One of my colleagues recently died.

When I started at my current hospital, she was my main preceptor.  She was a stickler for getting things done correctly – no shortcuts.  When I would come across a patient or apparatus that I was unfamiliar with, all I wanted was for her to tell me what to do or show me how to operate it, but every time she insisted on having me look it up.

I came to appreciate the wisdom in that.

We worked together for several years.  She eventually went to a different department, I started working per diem, and we didn’t see each other much anymore.  But we’d run into each other here and there over the years.

She was very kind.  She wasn’t the type that was into gossip, but she did always want to know what was going on with you.

I saw her about a week before she died.  Everyone knew her time was short, including her.  Yet when you walked into the room, her face would light up and you’d get the impression that she was thinking, “Ah, just the person I was hoping to see.”  She handled the whole thing so much more gracefully than the rest of us.

I was thinking last night about how she simply isn’t in the world anymore.  And how weird that is.  I feel like we are all connected by invisible strings to the people we know, and when one string is cut, even the thinnest one, it throws you off balance.

I’m feeling a bit off-kilter for sure.

How’d we get to Volume 8 already?!  I think hosting this Grand Rounds finally ties me up with GruntDoc, who has hosted 7 times.  Grand Rounds is the weekly round-up of blog posts by medical bloggers.

Whereas in the past the host would post nearly every link they received, it appears that we are now moving towards more curated content.  I said in my previous post that I wasn’t going to institute a theme, but I was definitely more drawn to the personal-story type posts.  Thanks to everyone that submitted!

Ever been put in an awkward position?  How about if it was a position that you created yourself?  Bongi, who blogs at other things amanzi, describes a situation he found put himself in that he calls “buff and turf” – and it didn’t turn out very well for him.  He leaves it to our imagination to come up with what the other surgeon’s response was.

Working with children is hard.  Well, I think it’s hard.  I can relate to my own kids just fine, but finding common ground with a child you’ve just met and have only minutes to spend with is what I consider a unique talent.  The medical student that blogs at d.o.ctor used a classic technique to try to bond with her small scared patient.  Did it work?  Read on to find out.

What would you think if your nurse told you, “Buck up.  You’re going to feel terrible for a year?”  Would you believe it?  Jessie Gruman describes her insights as she worked her way through an entire year of feeling very “sick-ishly.“  I can tell you I found insight #3 somewhat surprising.  It’s something I simply wouldn’t have considered.

I shamelessly grabbed this next post from Twitter – Jordan, who blogs at In My Humble Opinion, wrote a touching post about mothers.  In Praise of Mothers wasn’t quite the post that I was expecting (and apparently the first commenter wasn’t expecting it either); it was even better.   And I’ve tried several times here to explain why, but I can’t.

And I shamelessly grabbed this one from Google Reader – Dr. V at 33 Charts shares his answer to the question, “How Often Should A Physician Blog?“  You could easily take the word “physician” out and apply the answer to any blogger.  I have been blogging for over 9 years now.  My posting frequency in the very beginning was about once a week.   Now it’s more like once a month.  He has some great insights that I found myself completely agreeing with.

What happens when you check up on a patient only to find that you’re the “last to know?”  In Duly Notified, Dr. Wes encounters an unsettling bit of difficulty when he opens the electronic chart of a long-time patient.

The next submission is an interesting read.  When someone suggests that you “build a coping system,” does your brain sort of shut off a little?   Yeah, yeah, coping.  Easy to suggest, a bit more difficult to implement.  But Will wrote a post that makes it seem doable.  He breaks it down into easy-to-digest sections and provides lots of suggestions.

Solitary Diner describes her “middle of the night chart review.”  Who amongst us medical professionals haven’t found ourselves in this position?  It’s a right of passage.  Welcome to the world of health care!

Medical Lessons brings up an interesting point – can cancer awareness initiatives go too far?  Where’s the line?  What if it seems silly to adults but might actually be helpful to children?  Should Barbie be bald in the name of cancer awareness?  (My take?  Sure, why not.)

Here are a couple quickies:  Insure Blog covers the situation of an autistic young man when a program his family has come to depend on is restructured – leaving them out.  Behaviorism and Mental Health explores a different perspective when addressing the problem of increased violence in California’s state psychiatric hospitals.

I hope you’ve enjoyed reading these posts I’ve selected for this Grand Rounds.  The calendar tells me that Volume 8, No. 18 will be held at USA Today (!), written by Dr. Val Jones.  Send submissions to val.jones at getbetterhealth dot com.  As always, thanks to Nick at Blogborygmi and Dr. Val at Get Better Health for keeping the whole thing going!

Dr. V at 33charts is hosting Grand Rounds this week!  Go read his carefully curated links.  I liked what he said at the end about each host essentially bringing their own flavor to the ‘Rounds.  (paraphrasing there!)  There have been a few warbles here and there about how it should be hosted, but I’ve always thought that each blogger should do what feels right for them.

Having said that, codeblog will be hosting Grand Rounds next week.  It’ll be my 7th time hosting and I’m excited.  Mostly excited because now someone will tie up GruntDoc‘s 7-time-hoster record :-)  But!  Also excited to read what you send my way.   I have never requested that submissions conform to a certain theme, and I’m not going to officially request it now, either.  All submissions will be considered, but my favorites are the personal stories and anecdotes from the world of health care.  My past entries for Grand Rounds have been silly & gimmick-y, but I have a feeling that I’ll employ a simpler format this time around.

E-mail me at codeblogrn at gmail to submit; please put “grand rounds” as the subject.  I’d appreciate if you could get them to me by Monday afternoon at the latest.  Thanks!

Happy New Year!!!

At the end of December, codeblog turned 9 years old.  It amazes me that I’ve been doing this for that long.  I was so excited when I was asked questions for the Reader’s Digest article “50 Things Your Nurse Won’t Tell You.”  My comments appeared in print, and in the online version here and here.

For that last link, the quote was this:

“If you ask me if your biopsy results have come back yet, I may say no even if they have, because the doctor is really the best person to tell you. He can answer all your questions.”

This blog took issue with that comment:

“And still another nurse admits that the nurse might falsely say that biopsy results are not back, “because the doctor is really the best person to tell you. He can answer all your questions.” The physician may be the best person to tell you about some things, but he–or she–can’t necessarily “answer all your questions”; nurses are more expert about a number of aspects of patient care. “

I stand by my comment.  If your biopsy results come back with a specific form of cancer that I know nothing about, I’m not going to march into your room and say, “Hey!  You have cancer!  Unfortunately I have no idea what they will do to treat it, if it even can be treated, or what your prognosis is.  And no, I also have no idea when your physician will be in to discuss these things with you.”

There have definitely been times in my life that I have just wanted to know.  But I think those times have been fairly straightforward.  I would have probably paid good money for someone, anyone, to call me with my betaHCG results when I was having symptoms of a miscarriage, but instead I had to wait for the doctor to call.  No one else would tell me.  But I had already done hours and hours of reading about what those numbers would mean and felt fairly prepared to interpret them on my own.  Every minute I had to wait was agony.

I think things would be different if I had no idea what to do with the results.  I would most likely be okay waiting a few extra hours for some results if I could get them from the doctor who could then answer my questions rather than have someone less knowledgeable report them.

Then again, maybe there’s something to be said for getting results and having a chance to do my own research so that I would have a chance to let the information sink in and be able to come up with appropriate questions.  I guess it’s a grey area.

Anyway, I was completely tickled to be in Reader’s Digest.  My grandmother read a LOT and I spent a lot of time with her when I was younger.  I also started reading a lot, and she had many books around.  When I went through all the books, I asked her what I could read next and she found a box of old Reader’s Digests for me to go through.

I (metaphorically) devoured them.  I remember one had a story about the Titanic and what happened hour-by-hour.  I read that probably 5 or 10 times.  Every issue had several interesting things to read.  She renewed her subscription and I was so excited when an issue would arrive.

I think she would be so proud that my name was in RD.  I wish she were here so I could show her.

So, Megen wrote this post recently about “Therapeutic Presence.”  The following passage really caught my attention:

Question is: are there more things in nursing, Horatio, than science can explain? Can we touch patients and zap them with calmness or take away their pain? Can we, by our mindset during our provision of care, substantially affect our patients’ outcomes? Can any of this be taught? Can we do it on purpose? I don’t know. That situation has captured my attention, though, because the flip side must also be true—if I despise my patient, she can probably tell that too, regardless of how tightly I’m controlling my behavior.

 

Little backstory:  A few weeks ago I had a laparoscopic cholecystectomy.  Basically, a very nice surgeon made a few incisions into my abdomen, inserted a camera and some wrenches or something, and took my gall bladder out.  I had never had surgery before.  Never been intubated.  I have been on “the bed side” quite a few times, but never for surgery.

A week elapsed between the time we decided to do surgery and the time the surgery actually happened.  It was a really hard week for me as I was very anxious about the whole thing.  I’m not even sure what exactly it was that I was nervous about.  I trusted my surgeon completely, I had full confidence in the hospital I was having surgery at, and I know it’s a procedure that is done thousands and thousands of times a year with a very low complication rate.

Still…. well, I guess I have never been completely unconscious in a room full of people who were looking at my insides.  I have never relied on a machine to breathe for me.  I had never been under general anesthesia before.  Basically, I was going to be vulnerable and exposed.  One of the biggest things that caused me angst, though, was that I would wake up still intubated.  The anesthesiologist assured me I wouldn’t remember being intubated at all.  That was helpful.  I believed him.

Anyway, I was supposed to tie this in with the passage at the top, wasn’t I?  The point is that I was very nervous and the morning of the surgery found me in the pre-op area holding back nervous tears, sometimes unsuccessfully.  I had the footies on, had the gown on, admission assessment was done, IV inserted and then we were just hanging out waiting for the surgeon.

One of the nurses who would be with me in the OR came to wait with me and she was genuinely so sweet and caring.  Her general demeanor really put me at ease.  We really were just waiting for the surgeon to show up; it was about 10 minutes past when I was supposed to go in.  I was in the middle of mentally deducting stars from my future Yelp review of him when he finally showed up.  We had a little chat, and then he left to go scrub.

In the meantime, a second OR nurse showed up in my little pre-op area.  When the surgeon left, and it was time to go, I started crying a little again.  The first nurse was at my side and was very sweet and reassuring.  The second nurse was behind me, to help push the gurney to the OR.  When she realized I was upset, she put her hands on my head.

I am not a touchy-feely person.  When my patients are distressed, I’ll put my hand on their hand or arm and that’s about it.  Before this experience, if you had asked me what would reassure me if I was upset, touch would actually be way down on the list, and touching my head?  No way.  But for whatever reason, her hands on either side of my head was exactly what I needed right then and I was immediately calmed by it.

Why? Why would someone find solace in something they would normally consider to be annoying?

By the time we got into the OR, I was ready for some pharmaceutical assistance.  I moved over to the (very narrow!) table, and as the nurse was strapping my arm to the board, the anesthesiologist appeared next to me.  I told him I could really go for a nice intravenous cocktail anytime and he said he already injected some Versed.  The last thing I remember saying is, “Well, I don’t fee…”  Heh.

I woke up in the recovery room and felt nausea and pain.  All I had to say was “hurts” and “sick” and I was out again.  The next thing I remember was being asked to scoot over to my bed on the surgical floor.  I said yes when they asked if I wanted some morphine for pain, and dang!!!  That stuff really burns.

I went home later that day and my recovery was very uneventful.  I was really amused to see that my incisions were covered in skin glue!!  No dressings at all.  Just 4 incisions with a coating of glue over them.

Anyway, I had barely even remembered what the OR nurse did until I read Megen’s post.  I think she’s on to something.

At work, we have Voceras.  They are little phones that we wear around our necks.  We use them to call each other, other departments, take phone calls.  They were a little annoying at first and kind of hard to get used to using, but now we all use them every day and I personally have found them to be really helpful.  Our unit is large, and instead of walking around trying to find Susie Q RN to tell her she has a phone call, we just click our Vocera button and can reach her instantly.  Easy.

They added a feature a little while ago.  The Voceras now tie in with the patient monitors.  I don’t know how it all works; for all I know, the unit secretary brings out a magic wand, chants a spell, and then the monitor and Vocera both know what patient I have that day.  This results in a couple of things.

First, when MY particular patient puts their call light on, in addition to hearing it throughout the unit, my personal Vocera makes a sound so that I know without looking around that it’s my patient who needs help.  Next, and this is pretty interesting – when my patient has an arryhthmia, my Vocera makes a “do-dunk” sound.  It kind of sounds like a knock.  I look at the little screen and it tells me which room is alarming and what the alarm is.  All very helpful when I’m in my other patient’s room.

So one day, I had a patient that wasn’t doing very well.  We were communicating with the patient’s family and trying to decide whether or not to make him a no-code, or withdraw life support altogether.  It’s an understandably difficult decision to make and the family was struggling with it.  As the day wore on, though, the patient was becoming more and more unstable.  The monitor started alarming, which made my Vocera start doing its “do-dunk” sound when the patient started having bradycardia.  The family still wasn’t comfortable with the idea of taking him off of life support though.

Then it came to be my turn to go to lunch.  We had a break nurse, so she could completely take over caring for my patient and only my patient while I was gone.  I brought her up to speed on the situation.  As I left, I could see the family coming out of the room to talk to the nurse that took over for me.

I went to the cafeteria to get lunch, brought it back to the break room, and started to eat.  I was talking with a coworker about our kids when I heard the familiar “do-dunk.”  But when I looked at my Vocera, it said, “Room 2-0-1-1 ASYSTOLE.”

And that is how I found out, over lunch and lighthearted conversation, that my patient had died.

I told my co-worker what my Vocera said, and without even looking up she replied, “You know, you can push that ‘Do Not Disturb’ button.”

Um… yeah.

When I returned from lunch, the break nurse started to say, “Your patient…”

I just said, “Yeah, I know.”

Online Nursing Degrees is doing a series of interviews on nurse bloggers.

To learn more about how nursing students mature into seasoned healthcare providers, we studied popular nursing bloggers to see what they had to say on the subject.

We found the voices of dedicated professionals with intelligent conversations and compassionate stories illustrating what is happening: in hospitals, classrooms, organizations, public health, state-run or federally sponsored institutions, private hospice care, and more. These are nurses (some currently students themselves) who intimately understand the questions, concerns and the feelings shared by many nursing students: they embody the statement, “Been there, done that.”

You can see the whole series here (we are at the midpoint now, each day another link will go live).  My interview was posted today.  Enjoy!

Well, what better time to post my interview with Erin at Tales of a School Zoned Nurse than now, when everyone’s headed back to the classroom?

Erin is a school nurse in the “cash strapped state of California.”  Her position covers two elementary schools and a middle school – almost 2000 students!!  She has been blogging since last year and her blog has definitely become one of my favorites.

She says she was never too set on working in a hospital.  After nursing school, she worked at a couple of summer camps, which gave her the idea to look into being a school nurse. She was hired right away and “leapt in without a second thought.”  She is starting her second year in this position.

Erin’s daily schedule is quite varied:  hearing and vision screenings, cleaning up playground accidents, making various referrals for a number of issues (such as dental and vision checks), scoliosis screening, making sure the school in compliance with state mandates (e.g. immunization requirements), checking on diabetic children and dealing with whatever else arises during the course of her day.

She blogs a lot about the parents of her students and I am almost always blown away by her Scary Parent stories.  She says incompetent and neglectful parenting is by far the most frustrating part of her job.  (Read Exhibit A, Exhibit B, and the continuing saga of Exhibit C)

One of the highlights of Erin’s job is her ability to be a good role model to the kids.  She’s spent time in the classrooms and after-school programs talking about her job and as a result, the kids got to know her and look up to her.  “It feels good to be someone kids turn to when they need someone to talk to or confide in.  It’s satisfying when I’ve made a different to someone, like seeing a student with glasses after making a vision referral.”

Being rather new, Erin does have other experienced nurses she can go to if she has questions.  She is the only nurse at her 3 schools, but there are 10 other nurses spread throughout the district.  They stay in contact often by phone and email.  But other aspects of her job aren’t as supportive – the computers she has to use are “from the dinosaur era” and she carries her audiometer and vision charts with her because there aren’t enough to go around at the schools.

Her position is salaried on a teacher contract, so she works 7.25 hours per day.  The timing is left up to the nurse since they cover different sites on different schedules.  Depending on what school she’s going to that day, her schedule is generally 8-3:15 or 7:30-2:45.  She’s able to accomplish what she needs to do in those hours, but not everything she wants to do.  “I can finish the required health screenings and state mandated requirements, but there is never enough time in the day for the other stuff that I want to do:  get new shoes for the girl whose mom won’t take her in, diabetes teaching for my newly diagnosed diabetics, following up on referrals so kids can get the glasses they need.”

To prepare for her job, Erin became a certified school audiometrist (a 4 unit class).  If she decides to remain a school nurse, California requires a separate license, which requires more education.

And of course, my favorite question:  One of the biggest complaints given by hospital unit-based nurses is that they rarely have time to eat or go to the bathroom. Do you find that to be the case with your job as well?

“I don’t always get to eat when I want to, but there is time during the day – eventually – to do so. I’ve learned if I bring a hot lunch I’ll probably need to reheat it at least once during my meal, because I usually take lunch at my desk and am frequently interrupted by tetherball accidents.”  (How many nurses can say that??)

My son will be starting Kindergarten this year and one of my main concerns is his peanut allergy.   His preschool was peanut-free and this will be the first time that he’ll be out in the peanut-filled world for such a long period of time without my own constant vigilance.  So of course I wanted to get Erin’s take on the current allergy situation:

“Food allergies are definitely a big concern, and though I haven’t myself, I know many school nurses that have had food allergy related 911 calls. It’s a huge gap in our care: nurses are technically the only epipen trained staff (just starting this year other school staff can volunteer to become trained, but most I’ve talked with don’t want that responsibility), and when we have three school sites we obviously might not be at a school site when an incident occurs. I do my best to reduce any incidents by first calling the parents to find out exactly what kind of reaction they might have – sometimes parents claim allergies when their kid just doesn’t like the food.  [Ed:  ARRRGGGGGHHHH!!!!!]  At the school, I notify the staff and call the student into my office so I get an idea of how well they understand their allergy. Then…. Then I just hope for the best. For parents, I really recommend talking directly with your child’s teacher and nurse – please! And bring in those Epipens!”

(Not only do I have 2 separate boxes of Epipens; one for the classroom and one for the office, I have a brand new bottle of Benadryl that I’ve already opened, taken all the plastic off and marked the appropriate dosage on the medicine cup.  I also have his photo taped to each bag of meds, which includes a copy of the doctor’s orders.)

And this is what Erin wants you to know about school nurses: “The job is what you make of it. I think there’s a reputation that school nurses have that is undeserved: we’re practically retired nurses working a boring job. There are certainly those nurses that do this job for the schedule, just like there are those hospital nurses that just do it for the money, but we’re not all like that. It just depends on how involved you are with your schools and kids; the more involved you are, the more you see there is to do, the more there is to keep you busier than you have time to be…but the more involved you are, the more rewarding it is, too, even if exhausting.”

Thank you, Erin, for giving us some insight about being a school nurse!

So, I’m considering a career change.  It’s probably far off, as my little baby is only 1 year old and won’t be starting school for awhile, but I wanted to start preparing as much as I could.  I am interested in hospice, either in-hospital or in a home setting.

Are there any hospice nurses out there that read this blog?  If so, please contact me – codeblogrn@gmail.com

Thanks!

Well, not my heart.

I was contacted awhile ago and asked if I wanted the chance to read and review Tilda Shalof’s new book, Opening My Heart.  (Amazon link, but NOT an affiliate link – I live in California and due to a new law, Amazon has cut all ties with us).

I had the chance to include a story in a book that Tilda edited a couple of years ago called Lives in the Balance.  So I had fond memories :)

I’ll say up front that I enjoyed the book.  I had a range of emotions while reading it – frustration, worry, happiness.  Frustration because although Tilda is a very experienced ICU nurse, she doesn’t take her own health seriously at all.  I read with disbelief as she described her incredible denial of the obvious need to treat the heart condition she was born with.

I was amused at her doctor’s and husband’s reactions when she tried to tell them that if anything went wrong with her surgery, she didn’t want to be kept alive on machines.   She explained that she used to have a dog and her husband absolutely refused to euthanize the miserable thing.  I liked this passage in particular:  “To Ivan, love means never stopping love or giving up.  This is what families say.  They can’t let go because of love.  I hope no one loves me this much, ICU nurses often say to one another.”

Amen, sister.

Tilda writes about her surgery and subsequent recovery, which I found fascinating.  I love hearing about patient experiences, and having a nurse tell it from her point of view was pure brain candy to me.

She writes a lot about her friends and coworkers and her interactions with them.  I admit I found those particular parts of the book a bit draggy, but maybe others would find them an enjoyable read.

Lastly, she wrote a lot about depression after her surgery.  I don’t know for sure, but I don’t think this is addressed much when the doctor is informing the patient about what heart surgery will be like.  I think it needs to be given more consideration and that patients need to be told that it’s a completely normal thing that happens after such a big surgery.  Not dealing with it can impede healing and recovery.  I was really pleased with how much attention she gave to this particular part of her experience.

Anyway!  Tilda very sweetly agreed to be interviewed!  I am really excited about posting an interview with her on codeblog.

How did you get started writing books?  Did someone come across something you wrote and suggest you write/publish a book?  Or did you write a book and send the manuscript to agents?

I had been writing for many years before I got published.  Taking writing courses, sending my manuscripts out, and receiving numerous rejection letters from publishing houses was the extent of my writing hobby for years.  In 2004, I got a lucky break when I sent my true stories of being an ICU nurse to one of Canada’s top publishing houses, McClelland & Stewart.  To my surprise and shock, they offered me a book contract on the spot.  They said it was a new perspective, a real insider’s view.  Well, who better to provide that than a nurse, I thought?  I hope with A Nurse’s Story and my other books, that I’ve opened a door to more nurse writers to get their stories out.

Have you always been a writer or is it something you started doing as an adult?

Yes, I’ve always been writing, recording my life and observations, but it was only in the last few years that I have been published.  It took me a long time to be ready to share my stories with the public.  I had a lot to learn about the craft of writing.

Many nurses haven’t published books – what is something we’d find surprising about being a nurse author?

The most surprising thing I’ve learned from being an author is not how many amazing nurses’ stories there are – I knew that – but how few are actually undocumented.  Nurses aren’t speaking up enough and thus their voices aren’t being heard. I hope I’ve started a trend with writing about my nursing life.  Other nurses love to read these stories and the public needs to know what we do. It’s a matter of their health and safety to understand more about the roles and responsibilities that nurses have, otherwise, misconceptions and stereotypes can flourish.  Otherwise, we also run the risk of being invisible and completely overshadowed by doctors who traditionally have had a lot more power and stronger voices.

You mention your coworkers and friends many times in the book – do you use real names?  How do they feel about being mentioned?

Yes, I use real names of friends/co-workers and usually ask their permission to do so.  So far, no one has objected, and most are pleased, or at least in agreement with what I’ve said about them.

Do you do a lot of book promotion (signings, readings, etc)?

Not much book promotion per se, but a lot of speaking to groups of nurses, doctors, and the public at large about what nursing is all about.  Now that my new book, Opening My Heart is out, I enjoy speaking also to patients.  I love to be invited as a guest speaker and wherever I am invited, I am thrilled to go.  Also, I enjoy connecting personally with nurses on my Opening My Heart Facebook fan page and one-to-one emails through my web-site – www.NurseTilda.com.  That’s truly the best part about being a nurse author – connecting with other nurses.  If anyone writes to me, I always write back, usually in a day or two.

Do you have marathon writing sessions or do you write a little every day?

Both!  I love the opportunities to immerse myself in my writing world for extended periods of time, but for an hour in the morning after a night shift, or on a day off from work, in between household responsibilities and being with my kids – two boys, 16 and 14 – I squeeze in some writing, too.  If you wait for the perfect conditions for writing, you might not ever do it.  You just have to plunge in amidst the chaos of a day.

————-

I thought Opening My Heart was a great read and I recommend it.  And thanks to Tilda for taking a few moments out of her day to answer some questions!