Broken Heart

Last time it was the newborn baby with the fatal diagnosis.

This time it was the four month old with a 'non-accidental injuries' list longer than my arm.

Memo to self – do not work evenings on Valentine’s Day ever again.

Sometimes this job really hurts.

I just want to be Noticed

It must be some funky moon phase because we've had more people presenting with psychiatric concerns than usual, and most of them have had more drama than the usual Tylenol overdose or suicidal ideation.

Among the many, a few stood out. Those were:

• The girl with the hair scissors, nail file and dual pencil sharpener hidden in her underwear. (Prior to knowing the patient's gender the social worker noted that the patient had to be a girl, as a boy would never hide stuff like that in his skivvies!)
• The boy who "fell" down the stairs 48 hours ago, received an immunization 8 hours ago, and now, suddenly, cannot walk or move his legs, and his hand grips are weak. Interestingly enough after a full work-up at a referring hospital, a $600 ambulance ride and a late night assessment at the specialty hospital he was given some ibuprofen which dramatically improved his sensation and mobility, to the point that he was able to walk out of the hospital to go home.
• The lady who wanted us to believe that she was too ill from her Tylenol overdose and subsequent Mucomyst therapy that she couldn't participate in a mental health assessment yet, so she pretended to fall asleep in her chair, then slid to the floor and refused to respond to people calling her (but magically could prevent her hand hitting her face when it was dropped over her) until someone hit upon the brilliant idea of saying "You must be so tired after all of this. Come on with me and I'll tuck you into bed for a nice nap." She rolled over, moaned and crawled forward, then was assisted to her feet and led to a room where she proceeded to stick her fingers down her throat to make herself vomit (all over herself and her bed while refusing to use a k-basin) for the next 4 hours.

All I can say is: I am so lucky.

Stories

There is nothing more enjoyable or more educating than a good story. As a child I would read for hours, and short stories were among my favourite (as well as frequent re-reading of my collection of Cherry Ames books, of course!)

As an adult the time available for reading is much less, and good stories are hard to find. So, imagine my delight when Kim, the author of Emergiblog, began a blog carnival just for stories of, by and for Nurses!

Yesterday the current edition of 'Change of Shift' was posted. I have voraciously read every edition, but this is definitely one of the best collections yet (and not just because one of my infrequent posts is there, LOL).

Props to the contributors - you make me happy and proud and sad in an ongoing swirl of emotions. These are great posts. Thank you for representing our profession so well.

Props also to Kim - without your leadership we would not have this excellent forum. Thank you.

Lines

Coworkers ... are they your friends or are they friendly acquaintances? Where is the line? How far do you go for the people you work with?

What about the colleague who is clearly depressed and stating suicidal ideation and funeral planning? I've engineered a physician assessment that resulted in subsequent script writing and a mental health assessment and I've made myself available for conversation whenever he feels it necessary. He is taking the meds but is resistant to most of the other steps suggested; has attended the mental health assessment but is not finding it or the meds helpful... Must remember, he is not mine to save. Just because he is a friend it is harder to know where the line is - but in this case he is still just a patient.

What about the colleague whose child is sick and who is receiving substandard (ie wrong) care? How do I let him know where to find the appropriate care and tell him what that care should be? How do I know I am right? I'm just the nurse, and the doc is the doc, but sure isn't following any established standard of care... Must remember, I can provide information and options, but that is all. Just because the parent is a friend, it is harder to know where the line is - but in this case his child is still just a patient.

What about the colleague who is in labour, but whose is having complications and requires care that differs from her requests on her birth plan. I must care for her appropriately despite her stated wishes, but how do I help her to see this need? How many decels can I safely ignore without putting the child (and myself) in jeopardy? Must remember, I have two patients, not just one. Just because the mother is a friend, it is harder to know where the line is - but in this case the mother is still just a patient.

I wish that line would stay still!

Blast from the Past

I saw the name on the chart I'd just been handed and my heart skipped a beat. It couldn't be - but it was... Suddenly I was transported back to my high school days and I blushed miserably.

I'd tried so hard to make J notice me. I made endless drives past his house in my Dad's car, took his 12 year old sister out shopping, went to church with his grandmother and mother, walked home from school with his younger brother (who was in my grade) even though it took me well out of my way to my own home, and came to every friday night family movie night in his basement for months. Always without success. I was welcome, but was always treated like his kid sister. The whole family tried to encourage his brother to like me, but that never worked either. His brother just wasn't that into me, and vice versa.

In retrospect, this was to J's credit. A 26 year old with a 16 year old would not in any way have been an appropriate pairing.

Back to the present. It's 22 years later and my biggest unrequoited crush is now about to become my patient. I begged a co-worker to take this patient for me, and then made myself scarce while J was placed in the department. Professionalism was absolutely not possible.

Besides, I didn't want my memories of the kind young man he was tainted by whatever he had become..

Red is Blue

"Everything is changing. You're looking for the cure.
And you feel like you're the loneliest girl in the world.
Trouble in your head now, don't know what to do.
Seems like up is down and red is blue"

(Red is Blue ~ Ben Folds)

What is the deal with health care workers and depression?

Shrinkette quotes a Washington Post article that states "One in 10 American women takes an antidepressant drug."

Well here in Canada far more than 1/10th of my health care colleagues take medications for depression, and a significant number of my patients (especially women of childbearing age and the elderly) are taking mood stabilizers and antidepressants.

I was vaguely aware of this trend, and then as I read more in the blogosphere I've noticed lots of posts about my on-line colleagues (nurses, doctors and paramedics) and their ongoing struggles with depression. Most upsetting to me was Dr Dork who completely disappeared from the blogosphere after admitting that he was dealing with a depression crisis. As I read the comments to his post Dr Dork: Lazarus, arise ! I was struck by how many bloggers echoed his sentiments, including and Kim, whose writings I read every day, and whose writing never gives away the fact that she, too, sometimes needs help.

Why do so many of find ourselves frequently deep in the doldrums? Is it what we do? Are we so sad because we deal with heartbreak and sorrow on a daily basis? Or is it who we are - we are sad so we join others who feel the same well. Hell, misery loves company, right? Or is it that those of us who experience depression are more likely to end up in helping fields, allowing us some small feeling of making things better for someone else, since we can't do the same for ourselves. Is it a chicken and egg story with each of the parts chasing the other?

And why does it matter to me?

Because I think, after years and years of self diagnosed dysthymia, I'm finally ready to ask for help. I am finding it harder and harder to just press on, to put on a good face. At home it is easier and easier to retreat away from my real life into the computer, or instead of being home, to pick up even more shifts and work at a pace that prevents me from thinking about anything other than the patients in my care.

The asking for help is hard. Really hard.

Despite my knowledge that mental illness is just that, an illness, I continue in my reluctance to admit that I am sick. I want to believe that I'm stronger than that. I don't want to think that this could be hereditary. I've worked my butt off for years to prove that I'm not like my other family members whose life challenges have been a frequent and ongoing source of stress and concern. I'm afraid that if it is hereditary, I've passed it on to my kids, like some malignant gene that makes life miserable. I am mortified to have to ask my doctor for meds. My doctor is wonderful, caring, and a friend. Our children used to play together. I don't want her to know that I can't do it. There is no adult emerg doc that I work with who I trust enough to keep my need confidential. My pedi doc friends cannot prescribe an adult drug to an adult without opening them selves up to concerns about improper prescribing practices. It would be easier to ask a stranger, but there is no walk-in clinic doc that will prescribe, since they cannot do follow up. I can't go to a new family doctor as none in my area are accepting new patients. I can't think of any single person I could talk to without feeling embarrased at my weakness. I don't even want my husband to know, although he'd have to be blind not to recognize the problems after all these years. I also have difficulty accepting that I have these feelings despite having such an excellent husband, amazing kids, wonderful family, an terrific group of close friends and fabulous coworkers. There is nothing wrong in my life, so why am I so down?

Update. That was June, this is October. What a difference a couple months can make.

I did it. I worked up the courage (truly one of the hardest things I have ever done in my life!) and asked my Doctor to put me on an antidepressant. She was kind, supportive and prescriptive.

Swallowing the first pill was a real challenge - I wasted six before I managed to choke one down, but now they go down easily and they are working. I feel normal for the first time in more than five years, and probably closer to ten years.

Now my challenge is not to run though the streets with a placard proclaiming the benefits of my new medication. Truly though, this feeling is wonderful and I wish more people could feel it.

"I think I can make it now, the pain is gone. All of the bad feelings have disappeared. Here is the rainbow I've been prayin' for. It's gonna be a bright (bright), bright (bright) sun shiny day."

(I Can See Clearly Now ~ Johnny Nash)

You'll have to excuse me, I'm not at my best....

What do you get when you place a group of Emergency personel (nurses, paramedics & ancillary staff) in close proximity to large quantities of alcohol and loud music with a beat after a really busy stretch at work and lots and lots of rain?

That's right - a high school dance on steroids. A bunch of giggly, flirty girls and a competing bunch of horny, testosterone filled, strutting boys. A group that have been working hard and now are ready to party hard.

Boys: Just in case you don't remember the answers to those 'important' conversation starting questions you asked me last night:

• No, thanks. I'm happy to chat with you but I'm not going to go home with you. Nope. Not now. Nope. Not later either.
  
• No, I'm not a lesbian. These girls are my friends and co-workers, not my lovers. Really.
  
• Yes, I'm married. Yes, happily. Yes. Really.
• No, I'm not giving off 'unhappily married and looking for a great new guy' vibes. {Well, perhaps in your dreams, but since they started with you thinking/hoping I was a lesbian, then it is pretty clear that you don't have the best vibe reading skills. Especially since you can't even find my face because your eyes haven't left my chest in 6 minutes.}
  
• No, thanks. I don't want to dance. Really. {Actually I'm not on the dance floor because everyone else out there is dirty dancing. I don't dirty dance. I look like a duck having a seizure. So do you, but you don't seem to care, so feel free to go dance without me.}
  
• Yes, I really am 10 years older than you. Yes, really. {Nice try. I know I don't look like a teenager. I have a mirror, and no illusions about how old I look.}
  
• Yes, I can tell how drunk you are.
  

Girls: I'd also remind you of a couple things, since you also are likely not to remember.:

• Yes, your hair is flat, and you still look great, so stop stressing!
  
• No, I'm really not going to drink that shooter. No, it doesn't matter how often you chant my name or call me party pooper. Yes it is fine with me if you have the shooter.
• Yes I'm enjoying myself. No, I'm not drunk, but that doesn't change my last answer. Yes, it is fine with me if you want to get drunk.
• Yes, you really look hot, but it would be a bit more appropriate if your top wasn't completely falling open like that.
  
• Yes your husband would be a little upset if he saw how actively you were bumping and grinding with that paramedic.
• Yes, I really am heading home. Clearly I'm way too old to be here. Besides, it's 1:30 am and I have to be to work at 7 am. No, I don't mind if you stay. Really. Have fun and play safe!
  

Now, before you get the wrong idea, I want to point out that the evening was actually quite fun. We had a nice group of people. There were only a couple who really went over the top and the silly stuff was only a small part of the whole picture. None-the-less I was really surprised at how the people who I thought I knew showed themselves in an entirely different light once some alcohol was in the picture.

The evening also had another unexpected result. After watching a group of professionals overindulge despite their knowledge of the down side of excessive alcohol gives me a whole lot more empathy for those people who come to the department for stitches or whatever after a night on the town.

When Does the Nursing Start??

I had a busy shift in triage recently. Often there was a line-up and I'd be required to move on through ~ ABCD and focused assessment, two-three minutes per patient, no more ~ but every once in a while there was a lull and I could start some nursing care to make the wait to see the doctor more pleasant and to initiate care to reduce wait times once in the department - things like:

* providing ice to injuries and ordering xrays when appropriate
* providing tylenol and ibuprofen for fever & pain and pedialyte for vomiting
* offering blankets, water and popsicles to the people who had been waiting for hours to be seen
* collecting urine specimens and throat swabs and sending them to the lab
* applying freezing cream to the veins of kids who looked like they would need IVs
* reducing a pulled elbow (on the first attempt and only after a thorough assesment and history)
* removing the imbedded rock from the boy's knee and flushing it with saline before applying freezing gel

I acted completely within the scope of my practice, using standing orders, delegated medical acts and shared competencies to facilitate this or discussing with the physician prior to initiating care that fell outside these (such as the facial xray for the guy who accidentally shot his lip with a nail gun).

None-the-less it appears I did more than usual at this facility as no less than three people made comments to me

*"Why are you doing all that out there for? We won't have anything left to do when they get inside!"

*"Stop keeping them so happy - they'll just keep coming back!"

and, the real insult ....

*"What, you think you're a doctor now?"

Nope. I think I am a nurse and I am providing nursing care. I am amazed to think that I should do any less!