I wrote the poem below after my daughter had been very sick and spent several scary days in the PICU. I was only 6 weeks into my first semester of the nursing program, and ultimately had to withdraw that semester and restart again at the beginning of the next one.

The poem illustrates how I felt as I waited alone outside the CT scan room door. Every once in awhile I pull it out and revisit how it felt to be on the other side of the exam table, and to help me remember the feelings that my patients are experiencing:

TRANSPARENT BOX
I sat in the hallway in my transparent box,
Hard plastic chair digging into my thighs.
I watched them walk by from my seat in the corner,
Saw their eyes gaze just past me as I started to cry.

Important people surely with lives to be saved,
lab test and requisitions and orders for meds.
Yet I sat there invisible in my transparent box,
Did they realize my baby was in one of their beds?

Oh sure, one kind-of smiled and one sort-of nodded,
hurrying past the hallway where I waited in fear.
Stethoscopes swinging and lab coats like badges;
They can deal with diagnoses but were blind to my tears.

So I sat clutching my shoulders, trying in vain
To reassure myself they were wrong, and it’s only a test.
Shivering, shaking, my world falling to pieces
While they bustled on past me doing their best
      To look beyond me in my transparent box
      Where I found no doors, no windows, no locks
      No sympathetic ear to commiserate or heal
      No simple words to confirm what I feel
Just me all alone… in my transparent box.

Here is our winning joke for the month of June;

My daughter asked me ” Mommy do you get to sit at work?” I said yeah, ” she said where?” I said @ the nurses station, she said, ” Do they sell gas there?” I said no the gas there is free

Our Winner, nursenakia, will be receiving a $20 gift certificate from Nurse Station Catalog!

Submit a joke yourself, tell a friend, tell your colleagues! Winners are selected the 15th of the following month, and are contacted via e-mail for a mailing address to receive their prize.

(Please note, only G-rated jokes will be published and eligable for the contest)

It just never gets easier. Every situation is different, but every outcome the same.

I hate those stupid surveys that float around email that always ask “Have you ever seen a dead person”

Actually, I have, and I have seen more than I wish. It’s not some thrilling bit of info for an asinine survey. It’s a real event, with real people and real emotions.
You want to know what it’s  REALLY like? Think of this:

The family is sobbing in the hallway while the person to whom you spoke a day ago is now a discarded shell, the actual person having escaped to places Other.

The feeling of shutting off an IV and taking out the IV catheter from a vein that does not have any blood pressure.

The sound of the “death rattle” when the dying person loses their gag reflex.

The feeling of utter helplessness when you know you can’t do anything to make anyone feel better.

The fleeting feeling of fear when you give the dying person just a little more morphine because even though they are non-verbal, they are grimacing, and the hope that you didn’t give enough to kill them but just enough to comfort them. While at the same time the rational thought that even if you DID give them enough to suppress their respirations, your INTENT is to provide pain relief, and therefore you did nothing wrong so you give the morphine.

The sound of the shroud when you unfold it from the bag.

The fear in the families faces when they come to say “I think you’d better come….” and can’t finish the sentence.

The sadness in your own voice when you tell them that you cannot hear their loved one’s heart beat, and that you cannot hear their loved one breathing.

The difficulty in watching other grownups cry.

Having to call a doc and say “I need you to come pronounce my patient”
The heavy feeling of walking into the supply room and getting out the morgue kit.

After all their pain…all their tears….they thank you.  The family who loses a cherished loved one thanks you.

You go home, and hug your children and cuddle up to your spouse, trying not to remember the sounds of grief that echoed down the hallway as you punched out and left work.

My husband sent me an email yesterday with an excited “Check this out!” in the subject line. I clicked on the link and it was pictures of contemporary nurses, working and wearing nurse’s caps. Apparently my husband thought (as had I) that the wearing of caps in the workplace had died out some time ago.

It made me think about not only caps, but uniforms in general. Back when I was in nursing school the first time, our uniform was an uncomfortable and unforgiving white dress with a blue-edged pinafore. White hose only, and proper nursing shoes. I remember when I put that scratchy thing on, I felt like an imposter—like I was playing dress up in someone else’s clothes. But when we started our clinicals, I saw lots of nurses wearing the traditional white dress and I thought, “Ok, that’s how it goes I guess.”

Fast forward almost 20 years when I entered nursing school again. This time, our uniforms were white scrub pants, white scrub tops, and sensible nursing shoes. Still no caps, of which I was glad, but also no more dresses. It’s amazing how easy it was to bend, move, and lift wearing the nice, baggy scrub pants the school was now allowing. And while all the nurses I saw were in scrub pants and not in dresses, I could count on one hand how many actually wore white. Instead, scrubs have bloomed into lots of different colors and patterns.

After graduation, people joked that they would burn their nursing school scrubs. They wanted the freedom to choose their own clothes, and to step away from the white which in many minds during school, came to symbolize ‘student’ rather than ‘nurse.’
I guess I am different because I kept my scrub uniform, and wore it until there were one too many stains on it to justify its continued use. Even now, I wear white pants almost exclusively at work, and my tops are generally solid color and low-key.
Local hospitals have been establishing dress codes recently, in order to better allow the patient to understand who is the nurse and who is, say, the environmental service provider, seeing as everyone wears scrubs. So far my hospital isn’t quite on the bandwagon yet, although there was a pilot involving the colors white, black, and khaki. Now, however, we are just wearing really big badge clips with RN or LPN on them, and that seems to suffice.

I personally feel that the color white is associated with medicine, and that we should take ownership of it. Doctors, NP’s, PA’s, Residents…they all have white lab coats. Nurses are the only medical professionals who are traditionally associated with white pants. Sure its hard to keep clean, and sure they get dirty easy—but that’s why they are scrubs and that’s why they are inexpensive and budget friendly.
Me, I will be in whites until the day I retire. I’m even thinking of buying a cap, just for fun.

Scrubs at Nurses Station

These are all aspects of professionalism, and they are expected of us in the workplace.
What happens, though, if you are not on the clock?
Does professionalism stay at work, or do you carry it around with you at all times?
Think of the last day off you had—what did you wear when you ran your errands or filled up your car’s gas tank? How did you act when you went out with your friends to the newest club or bar? Did you tell anyone you are a nurse, and do you think if you did, that others would look at you differently if you weren’t dressed to the nine’s, or if you had more than one or two drinks?
Yes we know that licensure demands ‘good moral character’, but that is a broad and hard-to-define term. Are you less professional if you have a few drinks with your friends? Are you more professional if you dress up to run errands? And as licensed professionals, are we obligated to act the part of professional any time we are in public, or just when we are in scrubs and on the clock?
Is there a grey area somewhere…between living life as a person first, and nurse second. After all, while being a nurse is a huge aspect of who I am, it is not the complete definition of me. What about you?

One of the first patients I cared for during my first semester of nursing school was Mr B, a nursing home patient with multiple medical issues including ORSA in the secretions from his capped tracheostomy. Because of this, Mr. B was on special precautions, requiring any staff who entered to wear gown, gloves, and faceshield.

I was paired up with another nursing student to care for him, since the staff had noted he was very needy. My classmate and I sat down early in the morning to devise a plan of care. We decided we would ‘cluster’ our activities, not only so as not to tire Mr. B out but also to try to cut down on our visits in and out of the room, and thus decrease our exposure to the ORSA, and consequent risk of spreading it to other residents at the facility..

The first time we went into the room, we brought in towels and washcloths, ready to bathe Mr B and get his dressed. He had an appointment at physical therapy at 11, and given it was 0830, we thought we had plenty of time.

Yeah, right.

First we forgot the soap. Degown, deglove, damask, get the soap, regown, reglove, remask. Next we had to get some extra towels (we were still pretty green at bed baths.) Again, degown, deglove, demask, get the towels, regown, reglove, remask.

We were working on our physical assessment paper, so poor Mr. B patiently sat through a double assessment, as my classmate and I both painstakingly looked him over head to toe, wondering to each other if his capillary return was really <3 and if his skin should be considered pale or pink. Finally, we had him dressed and in a wheelchair, a mask on his face and over his trach, and ready to go to his appointment.

While he was gone, we tidied his room, changed his linens, and worked on our assignment together.

When Mr. B. came back, he didn’t want to eat his lunch. He seemed restless and irritable. And he was on the call light often. I tried answering from the door, but there was often something he needed that I just couldn’t get from the doorway. There were increasing rounds of gowning, gloving and masking for all sorts of things. He dropped his remote, he needed a tissue, needed the urinal, needed the pillow adjusted. Finally, I got my instructor and explained to her what was going on, and how I was beginning to think maybe there was something wrong with Mr. B.
My instructor and I went into Mr. B’s room together, and the image of her sitting on the side of the bed with him, her face near his so he could see, and holding his hand is an image that I want to carry forever, as her body language and words conveyed the compassion that all of us as nurses strive for. My instructor held his hand and asked him what was wrong.

“I’m scared.” Mr B said shakily. “I feel like its almost time to die.”
:”You are scared that you are dying, Mr. B?” My instructor reflected back.
He nodded. “Is there anything I can do to help you?” She asked.
“Just don’t leave me alone,” he said.

My instructor pulled me aside and said that for the rest of the day, I was excused from any duties but staying to care for Mr. B one on one. Together we checked his vital signs, which had been and continued to be stable, and we got him up out of bed and into his chair. I sat next to him and we watched television.I don’t think I’ll ever forget the show; it was a documentary on the History channel of the history of salt mines.
Mt. B seemed a little calmer. He began to tell me about his ‘lady friend’ who was expected later in the afternoon. He told me that they used to dance together “before I got too weak.” I remember how he lit up and smiled when he talked of her and how the two of them could cut a rug in the old days. Unfortunately, after only a half hour, Mr. B began to become agitated again. “I want to go back to bed now,” he finally told me. I went to the door and tried to get someone’s attention, but it seemed that all the nurses and aides managed to look away just as I tried to catch their eyes. I began to see how frustrating it must have been for Mr. B, alone in the room, having to rely on other people to come in all the time, and all the layers of protective clothing between him and simple human touch.

Finally, my classmate came by and helped me get Mr B back into bed. He seemed calmer, and after telling my classmate about the upcoming visit from his ‘lady friend’, he drifted off to sleep.

Soon my clinical day was over, and my classmate and I stayed a little late to work on our assessment paper together. Our instructor stayed with us, and we discussed Mr. B’s care, and the fears he verbalized. He had stayed clinically stable the entire day, with no obvious physical distress. His mental distress, we theorized, was from being alone so much of the time, and that our therapeutic presence had seemed to calm him. We stayed almost an hour late, leaving finally around 2pm.

Two days later, before school, I saw Mr. B’s obituary in the morning paper. His date of death was the same day that we had cared for him at the nursing home. 
Upset, I went to my instructor, who told me that Mr. B had died peacefully in his sleep within 15 minutes of us leaving that day. I remember feeling sad that he had passed, and then glad that perhaps I had made some bit of small difference during his last day on earth. I can only hope that that he and his lady friend are still up in the stars somewhere, dancing on moonbeams and cutting a fine rug.

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.