Career advice -- and commentary on current healthcare news and trends for savvy 21st-century nurses and healthcare providers -- from holistic nurse career coach Keith Carlson, RN, BSN, NC-BC. Since 2005.
Wednesday, February 27, 2008
The Nurse as Ogre
"The doctor sent me in to give your daughter her shots," I say.
"Yes, she told me. Can you give her some Tylenol too?" the mother asks.
"Oh, yes, I have some here for her." I give the baby some Tylenol, and already she's eyeing me with suspicion.
"Here's some information on the vaccines. Do you have any questions?" Sometimes I hope the parent will refuse the vaccines, just so I can be spared the trauma of administering them, but my trauma is nothing compared to the child's.
I ask the mother to lay the child on the exam table, and now the baby starts to cry because she knows that something unusual is about to happen. She can also probably pick up on Mom's fear and my tension, and by now the child is gripped with terror.
Giving four or more vaccines at a time is always a drag. First, if the child is already walking, we like to give the shots in the arm so that he or she will not be discouraged from walking due to pain, but those young deltoids are so small. If the child is not yet walking, we go for the large thigh muscles, but I'm no fool, and I know that even if they're given in the leg, these vaccines burn like a really bad bee sting, at best.
When I clean the baby's thigh with alcohol, she begins to scream. And I mean blood-curdling. My stress level is already probably high because we just had an 11-year-old autistic boy pinned down in another room in order to give him a shot and draw some blood. He was strong, and he pulled his mother's hair so hard I thought he would rip it from her scalp. The vaccine was fine, but we couldn't draw his blood since he moved so much.
Anyway, the baby is screaming, and I still hear echoes in my head from the caterwauling autistic boy. I steady my nerves, and I give the baby two painful injections in each thigh, about 1 or 2 inches apart. She screams some more, and I apologize profusely and hope that she won't be deathly afraid of men with goatees forever. Maybe she will.
This ogre business is truly awful, and I leave the room feeling bad. These Tuesday nights at the clinic are no fun, and with two pediatricians working, there's no escaping the old vaccine drill. I make a mental note to ask Mary to remind me not to work Tuesday nights anymore----Thursdays are so much more preferable with the lack of pedi providers.
There are just simply things that some nurses hate to do. For one, it's tracheostomy care. For another, it's wounds. For me, it's vaccines on little kids. I just hate being an ogre, and I'd give anything to lay that mantle down once and for all.
Saturday, February 23, 2008
Mindfulness and Mindlessness
Interestingly, when I began writing the previous paragraph, I rose from my chair in front of the computer to search for my copy of Full Catastrophe Living in order to find the quotes by Kabat-Zinn that I wanted to use. Apropos of the subject of mindfulness versus mindlessness, I ended up wandering all over the house to find where I had last left the book. This was a prime example of mindlessness in action a la Keith.
So, mindfulness can be about meditation, something I am now attempting to integrate into my daily life. But it truly is about so much more. As Mr. Kabat-Zinn so aptly states, it is indeed "knowing what you are doing while you are doing it." When I walk in the door of my house, I always try to be mindful about where I put my keys, my cell-phone and my other important belongings. I have a little wooden box where these things are supposed to live, and when they aren't there when I need them, I waste a great deal of energy on finding them---energy I could be using for more important things. The case of the missing book was very illustrative to me, and serves as a reminder of a continuing need for mindfulness in relation to both the physical, emotional, and psychological worlds.
One might say that mindfulness could be used as an excuse by a person with Obsessive-Compulsive Disorder to more sharply focus on their ritualistic behavior. While this is true, and while I do admit to a personal level of OCD, these two ways of being can be synthesized into a greater whole which serves the individual without pathological underpinnings. My goals are certainly above and beyond personal pathology, and my plan of self-care includes time for formal mindfulness practice, integration of mindfulness into my daily activities, as well as time to simply "be" without any plans or practices whatsoever.
This mindfulness stuff can be tiring and can sometimes feel like work. But once it is fully integrated, I hope that the "work" will be something that happens in the background without as much conscious effort, and mindlessness will become more and more an occasional blip on life's radar screen.
Friday, February 22, 2008
Afraid to Die and Barely Living
"So, what's most scary to you?" I ask.
"I'm scared that I'll look dead, and they'll think I'm dead but I really won't be. Then they'll take me away and bury me alive. That's what I'm really scared of---being buried alive."
I take a deep breath.
"Well, first of all, I'm going to tell you something. One day, when you die---and we all die---they will make absolutely sure that you're dead. I promise. Now, what do you think they'll do when they take you to the funeral home?"
"They'll make me up and and comb my hair and dress me in the clothes my daughters give them."
"Well, yes, but I'm gonna take a risk here and tell you something that someone else wouldn't tell you. The only reason I'm doing this is because we know each other so well and we trust each other, right?" (She's my former patient and I've been sent to see her as a nurse consultant to assess her increasing anxiety.)
"Oh, yeah. I trust you more than Dr. __________. You can tell me anything." She sits up in bed a little, a sure sign that I have her attention.
"Well," I continue matter-of-factly. "The first thing they do in the funeral home is look over the death certificate and make sure that it's you on the table. Then they check over your body and make sure that you are absolutely dead." (I'm stretching the truth here a little, perhaps.) "Then they remove all of your blood and fill your veins with embalming fluid. Believe me, they would only do that when you're dead." (And no one could wake up after that, I think to myself.)
"So, they won't bury me alive?" she asks plaintively.
"No, I'm absolutely sure. Now that we have that settled, what's going on with this anxiety?"
"I don't know, I don't know. I just wake up in the night and I can't breathe, my chest hurts, I'm sweating, and only my daughter can calm me down and distract me. I call her on the phone---even in the middle of the night---and she talks to me. Or my youngest daughter who lives with me tries to get me to play some stupid game. It doesn't always work. I just feel like I'm gonna die."
"Do you have bad thoughts, or want to hurt yourself, or feel like someone's out to get you?"
"No, nothing like that. I just get so scared---sometimes even during the day, just like that!" She snaps her fingers in front of her face. "I've always been afraid of dying. Always."
"Are you afraid of the pain of dying? What scares you?"
"It's just that I'm scared. I can't explain it. I hope I'll go up there," she gestures towards the ceiling with her eyes, "but I'm not so sure."
"Oh, I can tell you for sure---you've raised all of these wonderful children and grandchildren for all these years. You're goin' to Heaven, my dear, no doubt about that. You can quote me on that one."
We review some simple breathing techniques and talk about psychotherapy. She's housebound, agoraphobic, morbidly obese. Finding a therapist to come to the house is almost impossible these days. Her family is frustrated, and she's just afraid of dying. Period. Well, we could take into consideration childhood trauma and the like, but who's counting. She has a panic disorder, plain and simple.
"You try those breathing techniques I taught you, and I'll make sure Dr. __________ thinks about giving you something that you can take when the attacks are really bad. OK?"
"OK. Thanks. I hope you can come over again some time, but I know you're not my nurse anymore."
"Yeah, you know I don't work there full-time anymore, but I'm coming in to help every week or so. If you need to see me again, I'll come by, OK?"
"OK. See you soon."
And with that, the visit is over. She may die today, tomorrow, or in fifteen years. The only thing I'm sure of is that she won't be buried alive and she'll go to a Heaven made just for her. The rest is up for grabs.
Tuesday, February 19, 2008
As I approach the stoop, I notice a shopping cart filled with returnable bottles and cans to the left of the crumbling steps. I climb those steps and look into the yard to the left. Detritus of urban life litters what could have been a yard at one time: hub-caps, an eviscerated washing machine, the fenders of several cars, rotting lumber, moldy carpets. What looks like it may have been a cage for a few dogs now holds bag upon bag of trash. I hate to think how this will all smell in the summer heat.
I knock. I knock again. And again. I'd rather this person answer the door so she can get her meds and I can get paid for this visit. I knock yet again.
The door opens following a short period of undecipherable noise from inside. The room smells of stale cigarette smoke. I put my bag down on the table in what seems to be the cleanest spot. The young woman who sleepily opened the door says, "She'll be right there." I put my paperwork down on the table and I notice that it sticks to the wood. Hmmm.
There is yelling from the bedroom around the corner. "Why do these nurses come so early? I'm so tired!" I note that it's almost 9am and I should have been here at least 30 minutes ago.
"Is she OK? I ask. "I thought her regular nurse usually comes at 8."
"Oh, she just likes to complain." The young woman goes back up the stairs and I'm left to wait. A few minutes go by, and there is rustling and complaining from the other room as I ruminate on the other visits I still need to make.
"I'm coming, I'm coming," she yells, and enters the room in a bustle.
She smells of urine and maybe a hint of sweat and feces. I greet her warmly in both English and Spanish.
"Buenos dias, hello, how are you?" I smile. "Where's your med box and the paperwork?"
She opens a cabinet and produces the box and the all-important folder which any nurse who comes to the home can use to guide him or her as to what to accomplish during the visit. I have a secret piece of paper with the combination to her med box. She can't be trusted with her meds---like so many of our patients---so a locked box is kept in the home.
"Thanks." She smiles wanly and sticks her finger out so I can check her blood sugar with the glucometer on the table.
The machine beeps. "105. Muy bien," I say as I hand her some gauze to staunch the blood from her finger that I just pricked.
The visit is inconsequential as visits go. I am one more face, one more nurse who has come to check her sugar and blood pressure, administer her meds, and then be on my way. The fact that I speak Spanish seems not to impress her. She answers in English no matter what language I use. How tiring it must be to have a virtual stranger in her home each morning. What an imposition when one wishes only to sleep one's depression away. Her blank stare and flat affect belie her underlying mental illness, and I feel compassion for her even as I reel from the smell of urine that surrounds her. I wonder when the home health aide will visit her next, or if her family will make sure she bathes.
Not being a case manager has its rewards, and having relinquished the management of the intricacies of more than eighty people's lives, this momentary glimpse into a life on the edge of chaos reminds me why I so recently quit my full-time job. In my current position---covering for absent nurses and stopping in on patients who need a visit---there is no management, no follow-through. It is simply a visit and nothing more. It is a fleeting clinical glimpse, a hello and a goodbye, and I move on to the next.
Sunday, February 17, 2008
At the Hospice
I visit another patient in her room, not having seen her for several weeks. "So, what's new?" I ask, as I sit on the edge of the bed. "Nothing that's good," she replies with a sigh. "Can I get you anything?" She reaches out her hand. "Just some black coffee and ice water. That's all." She's lonely, but chooses solitude as her health continues to decline, staying in her room throughout the day and night. I bring her some smiles and coffee, and honor her desire for quiet.
Another patient, quite new to me, asks for little, and does so apologetically. "I don't want to hurt you or cause you pain," she says, "but I'd like to get out of bed." Such a request is always honored immediately, and we reassure her that we are in no way inconvenienced by her requests, large or small. She is so sweet, so frail and thin. Her family visits and they look at photographs of happy and healthy grandchildren. Last time I was here, this room held another who has since left this world. It's a revolving door where death is concerned.
One bed in the house is empty. The last time I was here, that room was the center of attention, with a confused and agitated young patient, a morphine pump, and a devoted family sitting vigil seven days a week. He has since died, and for me there was no time for goodbyes. But working as infrequently as I do here, every leavetaking is a potential goodbye, and we make the best of each opportunity to be kind.
As for my friend eating the bow-tie pasta, he is always looking for answers, but the tangled neurons in his brain insist that the answers elude him. But still, he finds the wherewithal to ask the questions.
Thursday, February 14, 2008
Tonglen: Giving and Receiving
Of all the practices I know, the practice of Tonglen, Tibetan for “giving and receiving,” is one of the most useful and powerful. When you feel yourself locked in upon yourself, Tonglen opens you to the truth of the suffering of others; when your heart is blocked, it destroys those forces that are obstructing it; and when you feel estranged from the person who is in pain before you, or bitter or despairing, it helps you to find within yourself and then to reveal the loving, expansive radiance of your own true nature. No other practice I know is as effective in destroying the self-grasping, self-cherishing, self-absorption of the ego, which is the root of all our suffering and all hard-heartedness.
Put very simply, the Tonglen practice of giving and receiving is to take on the suffering and pain of others and give to them your happiness, well-being, and peace of mind.
Tuesday, February 12, 2008
Sweet Relief and The Great Unknown
The down side of such a situation is that I am no longer in relationship with any of my former patients, and am processing some feelings about having "abandoned" some of them. Also, coming and going from the hospice only intermittently does not afford me much continuity, and from one shift to the next I am generally in the dark as to who has died and who is still in residence. Thirdly, as a per diem visiting nurse, I have no control over who I am assigned on any given day, and while surprise and novelty can be exhilarating, some modicum of normalcy and regularity may at times seems somewhat alluring.
Still, this nurse who has freed himself from relative captivity is a happy man, and no amount of money would get me back on the full-time horse any time soon.
Friday, February 08, 2008
Finding My Way
For myself, I'm finding that I actually need to start scheduling "down time" wherein I have nothing to do and in which I explicitly deny myself the ability to do anything work-related. This entails blocking out my calendar for periods of "doing nothing" and then taking the reins of those hours by choosing a self-care activity for that period of time. Whether it be reading, napping, drawing, going to a museum or listening to music, those hours must be used for self-care and healing, otherwise I will most certainly fill them with activity and busy-ness, eschewing self-care for "productivity".
Today, with back pain flaring and physical discomfort at the forefront of my mind, getting someone to cover my hospice shift for tomorrow was my paramount activity. Luckily, a thoughtful colleague took my shift and I will spend some time truly caring for myself tomorrow, and severe pain is something that simply screams "Healer, heal thyself."
With the physical pain has come some grieving that still needs to be processed from losses incurred these last few years. Perhaps as grief slowly heals and changes, the areas of my body that hold such severe pain will begin to release. Until then, self-care must be a constant focus, or leaving my full-time job to decrease stress will have been a wasted and fruitless effort, and that, I must say, would be inexcusable.
Tuesday, February 05, 2008
Calling All Nurses!
True-life stories from nurses who know
Kaplan Publishing, the #1 educational resource for nurses, is launching an exciting new
series of nonfiction books that share the stories behind the relationships, experiences, and issues nurses encounter on the job—whether they work in a hospital, clinic, home setting, hospice, private medical practice, or elsewhere.
These slice-of-life stories are written by nurses from all walks of life and provide
unique personal insights into powerful universal truths. Entertaining and educational,
inspirational and practical, each book will feature 20–25 true stories about the experiences and relationships that inspire and enrich the lives of nurses and all those who come into contact with them.
We are now accepting stories for the following anthologies:
REFLECTIONS ON DOCTORS
No one works more closely with doctors than nurses. What is it really like to work with
them? Share a story about an event that explores:
* A positive working relationship with a doctor
* Dealing with interns
* Power struggles
* Gender dynamics
* What you do if a doctor misses something or makes a mistake
* The challenge of public perceptions about nurses and doctors
Submission Deadline: February 15, 2008
Send stories to: firstname.lastname@example.org
FINAL MOMENTS: DEATH AND DYING
Experiencing the death of a patient is a rite of passage for most nurses. Share a story
* Your first encounter with the death of a patient
* A patient who made a life-changing impression on you
* How you have dealt with grief
* The controversies of end-of-life decisions
* The challenges of caring for people as they die
* The harrowing experience of telling family members their loved one has died
Submission Deadline: March 1, 2008
Send stories to: email@example.com
MEDITATIONS ON HOPE
So many people want to know how nurses do it. Share a life-defining or life-changing
story that explores:
* How you stay positive and focused
* How you maintain hope in the face of patients' suffering, or finding the silver
lining in a dark cloud
* Experiences that have brought you understanding and healing
* A patient, an event, or a day that buoyed your spirits or that required your greatest
reserve of strength
Submission Deadline: May 1, 2008
Send stories to: firstname.lastname@example.org
Payment: $100 if published, along with a complimentary copy of the book.
Story length: 1,000–2,500 words
Point of view: First Person
Nonfiction: All stories must be true, previously unpublished stories from your personal
Tone: Inspiring, poignant, and, when appropriate, humorous.
Format: Microsoft Word, 12-point Times New Roman, double-spaced
Contact info: Each submission should include your name, address, phone number, and
Remember: Tell a story that has a beginning, middle, and end. Write from your heart
about a life-changing or life-defining experience. Be sure to make your story
rich by vividly painting the characters, the setting, and dialogue.
Due to the volume of submissions we receive, we cannot acknowledge receipt of submissions or provide status updates. If your story is selected for publication, you will be notified by e-mail. Manuscripts will not be returned. Authors may submit multiple stories for any of the three books.
Before final acceptance, you will receive an agreement that outlines the terms and conditions of publication. All manuscripts selected for publication will be subject to editing.
To Submit Your Story
Typed submissions are preferred, but we will accept a hand-written submission.
Each submission must include your contact information, including your full name, mailing address, phone number, and email address, if you have one.
Each submission also must include a story title and word count.
Electronic (emailed) submissions are preferred; mailed submissions are acceptable.
Email: In the subject line, cite the story title and the anthology for which the story is
intended. Type the story into the body of the email or send an attachment in
Microsoft Word. One submission per email.
Mail: You can send more than one story per envelope. Include one self-addressed,
postage-paid envelope for each submission. Send only the paper copy of the story; do
not send computer disks or CDs. Mail to:
1 Liberty Plaza, 24th Floor
New York, NY 10006, USA
We cannot accept phone calls.
Sunday, February 03, 2008
Family Caregivers Are Speaking Up
Ms. Mintz is the wife and caregiver of her husband, a man living with Multiple Sclerosis since 1974. Over the course of the interview, she recounts harrowing tales of hospital discharges devoid of planning, of caregiver burnout, of turning to neighbors in emergent circumstances to assist with transfers and other activities of daily living. Ms. Mintz laments the American healthcare system's apparent blindness to the acuity of patients as they are discharged to home with woefully unprepared families and caregivers shouldering the burdens of increasingly complex care.
The subtitle of Mintz's book, "It Doesn't Have to Be This Hard", speaks to the fact that Mintz is a caregiver who cares about other caregivers, and has penned a book with the goal of providing resources and empowerment to those responsible for the care of loved ones living at home. Additionally, The National Family Caregivers Association appears to offer resources, connection, Pen Pal programs, advocacy, volunteers, workshops, trainings, and much more to the tens of millions of Americans who choose to care for their loved ones in this Herculean manner.
During the course of the interview, Mintz lamented the lack of seasoned professionals who can coordinate the care of chronically ill patients and provide support and resources to families. Having recently left my job with a Disability Care Coordination Organization (DCCO), I would like to know what experiences Ms. Mintz and her organization have had with DCCOs---if any---and how her organization and various DCCOs could partner with state and federal government to improve care management programs, and to increase access to such programs for families across the country.
Providing care for a chronically ill loved one at home is no small undertaking these days, and while sick family members were generally cared for at home throughout the early twentieth century, doing so in this current economic climate has become next to impossible for so many families. Hard evidence is available that the majority of home foreclosures and bankruptcies in this country are not caused by frivolous spending and credit card use on the part of homeowners. People in this country are losing their homes due to the high cost of healthcare and from losing their jobs and careers due to illness. Astronomical medical costs, a sour economy, a pharmaceutical industry run amok in the halls of Congress, and a healthcare system driven by profit and market forces have all contributed to untold suffering for patients and caregivers alike. It is a sad state of affairs, and heroic people like Mintz are working hard to assuage that suffering, one family at a time.