Tuesday, April 14, 2009

Soft Shelled Soul

My life is good. My son (now almost 2!) is more like a little boy than a baby. He's my buddy. I often think about his innocence, and the sincere love of my wife for me and him during the drek of some of my more challenging, heart stopping, tedious, or humiliating shifts. I endure the ebbs and flows of an often scary, dysfunctional career choice for them, and through my family, I get stronger when the tide ebbs and flows.

Nursing is fucked. At least in the beginning. New nurses in my unit are treated like sub humans. Everything we say or do is mocked and considered stupid. And in all honesty, a lot of the things that we new nurses do is pretty darn mockable and stupid. But more often than not our treatment is excessive and has no purpose other than to amuse bitter, older nurses who feel resentfull that the profession has moved ahead and sky's the limit. It is no longer a career choice for those who seem to have chronic, deep self esteem issues and hide behind "a calling".  I hear abot the chaos of their personal lives: divorce, or other wise never married, twelve cats, vacation money spent on taking the dog to the vet.. Nurses are smart people, not particularly intellectual, observing some rigid hierarchy that takes at least 5 years to climb on and carve a niche of protection for oneself. I don't get to work with the other 12 new grads they hired into the ICU. It seems I am on the opposite weekend schedule as almost all of  them. I work except for two or three almost exclusively with senior nurses. I've spent a lot of time wondering if I am still paying dues, or if I  am the young being eaten (frustrating at 32-ooh they hate that. Second career er's).  Perhaps they are just foul tempered in general-and this seems to be the case. But an especially vicious, degrading venom is saved for new comers to the field. I would take this venom with no complaint if it came with information on how to do my job better but the majority of the time I am sighed at, snapped at, loudly gossiped about, IGNORED COMPLETELY I am not privy on how to do my job better. The worst part is that all of the experienced nurses do the same task differently and if they do bless you with advice, solicited or not and you choose to not take it, shit-you're fucked and MAN they resent that.
I have come to find that the constant stream of disrespect is not about me personally, though often the intent is to make it personal, only to make the sting worse. But I work with a group of people who have been together, most for at least five years some as much as 30 and have come to see new hires as management's way of reminding them that there is cheaper, happier, labor out there. To make matters worse, they are forced to "baby sit" us, to teach us, to guide us. They don't want to. Unless precepting they don't get paid any more for it. They are coiled snakes, Iam the urban backpacker, blindly smiling at the scenery, carousing through the grass after dipping my feet in the pool at the bottom of a waterfall when OWWW! I stepped on a snake. 

I got my first 1 to 1 patient assignment two nights ago. She was my patient again last night.
During shift assignment I asked if I could have the admit, I told them ,"I need the experience, with paperwork and otherwise." I'm tired of my admits being confusing disastrous affairs. Endless paperwork I never see unless I'm admitting, trying to still balance my other patient. I am here to learn. Practice. I was not cavalier or loud. I stated a plain fact as none of them showing any pretense of liking me, a reasonable request. They got a hearty laugh out of that.  The oldest one, Rhonda, shook her head and said, "You'll never want an admit again." More evil laughing. Fuck them. I'm here to learn. I practice the number one rule, applicably to any situation in career, love, life: Do you job well, be the best, no as much as possible- and then you have a foundation.

My admit was a direct admit t from the OR, preceded from a frantic call by the OR nurse, with little to no information other than, "I don't know what's taking them so long to close her up." I asked how much blood had been lost. "They said only 300cc's but I counted 20 completely soaked towels." The patient's arrival was preceded by the general/trauma surgeon covered in sweat, writing orders. Telling me to anticipate an anxious family. This struck me as odd because the surgeon doesn't normally bring the family talk to the ICU.  "Just get the FFP in her as fast as possible, use whatever vent settings keeps her alive. She's not a full code, no compressions or defib. Other stuff. In the paperwork somewhere."  Then he split. RT got ready with a vent. The only other white male nurse on my schedule, Roger (sorry p/c world but you notice these things when you are a minority) with just over three years experience, one foot inside the circle the other foot still dangling out did his best to prep me for battle. "I'll do compressions, you just get drugs." 
He more or less gave me a pep talk which was nice. The patients arrival reminded me of a trauma arrival in the E.R. Everybody happily pumped at first, then within five minutes everyone is sick of waiting, all jokes had been told, just ready to get to work. 
My dyke supervisor hadn't shown her close cropped head yet during the shift, which was unusual. I thanked god. She is a barrage of insults, veiled threats, dirty looks, intentionally confusing verbal directions. She adds the cluster to the fuck. Gross. She just makes life miserable and nasty.

My admit was a bowel resection gone on too long, patient too old (past 75 years) to be so morbidly obese at 155kg+, her  hernia not dealt 
with for like 40 years. AMS for 5 days, apparently her bowels had been recieving no blood flow for this long-her hernia cut off blood supply. 1500/cc's of dark brown fecal matter suctioned from her NG tube prior to surgery.  50% of her gut had to be removed. She had no neuro reflexes. Levo at an outstanding 20mcg/min to start.  5 liters LR already in. She came to me with a A-line BP of 75/30. HR good. Order for 4 units of FFP waiting.  
I hooked up the A-line to the monitor while Roger got the bed situated, RT started hooking up. The OR nurse looked freaked but I ignored her. She looked to rattled to even figure out how to disconnect the portable monitor. She's always jittery so I tried to pay it no attention. The anesthesiologist starting apologizing to me for the
 chaos and the fact that the patients right IJ line  wasn't sutured in place and then I got a little freaked. Looking back, I realize- the OR nurse and the anesthesiologist  were trying to give me an updated report from the phone, also going over info I already know-but they didn't really help get her on our monitor or set her up. They both asked, "any questions?" at the same time. How do I know? I'm trying to get the patient at least hooked up- the levo was so high that her extremities were mottled, we couldn't even get a pulse ox reading. Any questions? Yeah. One. What the fuck? What about that category status?

Then walks in the supervisor. Fucking EVERYTHING up. Barking orders, pouring on the confusion. Asking for the patient's property sheet. It was so frustrating. I was 50% set up. Getting ready to take  a step back and evaluate the patient. Roger had got a little ahead of himself and had put the IV pole on the left side, even though I had told him the IV lines were on the right IJ. I had already set the room up. As the patient came in I didn't notice Roger moving the pole. By the time I did the supervisor had already started her fucking harassment. "The R.N. formerly Known as Angry Male Nurse, why did you put the pole on the left side?" First off, in this stress full situation, why ask me why? Do we really have time to explain? I continued to set up the A-line, I wanted to say, "Roger did it" so she'd get off my back but then I would be ratting Roger out, who while not being the most impressive or experienced nurse around is the only one offering help. So I say, "I didn't move it over there. " Roger finally mans up and says, "I did, I didn't see the line." Supervisor's tone TOTALLY CHANGES.  
"Oh, yeah too many people to see. No problem. Well lets move it back over." WHAT THE FUCK?

Then she barks her first direct command at me, "T.R.N.F.K.A.A.M.N. (me) start your assessment we'll move the pole." Fine except 1) my physical assessment doesn't mean shit if I don't know if the patient is alive or not and I'm 20 seconds from having the A-line running 2) Dr. Drugs didn't suture in the Right I.J. and Roger is  so fucking scared of the supervisor he's literally YANKING OUT THE LINE. I pull the lines with my right hand to get some slack and I compress the IJ insertion sight with my left. In my head I was thinking - I should explain what I'm doing to the supervisor- but then another part of my head said- isn't it abundantly obvious what I'm doing, focus on keeping the line in, yell at Roger to stop moving- I yell at Roger, "Line!' and my supervisor, I swear to god tries to pipe in "NE!" Like she's got it under control. She tells me to get out of the way again but Roger is too far away to give slack. I don't say anything. I'm literally stretched out over the bed, one hand on the jugular one hand holding the line."
She literally screams, "Fine! You don't want my help than do this yourself!"

She storms out of the room, no doubt to run from module to module telling any nurses with 10+ years how horrible I am. That's how I know how irritable she is. The more annoyed she is the less years of exeprience it takes her to slander me. I 've had her at the 5+ years before. That's not paranoia, people. Some of the ancillary staff, R.T.'s, the one tech we have until midnight, have told me verbatim the bullshit she tells people about me. I can never win.
Roger brings the line around. 
"Man she makes things difficult", I say.
"She can be a bit of a drama queen," Roger replies. But drama queen doesn't cut it. First off, she looks like an old dude. She has the worst case of penis envy ever had, I know she's wearing a fake dick.  She slanders, she lies. She cannot have a single interaction with me without making a joke at my expense, rolling her eyes, glaring at me, cutting me off.  She's thinking "How come this weird, wrongly confident guy gets to have a dick and I DON'T? I wish I could sit down with her and say," It's just a dick, boss. It's what's on the inside that counts." In her head she thinks life is easier for me because I'm a guy. A white guy. Just like the ones that treated her  former Iowan redneck ass  like total shit. I can totally picture her figuring out around the twelfth grade that the reason why no guy ever asked her to prom is because she's freakishly boyish, likes to kick football player's ass, and finds the smell of vagina somehow alluring...vowing to hate. Her last ditch attempt at femininity was to become a nurse but she quickly realized that for those with the right moves it was a way to burn to memory her unspoken desires. To this day she lives alone, childless, doesn't have an old lady, loves the 49'ers. So I suffer.
But this time, like many other times, I have my patient to retreat into, to focus on, to nurse.  I get working. It's Roger and me for about an hour and a half. He's grabbing the UA, pulls an ABG for me, relays some lab values, he grabs the four packs of FFP for me. We double check them off together. Team work until 11:00 p.m. when the supervisor comes back into the module. I see her walk in. I hear the older nurses laughing. I hear one of them say, "He'll never want another admit again." Then Roger is gone. Sadly, for the next two shifts he cops an attitude with me. Just like that. I know what happened. The supervisor made it clear. Him or me. Roger has a family, too.  Supervisor leaves and the charge nurse says, "They should of just let her go." It's a fucking hernia you jaded psychopath! Being old doesn't mean you should die. The charge nurse is like 65 years old herself. What the fuck happened to these nurses to make them hate so goddamn hard?
As they are laughing at my fading vital signs 65/30, still no fucking O2 sat because she has no peripheral blood flow. I ask the RT to get one that adheres to the head. "Nope. Can't do it. We are only supposed to use those as a last resort in the case that we can't get a pulse ox reading from the hand and we've tried repeatedly."

"I can't get a pulse ox reading and I've tried repeatedly,". I'm getting the vibe she's been Supervised if you know what I'm saying. The intern walks in. "Still no pulse ox? Can you get one of those ones that goes around the head?" The RT sighs and says, "I'm really busy, but I 'll see what I can do." Like it's a personal goddamn favor or something. You'd think the Respiratory Therapist would want to know the saturation of the patient she's setting the ventilator to minute by minute but hey, an ABG once every 4 hours is good enough I guess.
She comes back with the head band. "TRNFKAAMN, this is it. Alright. I did you a big favor here."
Is she going against the will of the Supervisor, does she have a limited stash? Or was she just to lazy to go get one? No doubt she's busy, we all are but fuck, we need a goddamn pulse ox reading. Either way, I thank her profusely, I act as if a great personal favor has been performed.
Intern wants a C.V.P. Got to set that up. Haven't set up an A-line and CVP simultaneously from scratch before. It takes me about 10 minutes longer than it should have. I see  the Supervisor an
the old Burnouts watching the monitors from outside. "Wait-there it goes, nope!HA-Ha!" It is sport. I plug it in wrong like 5 times but eventually I realized I had the CVP in the right ports, I just needed to zero the monitor out before it would start reading. Low and behold- got 'em both. Now that knowledge is mine. CVP=5. That's low. The written order is to continue bolusing until CVP is above 15. We gots along way to go.
My patient B.P. sank then rose as we brought the levophed up to 40mcg/min. The resident walks in. He sees the patient start to move her right arm. The k-hole (ketamine) Dr. Drugs had put the patient in to paralyze her is starting to wear off. I'm relieved. She's got neuro reflexes slowly coming back. So what's the first order form the rez? Fentanyl and Versed. Fucking drip. I literally said, "My BP!" The rez went on some diatribe about how much pain she must be in, I was thinking yeah, but think about how much pain she WON'T have when she's dead. He insists. An hour later, with the smallest rate of Fentanyl and Versed possible, she takes a dive like a bomb over London in 42'. which also happens to be her systolic blood pressure again. 

And then my friends, the light shone upon me. The gift of experience, the undeniable truth of going-thu-it came to visit me that eve, and left me as excited as a waking seven year old who has left  a molar underneath the pillow. The intern and I concluded: She's not dying tonight. We went to town. Dobutamine. Max it the fuck out, to start. Pound a bolus down. Family comes in. Intern and I tag team to stay functioning. I listen to their fears, he gives them the surgical realities. Intern manages to sink a one and a million shot at 4 am with a new triple lumen in right groin. Now I got accesss baby. 2 bags of albumin down the hatch. Next up: Fuck it 25% Albumin.As I'm running by  Charge Nurse says, "You asked for it." I tell her do you hear one iota of complaint from my mouth. "No. Nope," she says. Good. Shut the fuck up.No one would help me if I asked. Certainly no one offers. Snickers and asshole comments as I run. I'm sprinting to other modules to grab pumps, bags of saline since I had used all of ours. At 4:30Am the intern says, "This is a lot of work for you isn't it?" 
Fortunately he was over sedated by the day shift nurse who is approaching an increased age and mentation  where I wonder if she knows where she is during work, I can't believe she's a nurse in the I.C.U. let alone taking care of people. She means well and is generally nice. Fuck it- that counts. I know the reason why the sedation was up so high because 1) she can't figure out how to operate the ancient "computerized" pumps and 2) she had the observationist tech do it (SEE:LAST ENTRY-dude got me $4K back on my federal tax returns)  I pull back on his sedation, tighten his celestial reins and it buys me time. He doesn't have too many meds, he's certainly not shitting after the opiate load he got today, I just duck in and reposition him q2 hours. 
Supervisor tells me I have to take lunch.  My turd of a charge nurse takes over which means she parks her fat ass in front of the monitor and calls the other modules to tell them how funny it is I'm running my ass off. "Yeah. One of the new ones."
While I'm having lunch one of the most vicious of the old guard strolls in on his third lunch break, his assignments are a fucking joke, a facetiously asks me how tonight is going. This fucker never asks me that. I tell him, "Going well. You?" He doesn't makes eye contact. 

Day break comes. I hear the morning traffic start to blare out from television in the conscious patients' room. At 5:30 AM my experienced co-workers were forced to take over my other patient. I had so many pumps and drips going that according to union rule, or maybe it's in the old testament, not sure which, my patient became a 1 to 1. But never missing the opportunity to insult and degrade I hear my supervisor tell the day shift  supervisor, "Well, she's a soft 1 to 1."
Her tone insinuating, we have to, but we don't want to. Listen friends: I know it, you know it, she didn't want to give me credit, her insult was an admission of truth, there was no sarcasm to decipher no questions without self incriminating answers to stumble through: her dislike of me was a gift of credit. For if she had said "Wow this patient was a fuckin train wreck and you need some good staff on this one"-well that would have done me justice. That would have put my rank higher and I honestly would have thought that she was goofing on me. Her answer was a begrudging admittance of truth: a soft one to one, for a soft new nurse whose shell hasn't hardened yet from years of overwork, abuse from superiors, no breaks, distended bladder so-called friends hating/loving you from  one minute from the next. A soft 1 to to 1.
The patient was mine again the next night. During the day the Attending M.D. had come in, broke some rules and stabilized her with techniques unavailable to the night shift. I can't elaborate but he did what Attendings usually do and ignore patient wishes in the place of his ego's demand. No matter. She didn't die that night either. 
Three people, it's true! No less than three people told me I did a great job of keeping that lady alive.  Somebody noticed. And even though the Supervisor apparently heard that one of the people who had told me I was doing well was too valuable to her to have a compliment like that stand. Even though he too stopped mysteriously talking to me 3 hours after his compliment, the compliment had been spoken, like a wish thought out during a birthday, or a coin thrown in a fountain, or victory in snapping the majorous side of a wishbone. 
     The RN that complimented me, Chuck, normally works float during the day but was filling in as house supervisor for the vacationing real one. People generally thought it funny that Chuck was House Supe as he normally just does lunch  breaks. I needed a compressor for leg squeezers and two of the senior nurses told me to call him to bring one up. My supervisor found out and did her fake drop the jaw thing, parade around the base desk, smacking her fore head, accused me of violating the chain of command by calling the house supe who happened Chuck that night. I detected a faint smile underneath her rant. Happy, he fucked up. Of course the older nurses who told me to do it didn't speak up. When Chuck delivered the compressor he said he was glad he could help out  but in the morning when I thanked him again for the compressor he just said "whatever", scowled, and literally turned around and walked away.This is my Supervisor's way. I have experienced this with other older nurses as well when they turn someone against you. "I can't believe he did that to you, who does he think he is?" The person who previously wasn't aware thatthey had been insulted now feels SUPREMELY insulted.)
The vicory was still mine. And while I do not believe I could ever function in this high acquity without the support of my co-workers, it's too exhausting and inevitably a fuck up will slip that will put yur career's fate in the hand of the Supervisor on duty, well that's it.  However, tonight I got one step closer to independence and got just a little bit closer to not being at the whim of those who are so "experienced" as they recipricate the abuse they no doubt at some point endured or continue to endure.
I never was a bully in school. I moved a lot as a kid, some years I was popular, other years I was shit. But I never broke down an teased others to make myself look better. Now, I talked shit about every more popular, better off, better looking kid under the sun to my friends out of jealousy but this was out of general disgust of human behavior and a deeply disturbing underlying antisocial outlook on circumstances at the time but I never attacked the vulnerable. It's not in me. It wasn't then, isn't now, never shall be. 
The only thing is, is it obvious? or hidden like I like to tell myself that it is. Wanting to consume the biggers power, experience, knoweldge, standing.
I think of what the only new hire with experience in the group said to me as a friend during orientation, "I may have been a nurse for only six months but these bitches are going to hate you forever, for life. You do just the right things to piss off the older nurses.  They hate you because you are right and that's why you don't realize you are doing it."


Wifey said...

Great entry, baby. You are in a war zone and grow stronger every shift. And saving people. I am so proud of you. You should write a book someday.

JanetBoydArt said...

Thanks so much for your true and helpful writing. Now hear this. I have been a nurse since 1964. Pitiful, i know. Surely a person with more that six neurons to bounce around could have found a better way to make a living in that time. I have a new job as a home health nurse in the country,,,and they are making me pay dues. They are being mean and i know talking shit about me. You have helped me deal with it. Helped me not take it personally. Even tho a secretary made a point of being nice to an aide, just to show me that it was personal. She treated me like shit. I thought, of she is having personal problems, then she was all super friendly with an aide in my presence to make the point that i was the dick head. You put things in perspective, my position is less stressful than yours. Thanks. You talked about the poor self esteem of the nurses. Yes this dysfunctional profession is pervaded with self esteem issues, for many and complex reasons. I have noticed, having had many many nursing jobs. (always thought that the grass was greener, usually it is not) On stressful units the nurses are bitches, on the rare, very rare unit where nurses are not overworked the nurses are nicer. I do wonder why you started in icu. why not get your feet wet in something easier, like rehab, then move to med surg then to icu. working at least a year in each unit. thanks, jan

JanetBoydArt said...

Nursing is the Guru Master from hell.