I have a patient who went on hospice care a few days ago. She appears fine. She is not fine. And she knows it. She is just waiting in a small hospital room watching reruns of CSI and whatever junk they have on TV these days, making herself happy in small ways with the food she can tolerate, complaining about things that she can control when she feels overwhelmed by the things she can’t.

Oh my God, how humbling. What would I do in that position?
What would you do?

Imagine this. You are sick but trying so very hard to beat it. You go to the hospital for a stomach ache. You are told that you have an intestinal blockage and it’s a tumor recurrence. Furthermore, there is nothing more they can do.”I’m sorry, there is nothing more I can do. I can make you comfortable, and keep your pain to a minimum…but there is nothing medically I can do to stop the progression of your disease. You most likely have about 2 weeks left.”

Oh my god. What if that were you? What if you only had two freaking weeks left and you are too sick to go home, too sick to do much, but well enough to be aware and to understand. Well enough to realize “Damn. The writer’s strike doesn’t matter to me because I am not going to be around to see the new episodes of The Office. Christmas ads mean nothing to me because I won’t be home for Christmas this year. I won’t see my cat or dog again. Ever.” It just goes on. No more summer corn on the cob. No more Valentine’s day candy. No more fireworks. You don’t need to worry about taking next year’s summer clothes out of storage and trying them on to see if they still fit.You can cancel your dental checkup and your next haircut. Any appointments you have…you aren’t keeping them.All of life’s special things, and all of life’s mundane things will continue on, but they will continue on without you. You won’t be there.

How would you feel? How would you handle it? You can talk, eat, drink, and have minimal pain. You are tired but not exhausted. You are alert, you are in your right mind, but within 2 weeks - FOURTEEN DAYS - You will become progressively more and more ill. Then you will die.Nothing we can do about it…. Would you cry? Complain? Retreat inward? Would you change anything? Would you mend relationships? Would you rebuild bridges knowing that your particular bridge is going into the great beyond? Would you confess your love for someone whom you’ve never told? Would you confess your hate for someone whom you’ve never told?

Put yourself there. It’s a scary place.

You really can tell infection by smell.
You can also tell impending death by smell.
Little old ladies can poop more than your average quarterback.
Little old men can have ‘innies’
The average man is NOT 7″ long
If someone says that they think they are dying—BELIEVE THEM
If you don’t clamp off your IV catheter before you attach the clave, you will see an amazing arc of blood.
Urine comes in many fascinating colors.
So does poop.

Yesterday, the ED was on Red which means there were no beds available. My side wasn’t quite slammed yet but with the acute side of the ED full, it was only a matter of time until our side got full not only from our own designated patients, but also with patients who may better have been on the acute side, were there any room. Basically, a relatively normal day.

I got to work prepared for a busy 12 hour shift. I asked the charge nurse, who is one of our Nurse Leaders, what my room assignment was and she smiled. handing me the charge phone, she said “We’re training you today for charge.” Now, I have asked for this opportunity several times and I feel ready for it. But the minute that phone was in my hot little hands, I felt a surge of panic.

Me? In Charge of the whole Urgent Care section of the biggest ED in my city?? ME???

I swallowed hard, my mouth gone dry. “Cool!” I managed to say, telling myself that I want this.

The Nurse Leader took pity on me. “You’ll only have two beds to care for all day, and I’ll be here,” she said. “Until 4″. Which meant that from 4pm until I was scheduled to leave at 10pm, she wouldn’t be there.
I smiled weakly. This is something I can do, I thought. I hope.
The phone started ringing almost immediately. Calls were coming from Triage..can I take this or that patient, do we have a bed for one patient, can the attending come to triage and evaluate another patient….I just kept answering calls and doing my best. Using critical thinking and my nursing judgement, (which apparently I do have!), I fielded each call and cared for my two beds.
I did my best to assign beds fairly, alternating between the different zones so that no nurse was unfairly overloaded. I asked lots of questions, and helped the other nurses as much as possible.
Before I knew it, it was 4pm and the Nurse Leader was leaving. She told me not to worry and told me I could page her at home if I had to. “But really,” she said. “You are doing fine. You won’t have any trouble.”
So I kept on going and the night was going very smoothly.
Until we ran out of beds again.

Around 9pm, we start to taper the patients we take on the urgent side, since staffing goes down for the overnight shift. Concurrently, at 9pm not only did we get five more patients to be seen, the rest of the ED had gone red again and there were 10 acute patients who had been waiting for hours in the lobby. The charge nurse from the acute side called me, begging for me to take some of their patients into the urgent side.

I sat and thought.

I had five patients waiting who were appropriate for my side of the ED, and I had to take them first. The urgent patients become my priority. Not because they are sicker than the acute patients, but because after midnight, we would go down to one nurse and one provider and if I took patients with heavier needs, the nurse/provider team would become overwhelmed and the patient care could be compromised.
I reviewed some of the charts for the acute patients, and found a few that could conceivably come over to our side if necessary.
I helped the rest of our nurses with their discharges, opening beds and filling them just as quickly.

All the while, I kept the attending physician aware of the plans, as well as the other providers and nurses.

When I left, all of our waiting urgent patients were roomed, we had one room reserved for patients coming in via ambulance/EMS, and there was a working plan for dealing with the overflow of patients from the acute waiting room.

When I walked out, my legs were sore and my brain was tired. It had felt good to give report and hand that ever-ringing phone to the next nurse. But I felt invigorated as well.

I did it. I ran the show for 12 hours. Everyone survived, no one complained.

Me in charge? Oh, yeah. I showed myself I can do it, and I can’t wait to do it again!

“A Dios mio! Pain! Pain!” I heard the woman’s cries all the way down the hall as she was led by the ED tech to my last empty bed. I sighed and took the chart from the tech. 60 year old woman with a three day history of left flank pain. “OK” I thought, this should be easy.

I went in to see her, and introduced myself. She was tiny, barely 5 feet tall, her graying hair held back in a bun. She told me her name was Sonya and that her doctor had diagnosed her with kidney stones at one of the other local hospitals. She’d decided to come here because “they don’t give me any help.” I had her put on a gown, started an IV and drew labs, and instructed her to give me a urine sample. “Thank you thank you,” she said in breathless, broken English. “The pain is very much worse.” I smiled and pointed her to her bathroom. She patted my hand before heading that way. I am always a sucker for the older patients.

In the meantime I checked on my other patient in the same room. David was a 30 year old “frequent flyer” who came in via EMS writhing in lower abdominal pain; he was going to be worked up for possible appendicitis, even though he’d presented five times this month already with similar symptoms. His tests had come back negative each time, and the doctors were starting to suspect he might be a drug seeker. David was resting comfortably, having received a morphine and phenergan IV cocktail.

I could tell when Sonya was back to the room by the progressive moans and groaning she made as she ambled back from the bathroom. I helped her into her bed and assured her we would make her as comfortable as possible. I told the ED resident that Sonya was in a lot of pain, and that she was ready to be seen.

Next I saw David’s call light go on and when I went in to check, he told me that the pain was back again, and he asked for more morphine. The pain was rated a 10/10 and he curled up on the bed holding his abdomen. I remembered his last visits, which were the exact same presentation but nothing was ever found on CT. I looked at the clock; it had only been 45 minutes since he’d received the morphine. I tried repositioning David to find a more comfortable position but it was useless. He was in pain no matter what position he was in. I asked the resident for another order of morphine and she wrote it with a sigh, mentioning that it seems David had increased his visits lately and maybe it was time for a psych consult.

The resident saw Sonya while I prepped David’s morphine.

When I took the medication back in for David, Sonya saw me and started moaning again. “Is that medication for me?” she asked. I told her I was sorry, it wasn’t, but that I’d have some as soon as the doctor ordered it. She looked so small and alone in the bed. I brought her an extra blanket. I quickly obtained the order and administered Sonya some morphine. She lay back happily.

Shortly, both patients were transported to CT. I went about my shift caring for my other patients.

A half hour later, after both of the patients had returned, “Look at this” the Dr said, indicating her computer screen. Sonya’s CT was perfectly normal, no evidence of kidney stones.

“And this too,” the resident said, changing computer screens. Sonya’s history came up on the screen; she’d had 15 visits in the last 2 months, all with pain. Futhermore, her history indicated a continuous use of street drugs.

The resident sighed and was about to get up and go see Sonya when her pager went off. She returned the call and turned to me. “David’s got a hot appendix. He’ll be going to the OR within the next half hour.”

As I sat filling out the pre-op paperwork for David and listened to the resident as she attempted to explain to Sonya that there was no evidence of kidney stone and that she would not receive any more morphine, I sighed. In this business, it’s so easy to gain preconceived notions and ideas. This was a good night to remember that nothing is ever necessarily just what it seems.

As I write this today, we are marching through National Nurse’s Week. This week there have been lots of fun things at work-free food, free gifts, bowling, and other things to do. It’s a chance for we nurses to be recognized and remembered for what we do for others.

Nurse’s week started in the 1950’s but was originally begun as a one-day celebration of recognition. Later, the ANA adopted the week of May 6 - 12 as Nurse’s Week, and it is permanently celebrated on these dates.

Nurse’s week is more than just a time to get free food and gifts, though. I find it to be a good time of retrospection. It feels like an affirmation of sisterhood (or brotherhood!). To me, having time where we are recognizably appreciated by management and media helps shine a light on our profession, and hopefully shows others that as nurses we are hard-working professionals within our profession.

If you are a nurse or soon to be a nurse, take some time to reflect this week on your reasons for going into the field. Use this time as a chance to reconnect with your initial feelings about nursing and to remember why you chose to become a member of this challenging, busy, tiring, fulfilling and awesome profession. Take a few minutes to relax and reflect; you deserve it!

For a great gift for a special nurse or for yourself, click here.

I had graduated. Before I knew it, I was in my very first hospital orientation, and it was two more weeks of classroom learning. Learning hospital policies etc… the studying started again.

The NCLEX-RN began to loom like a shadow….a big scary nightmare-inducing shadow. Dreams of failing it scored my sleep.  My fellow graduate-nurse buddies and I obsessed over and speculated on it…how many med calculations did so and so get? How many questions did it take to pass? How the hell will I go through with this? The Nursing Boards are a HUGE DEAL. Your life depends on it. Everyone knows the story of the graduate nurse who got her new job at the hospital, and bought herself a fancy car as a reward for finishing school. Then she took her NCLEX. And failed. She lost her new job, her paycheck, her car, and her sense of self-esteem. Yes we’d all heard of her and by whispered fears and nightmare study sessions we tried to ensure that we do not become her.

July 24, 2006 at 0830 I entered the test center. At 0910 I re-emerged into the summer heat feeling like I’d been hit by a truck.  My ENTIRE nursing education…all the labs, objectives, skills, vocabulary, notes, math and meds….all had been boiled down to one test WHICH TOOK LESS THAN HALF AN HOUR. The test itself is all computerized, and the number of questions you get is based on the answers you provide. The minimum number of questions are 75, and the maximum is 265. You can pass with any amount of questions. And you can fail that way too. I got the minimum number of questions. The computer shuts off when its decided that you either passed or failed. Turning off at 75 means you did very well, or really bad. The questions in the test seem to get harder and harder. When after my 75th question the machine clicked to grey and I realized it was over, I put my head down on the desk for a minute. That was it???

All the studying and I had four medicine questions about the same med and NO MATH? And almost all the rest of the questions were priority…no disease specific stuff, no peds, no OB, just almost all priority.
I came out feeling, and dreading that I had failed. I was completely convinced of my failure. I tried not to cry as I stumbled out. My mouth was dry going in…no gum, no mints, and no water bottles allowed. As I stumbled out of the test center is was watery in panic-induced nausea.
Oh my god I wanted to cry. Or laugh. Or sleep. Instead I went out to breakfast with a friend of mine who is already a nurse, and she commiserated with me and told me of her experience, when the exams were several days of written answers. Somehow that sounded better than what I’d just gone through.

That’s it. No more tests. Pass or fail. Thoughts of the student loans that I would have to pay off while flipping burgers at McDonald’s because I have failed the licensure exam hovered in my thoughts.

I went home and started checking the web for my results. The BON in my state posts pass or fail within 48 hours. Sometimes earlier (unusually) but mostly right at 48 hours, or at 10am, whichever comes last.
The first day of waiting I immersed myself in work. The second day I tried not to be sick I checked the site every 15 minutes from 8am on. By 0930 it wasn’t up and I thought okay, I really did fail. I will never be a nurse (By the way, you can retake the test if you fail, you just have to wait for a period of time.)  At 10am I decided to use the phone-in system. It would cost $10 but maybe it would have a result. My poor husband, who was at work and fielding my 10minute phone calls all morning, suggested checking the internet one more time. I did. My results were there. With a license number next to my name.

I PASSED. I was a nurse.

A real, live Registered Nurse. A PROFESSIONAL.

I could wear white pants and a stethoscope and not feel like an imposter. I had been deemed legally competent to practice nursing.

The feeling of knowing you passed your boards is like a weight falling off your shoulders. Literally. You don’t have anything left to study. You have no need for the $150 of exam review books that you’d been reading for the last several months in preparation. You are a veteran, a survivor of the NCLEX-RN. You went in the door of that test center a graduate and came out a nurse.

 Some people celebrated it with parties and drinking and fun. I went to work and began to sign RN after my name with great joy. Then it hit me.

Oh. My. God. I. Am. A. Nurse.

I am a licensed healthcare professional. I have been trained to assess you, and I am responsible not only for providing you with basic nursing care to meet your needs, I also will be providing you with specialized care. I know how to insert a catheter into your bladder and an IV into your arm. I know how to run the IV fluids and I know the reason for using normal saline vs lactated ringers and I can tell you if you ask me. I know the side effects and uses of all of the 15 medications I am giving you and I will tell you if you ask. I can give you a shot if I have an order for it. I also assess your spiritual, mental, and emotional health. I can talk to the doctors about my concerns and the doctors take me seriously as a peer. (Well, most of them) The new doctors ask ME what they should do for you and I can give them ideas, all the while reminding them “Well, I’m not a doctor and can’t prescribe but I have seen drug XYZ used in this case before” or “Did you want me to do ABC for this patient?” I am responsible if the aide/tech doesn’t complete her work and I am responsible to see that you have a safe stay in the hospital and that no matter how bad a shape you were in when you got here, when you go home you will at least not be in any worse shape.

I hug you when your mother dies. I hold your hand when you are taking your last breaths. I bandage your feet. I teach you how to breastfeed. I let you cry when you need to and I hug you until you stop. I laugh with you. I cry with you. I make you do things you don’t want to do, knowing that later you will thank me, and you do. I sneak you a cookie when it’s late at night and you have the munchies and hospital jello just isn’t doing it for you. I wipe your bottom when you can’t reach it and I hold your hair while you puke. I pack your wound and I measure how deep it tunnels. I change your bandages, your dressings, your diapers and your peri-pads. I sit with you and hold your hand where there are no words to say.
I do what it takes to make you well and failing that, I make you comfortable.

I am your nurse.