, knowing she could easily sue for the event. Comments on a viral post about the RaDonda Vaught case reveal a mass dropout of nursing students, fearful of entering the field. Meme pages about hating being in the nursing profession rake in thousands of followers (see @fucknursing for some good ones). The Joint Commission rages if they see water bottles at the nursing station (how dare you drink water on a 12 hour shift?) Instead of implementing safe staffing laws, government bodies are working on laws to cap nursing wages.

My dad pointed out in a phone conversation that nursing may be the only profession where a case like this could exist. "As a chef it isn't like you've got all your spices lined up and you have flour, sugar, and cyanide." Given, bakers don't often have a life at stake, but the sentiment is still the same. Truck drivers aren't allowed to drive more than 10 hours at a time for safety purposes. Some of us work more than 12. 

I am acutely aware that the cost-saving mechanisms and lack of staffing contribute to medication errors. Medication errors are most often systemic issues and the idea has previously been that they should not be punished unless found to be intentional or reckless. RaDonda reported her mistake immediately. Her remorse is clear. RaDonda Vaught is not entirely culpable. 

A legal nursing consultant who does not have experience using modern medication dispensing systems testified against RaDonda in trial. Why? Because a practicing nurse would never have testified against her.

I still love my job. I have a deep love for every patient that I care for. I do not love the system I work for.

I urge you to sign the petition below to grant Vaught clemency 

https://www.change.org/p/grant-radonda-vaught-clemency?source_location=discover_feed

AND/OR

Write a letter to Tennessee governor Bill Lee

Bill Lee, Tennessee Governor, State Capitol, 1st Floor,

600 Dr. Martin Luther King Jr. Blvd. Nashville, TN 37243

"Don't let the verdict change why you do what you do and the character of the person that each and every one of you are." -RaDonda Vaught