All Deaths Are a Great Loss

When I was in nursing school, an “elderly” instructor (she must have been at least 60)

Bones (Redivivus) by jparadisi

Bones (Redivivus) oil on canvas by jparadisi

asked our class,

“Is the death of a young person a greater loss than the death of an old person?”

The oldest student was maybe 30. Unanimously, we agreed that the death of a young person is the greater loss. The instructor’s expression let us know she did not agree,

“All deaths are a great loss. No one wants to die. As nurses, you’ll do well to remember this.”

My first nursing job was in pediatrics. I remained in pediatrics for 15 years, and my student perception of the death of a young person being a greater loss than the death of an old person was never challenged. However, now that I am an adult oncology nurse, I have a better understanding of what our nursing instructor was trying to teach us that day.

Few people would argue that the death of an older person is sadder than that of a young person, but that’s not what my nursing instructor had asked. She asked, “Which is the greater loss?” The losses are equal, but for different reasons.

The death of a young person is a great loss because the world loses a potential Picasso, Hemingway, or Madame Curie. The parents of the youth lose the legacy of grandchildren who may have been born to their child. If grandchildren are already born, they lose a parent. The dying youth loses a full lifetime of experiences, love, joy, and sadness — the bittersweet fruit of a ripe old age. A piece of hope dies with them.

When an old person dies, the world loses a Gandhi, Rosa Parks, or Mother Theresa. More commonly suffered are the loss of a spouse, a parent, a close friend, or confidant. We lose someone with whom we share common history and memories. Upon death, an old person takes a piece of life from those left behind. With this understanding, I sit at the bedside of elderly patients, holding their hands as they grieve out loud their cancer diagnosis and impending deaths. I grieve their loss as greatly as I did the loss of my pediatric patients.

Nurses know that every passing life is a loss and there’s peace in knowing there’s no need to judge.

How to Give Good Phone

by jparadisi

painting by jparadisi 2013

Nurses spend lots of time on the telephone. So much, that I believe How to Give Good Phone should be taught in nursing school as a subtopic of therapeutic communication. For the rest of us, here’s a crash course developed over the years.

We all remember that communication has three components: sender, receiver, and a message:

Sender. Nurses call other departments for a variety of reasons. We call material supplies requesting special bio-occlusive dressings for patients with adhesive allergies. We call the pharmacist with questions about unfamiliar medications. We call physicians requesting new orders when a patient isn’t doing so well.

Receiver. Nurses also receive phone calls. Physicians call to admit patients. The lab calls, announcing we didn’t send the blood tests in the right colored tubes, and they need to be redrawn.

Someone we don’t know calls, asking if his mother, who we also don’t know because she is not one of our patients, is done with her appointment. When we ask him for more information to find her, the caller misconstrued this to mean we’ve misplaced his mother, which brings me to…

Message. Clarity begins with the sender. Intuitively, message should be the simplest part of the communication process, but in fact it is often the most difficult, especially over the phone, where visual information is lost to the sender, the receiver, or both. This loss of visual information is what makes reading back a telephone order by a nurse to a physician a critical component of that type of communication.

Here’s another example: you’re calling in a hemoglobin value to the physician. If the lab value indicates borderline for anemia, but you strongly feel the patient would benefit from a transfusion, you would want to include the subjective symptoms you see at the patient’s bedside: headache, shortness of breath on exertion, and increased fatigue. Knowing that you are going to suggest a transfusion for this patient based his clinical assessment before pushing the phone number keeps the message on track and focused on the patient.

I’ve been the sender of a message to a receiver (not a physician), who appeared confused about our roles. She did all the talking.  This obstructed my message. Perhaps anxiety caused her to blurt out lengthy commentary irrelevant to the subject of the call, I don’t know. I let her talk until she needed to take a breath, then interjected, “May I give you more information?” each time this occurred, until finally my message was delivered, and we got to work on the real problem.

Why would I devote so much time to this phone call? Because I needed the services of the receiver on the other end of the phone. Interrupting her abruptly to tell her how busy I am, using a smug tone of voice, or getting angry would simply slow down progress, and patient care. Giving good phone requires a purpose, an intended outcome, and patience.

What is your biggest peeve about telephones at work? How does your unit help patients seeking information by telephone?

A version of this post was previously published on TheONC.org.

Poll: The White That Binds Ornament

Readers, I’m doing some marketing research, and I need your input.

Last week during my interview on RNFMRadio, Keith, Kevin and I discussed creating an ornament with the image of my painting, The White That Binds (Pinning Ceremony).  I believe Kevin’s suggested I consider doing this in time for Nurses’ Day, in May, and June graduations. The ornaments would be available to buy on-line. What do you think? You can leave further suggestions in comments. Thanks for your help!

The White That binds (Pinning Ceremony) mixed media by jparadisi. )

The White That binds (Pinning Ceremony) mixed media by jparadisi.

One More Skill On My Resume

Years ago, I had a coworker with the best attitude about learning new skills. At every in-service, sort of like Kenneth Parcell on 30 Rock, he would smile a toothy, freckled face grin, and say, “Hey, it’s one more skill to add to my résumé.”

In May 2010, I wrote Not All Days Are Magically Delicious, a post in which I describe my frustration while learning to apply a wound vac to a patient’s wound. In case you don’t feel like reading the post:

A wound vac is a small mechanical device in a fanny bag, worn by the patient 24/7. Black sponge is packed into the wound and covered with an adhesive, transparent film. A suction tube connects the dressing to a canister attached to the wound vac. When the wound vac is turned on, it sucks all the air out, compressing the sponge tightly into the wound. There is barely any sound as the machine “vacuums” the wound’s drainage into the canister. The suction stimulates healthy tissue, often reducing healing time dramatically. If an air leak is present, there is a loud sucking noise when the machine powers on, and the sponge will not compress. This means it needs more transparent covering to seal it. If that fails, the entire dressing comes off and redone, which is not very comfortable for the patient. (Excerpt from Not All Days Are Magically Delicious by JParadisiRN, May 2010)

For that post, I even made a little painting of a wound vac so you can see what I’m talking about:

Wound Vac by jparadisi 2010

Well, I’ve come a long way in two years. I am happy to report I have changed many more wound vac dressings since writing that post, and each time the machine starts up with the sponge fully compressed and without that awful sucking noise, the very first time. The trick is realizing that you can never apply too much drape (it’s like self-adhesive Saran Wrap). Doing so prevents those wicked little air leaks. I can now spot the problem areas before powering on the wound vac.

Whether you are a nursing student returning to school, or a seasoned nurse struggling with new technology, don’t give up. Keep at it. One day, that piece of equipment you struggle to manage will be another skill you can add to your résumé.

Shift Observations: When It Feels Like Work

Our fatigue is often caused not by work, but by worry, frustration and resentment.

Dale Carnegie

Derail photo by jparadisi 2012

I had one of those patient assignments I couldn’t get control of. The care plan refused to move forward in its time frame, despite fervent pushing. There were unexpected variables: The patient possessed few usable veins; those she had were challenging, and time was lost starting her IV. The infusion wasn’t available when expected. Once it started, the vein blew. No harm occurred to the patient, but another vein had to be found, another IV had to be started, all at the cost of more lost time. It became clear the patient was not going to be on time for a scheduled procedure in another office. This happens once in a while in the ambulatory setting, mostly because the parties doing the scheduling are unaware or overly ambitious about what can be done in a limited amount of time.

I called the RN at the office scheduling the procedure, explaining our patient would be late. Then I returned to my post, watching her IV, willing it to stay open and unobstructed. The expression on my face must have been intense: I didn’t notice our nursing student enter the unit until he came to me and asked, “Tough day?”

This student returned to school to pursue a career in nursing. His commitment, work ethic and accountability are rare. Despite raising a family, and going to school full-time, he finds things to do above and beyond expectations. He’s smart and funny too, with a natural ability to get along with our crusty, all female staff. He’s going to be a great nurse.

“Yeah, it’s a tough day,” I replied. Remembering how hard this nursing student works I realized, instead of whining, I had the opportunity, a choice, to show some professionalism. I explained some of the factors making the assignment difficult. Without thinking, out of my mouth came the words, “Solving the problems is what I do as an RN. This is what I’m paid to do. When things go wrong, that’s when my education kicks in full throttle. I’m here when the work is slow, for the times when things get tough.”

The student smiled and said, “Yeah, that’s what makes it a profession. It’s like when I had my company, the job was easy until there was a problem. That’s when it felt like work.”

He’s going to make a great nurse.

You’ve Come a Long Way Baby. Maybe.

Untitled. photo: jparadisi 2011

A friend of mine talks about aspects of one’s life occurring between bookends.  People use the cliché “things come around full circle” to mean the same thing, but I like my friend’s reference to bookends better. Coming full circle suggests ending back where one started, but the bookends metaphor implies a linear journey that includes revisiting one’s past, which is unavoidable if you live long enough. Personally, I prefer the bookends metaphor to the circle one, because I think moving forward is an important attribute of  happiness.

Today was my second shift using the new electronic medical record. Yesterday I practiced order entry, updating the home medication list, and documenting blood transfusions. Today, I focused on medication administration. The way the EMR works in our hospital, patients wear a bar code wristband and the medications are bar coded too. When giving a medication, the nurse deploys a laser scanner the size and shape of a pistol to scan both the patient and medications, verifying that the right patient receives the right medication, an important upgrade in patient safety. Scanning the bar codes exactly right so they register in the EMR is tricky. Most of the time I had to repeat the scan more than once before I got it right. I’m thinking it’s not very different from learning to start IVs: eventually my small motor coördination will develop muscle memory, and I will have a “feel” for getting it right the first time. It just takes practice.

Sometime during the course of the shift, however, I told a coworker that if my scanning ability doesn’t improve, my plans for a career at Whole Foods are doomed. We laughed. Then I remembered something from my nursing school days:

When I entered nursing school there was a nursing glut. Nursing shortages hadn’t occurred since before Salk invented the polio vaccine, and tuberculosis ran rampant. Around the same time, grocery store chains were investing in a new technology using lasers to scan bar codes on grocery items for prices at check out. After attaining my Registered Nurse license, I could look forward to eventually earning the same hourly wage as grocery clerks then. All through nursing school, both instructors and students joked about “scanning cans” for a living, if our careers in nursing didn’t pan out.

My very first nursing job paid an hourly wage of thirteen dollars and some change. Six months after graduation, the first wave of a nursing shortage hit where I lived, and my hourly rate nearly doubled in a single pay raise; a windfall. I never thought about scanning cans again, until today when I aimed a laser scanner at a patient’s wristband and medications, and I realized I have traveled a straight line punctuated by a bookend.

What I Learned in Nursing School about Customer Service

Detail of painting (2009) artist: JParadisi

     Many of my patients are recently discharged from the hospital. Most of them tell me about the wonderful care they’ve received there, and even mention their favorite nurses by name. I know a patient who memorized the names of all twenty nurses caring for him during a lengthy hospitalization, because he is so impressed by the care he received.

     Patients sometimes ask  if it’s difficult taking care of sick people. I always laugh when I’m asked this question, because it reminds me of the summer job I had before my last semester of nursing school. My classmates took summer jobs as certified nurse assistants, honing their new nursing skills. I needed a new, used car that summer, and working as a cocktail waitress in a resort town dining establishment paid better than working as a CNA.  

     While most dinner/cocktail customers I served enjoyed their evenings out, occasionally I’d get a cranky one or two. Besides the perennial customer complaining that his “medium” steak was not medium (is there any more subjective term in cooking than “medium”?), my favorite story is of the drunken male customer who began making lewd gestures and statements while I brought drinks to his table. I refused to serve this customer anymore alcohol, and he complained to the restaurant’s owner, who tried ordering me to serve him. I told him I wouldn’t do it; if he wanted to fire me on the spot, right before Labor Day, fine; I’d already earned the money I needed to buy the car and I was going to be a nurse soon anyway. Realizing he had no influence over me, the boss took a tray of drinks to the offending drinker and his buddies.

     Minutes later, the drunken customer jumped up on the  stage where live music was playing, and stripped off all his  clothes, butt naked. Horrified, my boss tried to man-handle the guy off the stage. He was prevented by the customer’s drunken buddies, who jumped up from their table and threw my boss out the door of his own restaurant,  dead-bolting it behind him. The bartender yelled to me, “Juli, get behind the bar,” and called the police.  I did as I was told this time.

     I’ve had one or two comparably difficult patients, since becoming a Registered Nurse. But, for the most part, I’m gratified by the graciousness, and kindness of the people who come in for care, trusting that my colleagues and I will take good care of them.