More Nursing Notes

Hierarchy 

    Seems way diminished. I’ve worked with plenty of young 20-something residents (doctors in their first few years out of school, when they are doing their practical training) who are comfortable with being called by their first name. But seeing a salt-and-pepper attending (boss doctor) introduce himself to patients and their families as simply Andrew was rather surprising. I’ve definitely felt on equal footing as a team member, and PT, OT, MD, RN, we always go by name, not titles.

Code status

    Different hospitals I’ve worked at in the US have different approaches and cultures around the code status conversation, but it is usually rolled out as this terrible question: “Do you want us to do everything?”  Couching it in those terms does not communicate that CPR (and intubation, and last-ditch medications that have serious downsides, aka “everything”) can have outcomes like broken bones, inability to wean off of the ventilator, and the fact that 40% of hospital attempts at resuscitation do not end up bringing somebody back from the dead.  The general public has a very sanitized, made-for-TV idea of what CPR looks like, and a lot of doctors who have conversations about the possibility of death want to get the conversation over as quick as possible, so they make shortcuts in communication.  So, unless someone has personal experience with CPR they are not disabused of the shiny miraculous TV version.

    Almost every patient I’ve seen on my rehab ward are DNR (Do Not Resusciate, sometimes called AND or Allow Natural Death) it boils down to they don’t want CPR attempted.  There is a bit of a middle ground where people can opt for transferring to ICU, being on IV cardiac medications, etc, but a lot of people opt out of those things as well.  There is an accepted risk with being alive, like the people with weak swallow reflexes who are at high risk risk of aspiration and pneumonia.

    I’ve only been in the room for one of these conversations so far, but Andrew handled it with aplomb, describing the different options and giving a clear idea that doing “everything” may mean quantity over quality of life.  This more nuanced conversation took only a moment, and it feels like it can circumvent the false belief that medicine can treat everything, always, endlessly.  Because it cannot, and it should not.

Schedule 

    30 minutes for lunch, 10 minute tea break, aka smoko.  So.  Humane.  I keep waiting for someone to jump out and yell “boo!” and there’s some trick to it all.  8 hour shifts.  I can work and take care of myself when I come home.  

Outside world

    The ward has direct access to sun, windows that open, and a little garden in between our ward and the neighboring one. I have seen a bird fly in a window, so it isn’t completely without hazards.  There’s patio seating and some garden beds planted with roses and some raised beds with some stunted and spindly tomatoes, and one really robust rosemary plant.  I’ve worked on floors that literally have no windows.  Let alone windows that open.  “Safety” has won out over psychological well-being.  

Yes, that's a grill in the corner and sun umbrellas and a pinwheel that spins when the wind blows. Almost as though people live here.

Home Visits

    In my first week of orientation the occupational therapist took my patient for a home visit, to assess safety in the lady’s actual home.  She fell in the shower, so that kind of answered that.  The 1:1 time and the fact that it takes places in the actual home the person hopes to return to is invaluable, though.  This past week, even more astonishing when compared to my past experiences as a nurse, a woman was able to take her husband home so they could have lunch at her house.  It was the weekend, so there wasn’t anybody who we asked for permission, there wasn’t any paperwork the wife had to sign, no CYA obstacles that anybody had to climb over.  This man just got to sit at his own kitchen table and eat a sandwich.

Uniforms 

    I've always appreciated the simplicity of a work uniform, scrubs aren't much to look at but you can put them on in the dark and they usually have enough pockets that you would know right away if they were on inside out. My current uniform consists of sets of work-issued scrubs with the hospital’s name embroidered on the breast.  The health system in New Zealand is called Te Whatu Ora, which is the entire public health system, hospitals and clinics on both North and South Island.  It means 'the weaving of wellness' which is rather lovely.  But back to the unlovely uniform. In addition to a blue top I have black pants. I could have gotten shorts instead of long pants, but wearing shorts to work is just too too too strange for me to even consider. That thin shield of fabric on my legs is a barrier against many a... substance.  The scrub tops have good pockets, a loop for my nametag, and a zipper at the side that one of the educators called “the fat zip” and she explained it was for when you get home from vacation and your uniforms don’t fit anymore.  The tops are boxy, billowy, and blousy and be-fugly, but hey, they were paid for by work.

The Rest of the Story  

I’ve worked with stroke patients in the acute, inpatient phase before, but that was always in the early part of their diagnosis and new disability, the crisis phase.  I feel like rehab is letting me see the rest of the story.  Sometimes that’s hard, because the story is that someone can’t return home to live independently, and patient and family both have to face that fact.  But sometimes the story is really great, and kind of the whole reason to do caring work in the first place.

My nurse manager sent out this email:

Mrs. R rehab, success or not, you decide!

I’m pretty sure almost everybody would know this lady if only by sight.  But when escaping, I mean discharging today, she left a couple of things so I took them round to her maybe an hour after she left.  I found her in her garden barefooted, trimming dead leaves etc. off some pot plants, and singing to herself as she did it!  And that’s why I do what I do for a job.  I suspect we all do, but don’t often get to see the end result.

Oh, and before you get any ideas, everybody here calls any plants in a pot “pot plants” to my great amusement.

Not That Kind of Pot Plant, The Other Kind

Disgusting Terminology

    Last but not least I have to end with something gross.  Because I wouldn’t be talking about nursing if I didn’t, right?  People here call having a poo a “bowel motion.”  And while technically true, I’m so jaded to the horror of the phrase “bowel movement" that this new play on the theme catches me off guard and grosses me out every single time I read it, hear it, or feel compelled to say it.  “Their bowels opened” gets bandied about as well.  I don’t mind the action, but the evocative quality of the phrasing is where the real horror lies.