Found in translation

She was old. She was Colombian. She was scared.

She was my patient.

And she barely spoke a word of English.

According to handover she could say “yes”, “no”, “hello”‘, and “thank you”. And that was about it. “Hello” is always good. “Thank you” is always welcome; and let’s face it, “yes” and “no” are pretty-much useless out of any understandable context. This was going to be a lilttle problematic. I’m a firm believer in the power of mime as a method of communication, but I would really like to understand what my patients are saying.

The only Spanish I knew was from what I had picked up watching American TV, and from a 60 second Spanish lesson that I got many years ago from a South American nursing home AIN. Somehow, I thought that a Speedy Gonzalez “Andelay, andelay! Yee Ha! Yee Ha!” would not be approriate. Nor would an Arnie-esque “Hasta la vista, baby”. The only nurse on the floor that actually knew some Spanish, didn’t want to talk to the patient, because she reckoned that she couldn’t remember much and didn’t want to look stupid. Fortunately, if it’ll help my patient, I’m quite happy to look stupid.

So I went over to her and bumbled through a greeting. “Beunas tardes, Senora”.

Well, the look of fear on her face evaporated. She lit up and started babbling something in Spanish. She was excited. Finally someone was speaking to her in a language that she could understand. To my shame, I had absolutely no idea of what she was saying.

I stopped her. “Perdano, Senora. Me no hablo Espanola.”

She looked a little confused at this. And said something else that I couldn’t understand. Again, I apologised and let her know that I didn’t understand Spanish. “Perdano, Senora. Me no hablo Espanola.”

I told her my name and that I was her nurse. “Me llamo, Penguin. Me enfermero. Me su emfermero.”

She then said something that I woud like to think was the Spanish equivalent of, “but Penguin, you speak so wonderfully, I can’t believe for a second that you are not a native Spanish speaker!”

This was obviously a little confusing for her, so I set about demonstrating my exceedingly limited command of her native tongue, by listing what I could say.

“Buenos días
Buenas tardes
Buenas noches
Sí
No
Uno, dos, tres, quatro, cinco cinco seis (I am pretty fly…)
Me llamo Penguin (I learned that from Family Guy)
Hasta la vista, baby (in my best Arnie impersonaltion)
Uno momenta por favor
¿Cómo estás? (Thank you Scrubs)
Me casa, su casa
Gringo
Muchos gracias, me amigo
Adiós”

During this, I kept pointing at the TV. The penny finally dropped with my impression of Speedy Gonzalez, “Ariba ariba! Andelay, andelay! Yee Ha! Yee Ha!”, complete with improvised sound effects of Speedy running away (turned out it was appropriate). She realised that I coulld only say a couple of phrases, but appeared far more at ease. I did a set of obs, and had to dig a little deeper into my repoitoire, for “where does it hurt?”

“Senora, donde duele?”

She pointed to her head.

“Poco o grande?”

She indicated it was a medium headache. I grabbed her some paracetamol and some codeine and kept bumbling, trying to tell her that I had some medicine for her “Estas medicinos para su….”

She took the meds, and looked visably more comfortable. She took my hand and said, “Gracias, gracias”. Truly, I was the great communicator!

Fast forward to the next day. I was working in a different area, but stopped by to see how she was doing. She had a couple of visitors including one bohemoth of a son. He was a unit. She saw me and excitedly started blurting something out in Spanish to her family. I said “hola”, and her son asked me if I was the nurse who was doing the pisstake Speedy Gonzales impersonation to his mum. I wasn’t sure where this was going… He then asked if I would step outside the room. More of an instruction than a request. Uh oh.

We went out into the hallway were he became less scary. “So Nurse Speedy… I want to thank you for all that you did for my mother yesterday. She can’t understand much English, and I wanted to say that I appreciate your attempts to talk to her in Spanish. You’re the first person that has tried any Spanish with her.”

That was a relief. He went on to say that his mum had told him that my Spanish was less than spectacular, but she could understand what I was trying to say and was really grateful that someone actually tried to communicate with her.

We ended up discharging her home to her family. Happy endings for all.

____________________________________________________________

I guess the moral of the story relates to how one communicates with one’s patients. Fundamentally, the provision of good nursing care is dependant on being able to communicate with your patients. A trained monkey can hand out pills and wipe bums, but it takes a bit more to be a good nurse.

We live in a multi-cultural society, where we come into contact with people from different cultures – not all of whom can speak English. Now for a moment, imagine how scary it would be if you were plonked into an alien environment, such as a hospital, and couldn’t understand what everyone was saying or make yourself understood. If you’ve ever been lost in the back streets of Beijing, you might relate… But back at the ranch…

Granted most communication is non-verbal, but it really doesn’t hurt to know a few words in another language. We can’t be expected to speak and understand every language that our patients speak, but knowing a few words in a foreign language shows respect for your patients and is a great ice-breaker. If your Spanish and Mandarin is as bad as mine, you’ll at least make your patients smile.

Adiós amigos.

What’s a wordle?

After seeing one over at Biting the Dust, I decided to have a crack at creating a word cloud that summarises what I’ve written about.

Putting the love back into intensive care

Your boyfriend has had a nasty accident.
He is in intensive care.
He’s intubated, sedated & ventilated.
He’s got a GCS of 3 and ICPs shooting into the mid-40s.
He’s got a catheter in and is incontinent of faeces.

Multiple choice question time.

How do you express your love and show your support for your comatose loved one?  Do you:

1. Visit every day and sit by his bedside, telling him how much you love him, and that everyone is hoping that he gets well soon?
2. Actively participate in family-centred care opportunities including brushing his hair and moisturising his dry hands?
3. Make a playlist of his favourite songs for him to listen to on an iPod, hoping that there’s someone in there to hear the music?
4. Start wanking him while the nurse’s back is turned and then ask if you can have sex with him.

I wish I could say the answer is either 1, 2, or 3.

I really do.

I guess that some people just have a lot of love to give…

Picture of the month – December CXR

Picture of the month - December

Something is very, very wrong with this patient…

Families and the nature of ingratitude

As far as being a nurse goes, I believe that I do a bloody good job. Throughout my years as an RN, I have had the privilege of working with good people, who (for the most part) do a bloody good job.

As part of a team, I have been involved in the care & treatment of hundreds of patients, with varying degrees of illness and length of stay. Some of these patients and their families take the time to actually say “thank you” for the care that they or their loved ones have received; many do not. Fortunately my self-esteem isn’t dependent on the gratitude of others. It is nice when people thank you for caring for them, but I’m not in the job for the thanks and chocolates.

One thing, however, that I cannot abide by is what can generously be referred to as RAUFS, or Rude Aggressive Ungrateful Family Syndrome. Even worse, is than this is a management group that enables this behaviour, and does nothing to stop it.

An example of this could be the hypothetical young adult admitted to hospital following an act of gross stupidity, resulting in catastrophic injuries that will inevitably lead to a lifetime of major physical and cognitive impairment. As much as I hate the term, they are going to be a vegetable for the rest of their life; planted in a nursing home, waiting for the respiratory tract infection that will one day mercifully end their life and any suffering that they may be capable of experiencing.

It should be pointed out that, typically, such a hypothetical patient has generally had multiple trips to ICU and theatre, and has had multiple opportunities to be allowed to die with some sort of dignity; but has parents who love their son or daughter so much that the refuse to allow them to die, and belligerently insist that their comatose dead horse be flogged and flogged.

A year later, and their son or daughter is still alive with the reflexes and quality of life of a turnip, and somehow it is all our fault.

“You did this to him”

“It’s your fault she’s not better”

“You people are useless – you have no idea of what you are doing”

I’m sure you get the idea…

This sorts of statements are often backed up by formal complaints.

One patient’s family, the mother in particular, was the straw that broke the camel’s back with me, marking my descent in jadedness. Their child (an adult) was the typical example listed above. Their parents were manipulative and made the typical statements listed above. After lodging complaints about nearly every nurse on the ward, it was my turn. And, holy shit… what a doozy it was – a one page rant with the most God-awful grammar and spelling outlining a laundry list of fictitious actions that I was alleged to have perpetrated. And it was nasty… really nasty – ladened with a vitriol that dripped from it’s poorly written page and threatening to burn like acid through the floor.

You bitch. You fucking nasty piece of work. Exactly what the fuck had I, and my colleagues, done to deserve this sort of attack against ourselves, personally, and against our professionalism at work?

Now some would say, “Hey Penguin, you need to be understanding… These people are going through a tremendously hard time. Stages of grief and all that… You need to offer understanding and compassion. Turn the other cheek, etc… It’s not about you; it’s about them… You need to help them cope and offer them a shoulder to lean on.”

Get stuffed.

Yeah, I agree that it is not about me, or about my colleagues, but rather about the parent’s inability to cope with the situation. As far as the rest of the sanctimonious touchy-feely bullshit – give me a break. As I looked around at the other long-stay patients, and as I thought about every other long-stay patient I had looked after, it became apparent, that although their families were grief-stricken, they did not behave is such a hideous fashion. Grief and the inability to cope with a situation, brought about by a combination of stupidity and the selfishness of not allowing a loved-one to die with some shred of dignity, does not excuse or really explain such disgusting behaviour. Nor does it excuse being complete arseholes on every visit.

Despite this, we all did our jobs and, in my opinion took exceptionally good care of the patient – after all it wasn’t their fault that their parents were such total fucktards. I’m sure that, in some twisted way, the patient’s mother thought that the high standard of care was a direct result of her kicking arse and taking numbers. In reality, it was because of the professionalism of those of my colleagues who had not yet refused to look after the patient.

In the end, the patient left our care after a year spent on our ward – during which time, despite being completely immobile, they developed a grand total of zero pressure sores.

And so they left. And the parents said nothing.

Not a “good bye”.

Not a “get stuffed”.

And certainly not a “thank you”.

Ungrateful bastards.

I don’t expect thank yous, sunshine, or lollipops; but I do expect that my colleagues and I can do our jobs free from malicious, fictitious and libelous complaints.

I also expect to be supported by my superiors when such malicious complaints are made. And I expect that my superiors will take the appropriate actions to prevent this from happening again, rather than pandering to the twisted egos of such complainants. But then again, I am a dreamer… After all the policy of “zero tolerance to violence and aggression towards staff” is simply just another fairy tale…

The moral of the story is that I strongly believe in providing whatever support patients and their families need in order to get through the, often horrendous, situations that they have invariable found themselves in. However, there is a line – a line that is generally drawn along the boundaries of human decency.

Cross that line, and you can go fuck yourself.

Perspective

I don’t know why, but it appears to be a common perception on the wards that all ICU nurses do is sit around on our arses and do nothing.  After all, we only have one patient.  I mean, really… how busy could you be with only one patient to look after?

I went down the other night to say hell to the guys I used to work with on the ward.

“You ICU guys have it easy – you send all of your difficult patients down to us to look after – and we have to look after at least four of them!” they howl.

Yeah, been there.  Done that.  Now shut your word hole and don’t be a wanker.

Now while I freely admit that I have looked after sicker patients on the ward, and that a slow respiratory wean isn’t the most challenging of patients; looking after just one critically ill patient often involves a hell of a lot more work than 4 or 5 healthier ward patients.

The same nurses who chastise me also like to have a dig at the guys in ED.  And to be truthful, I once did too.  Then I spent a shift in ED.

I guess it’s all just a matter of perspective.  After all, it is very easy to criticise and pass judgement on what you don’t really know.

That being said, I’m still sure that mental health nurses do three-eighths of bugger all…

Best compliment ever

The greatest compliment that I’ve ever received as a nurse, was from a patient, who years later still credits me with saving her life (but that’s another story).

I walked in to her her room one afternoon and her eyes lit up.  “Yaaay!  I love it when I’ve got you as my nurse.”

“Why’s that?” I asked.

“Because you always make me feel safe.”

Contributions from YouTube

The somewhat amusing:

The down-right sad:

The second clip is the song, What Sarah Said by Death Cab for Cutie, with video taken from House.  A discussion of the song can be found over at Pallimed here.

Don’t Panic! How to survive your prac placement as a nursing student

I love working with nursing students, and find it one of the more satisfying parts of the job. I like the idea of enabling them and helping them learn and gain the most out of their prac placement. I guess it gives me a warm, fuzzy feeling. I have absolutely no time for shonky nurses and the practise of shonky nursing; and have no intention of uninspiring the students that I work with to a career of apathy and substandard provision of care.

Surprise, surprise, though… I’ve often found that the shonkier the nurse, the worse they are with students. On the flip side, the nurses that I have worked with over the years, whom I admire and respect, are generally excellent when it comes to providing a welcoming and supportive learning environment for students and new grads.

So as part of my ongoing efforts to be the kind of nurse that I respect and admire, I present my guide to surviving a student prac placement.

The information presented is pretty-much the same as I used to provide my students, and comes from the perspective of a first or second year placement on an acute surgical ward in an Australian tertiary facility, but the principles are transferable.

Welcome

As a first or second year student, you will gain exposure to what it is like to practise as a Registered Nurse in an acute care environment. You are there to learn. This means working with your buddy RN, and taking every opportunity to learn, whether it be by observing procedures, assisting your buddy RN, or participating in in-service sessions. There is a lot to take in, and there is no denying that this can be a challenging and scary experience. Just remember that everyone that you see working on the ward was once a student, like you. You can do it.

Out of the avalanche of information that you have had to take in, in your first week, just try and remember the following and you shouldn’t go wrong:

Smile & introduce yourself

If you smile and appear enthusiastic about being there, the nurses that you woke with are far more likely to take an interest in teaching you their craft. No-one likes working with the angry/disinterested student. Do not be that student.

When you meet a patient, make sure that you introduce yourself and tell them your name and that you are a nursing student. To the often uninitiated patient, everyone looks the same. Apart form that, it is simple common courtesy. The added bonus is that if you appear confident in your introduction, you should hopefully make a good first impression with your patients and staff.

Prioritise

If it is mad busy and you feel swamped, remember your priorities:

• Safety

• Your own safety – use universal precautions, be careful with sharps, and use your goggles when there’s a good chance of projectile mucus / body fluids.
• Your patients’ safety – watch out for falls (patients like to do that a lot) and do what you can to prevent them – restraints, rails, avoiding TEDS on slippery floors, and proper supervision of patients in the toilet or shower.

• Observations

• Its always a good idea to make sure your patient is alive at the beginning of your shift.
• Obs before meds (especially if giving anti-hypertensives / insulin).
• Document the actual time that you do your obs.
• You can waste a heap of time on the never-ending search for the one working Dynamap on the ward (legend has it that there were originally three Dynamaps) – use your judgement – if it is not essential that you measure the patient’s SpO2, then go medieval and do it the old-fashioned way with a sphygmo and a axilla thermometer.
• Never put a thermometer in a patient’s mouth – some patients will eat them (and your fingers if your put them in there too).

• Meds

• Take your time – remember your 5 rights.
• If a medication is ordered for 0800hrs – don’t obsess about the time – in most cases, giving the medication within an hour either side is generally OK.
• You will never remember every detail about all of the medications that can be ordered for a patient. This is normal. Try not to feel overwhelmed. If you don’t know what a medication is, look it up. Only shonky nurses give out unknown meds. You do not want to be a shonky nurse. There should be plenty of MIMS around the ward. Use them.

• Nutrition

• If your patient needs to be fed (ie if there arms don’t work properly), make sure that they get fed.
• All the tablets in the world are of no use if the patient isn’t getting adequate nutrition. Without food the body doesn’t have the resources to heal itself
• Unless contraindicated, make sure your patients have plenty to drink.

• Washes

• Showers can wait – nursing is a 24-hour job.
• Try not to feel pressured into getting all your showers done before morning tea. Although it is nice, it’s a dumb idea, if you haven’t done your obs, meds, and the other more important things.

You are still a student

• Scope of practice

• Remember your scope of practice, and do not work outside of this. This is a huge point when it comes to assessing your perforance.

• Supervision by your buddy RN

• Always make sure you are supervised by an RN when administering any form of medication (including topical medication) or undertaking a clinical skill.

• Medication administration

• Again – direct supervision by an RN (note: not an EEN).
• Remember your ‘5 rights’.
• If you are dispensing a medication, and you do not know what it is, ensure that you check a MIMS before administering it to your patient. It is extremely poor form to be handing out drugs without knowing what they are.

• Take every opportunity to learn

• You only have two weeks to learn as much as you can. If you don’t know something, ask. If there is something in particular that you want to go through, let you facilitator know.

Staff Assist Button

If something happens and you need help quickly, use the staff assist button.

Examples of when you might use it include:

• Patient fall
• Patient unresponsive / not breathing / no heartbeat
• Patient having a seizure
• Patient ripped their own trachy out
• Anything else where you or your patient are in immediate risk and you need help quickly

Remember that no-one will think badly of you for using the button, if it is a false alarm.

If in doubt – hit the button.

DRABC

If something happens to a patient, remember the basics – DRABC. In an emergency situation, ensuring that your patient has a patent airway is often the most important thing you can do while you wait for the cavalry to arrive.

Emergency Equipment

At the beginning of you shift, always check that your wall suction and O2 is working and that you have masks, tubing, etc. There is nothing worse than not having this stuff ready and working when you need it.

If you make a mistake

If you make a mistake, don’t beat yourself up. Everyone makes mistakes. It will happen. Just make sure you learn from your mistakes.

Lessons learned the hard way are lessons not soon forgotten.

? Best Practice

Everyone does things differently. Watch your colleagues and buddy RNs. See how they do things. If they do something well – learn from them and apply it to your own practice.

As long as you apply the basic principles of an activity and adhere to hospital policy, it doesn’t matter how you skin a cat.

Ask questions

There are no stupid questions. If you don’t know – ask. You are there to learn.

Documentation

Make sure your documentation is top-shelf. It is a legal record of what you have done. Consider the following format when charting:

Start with: “Nursing: Neurologically GCS=13 (E3,V4 ,M6 ), MSQ = 6, PEARL, Pt afebrile, Other obs as charted….”
Work through your body systems, etc:

• Nervous (GCS, AOx3, seizures, muscle weakness, etc)
• Pain issues – “Pt c/o headache – rated 7/10 at 0950hrs – given PRN Endone 10mg PO – with good effect”
• Respiratory (trachy, suctioning, O2 requirements, SpO2, dyspnoea, etc) Cardiovascular (hyper/hypotension, venous access, ECGs, capillary refill, etc)
• Gastrointestinal / Urinary (input & output, bowel sounds & movement, appetite, nausea)
• Integumentary (wounds, pressure areas, rashes, drains, etc)
• Psycho-social (visitors, concerns, etc)
• Behavioural (aggression, abusiveness, non-compliance with treatment. If your patient has been abusive, make sure you document it.

Write legibly – there is no point documenting if no one can read your chicken scrawl.
Always make sure that your documentation has been checked and counter-signed by your buddy RN.
Check out your facility’s documentation policy.

Punctuality

Be on time.

Again – be on time. Being late will not be tolerated by your wards when you are working as an RN. It won’t be tolerated while you are a student, either.

If handover for the AM shift starts at 0700hrs, make sure that you are ready (bag away, handover sheet in hand, bum on seat) for handover no later that 0655hrs.

If you are going to be unavoidably late, or are sick, then make sure that you have the common courtesy to inform your facilitator/ward.

Take care of yourself

Your time on prac is likely to be pretty stressful. Make sure you eat well and get plenty of sleep. Try and have fun.

Some days are diamonds, some days are stone

Always treat your colleagues the way you would like to be treated by them. Some days can be crazy busy. We all have bad days, and can sometimes be short, forgetful or appear to be rude. Just remember this and be prepared to give people the benefit of the doubt. At the end of the day, we are lucky to be working with good people.

Cheers to Bones & Kel for their input. Always remember that the students that you work with today, will be your colleagues tomorrow.

Death and grief

Over the last few weeks, I’ve had quite a few patients that were cactus. They were circling the drain, waiting for the inevitable, with nothing short of a miracle able to alter their fates. As fantastic as mondern medicine is, there are simply some things that cannot be fixed.

As I was performing a post-mortem wash on a recent patient and preping them for their trip to the morgue, I was struck by the reaction of one of the wardies who came to help me roll the deceased and place them in their body bag. The wardie had never seen a dead body before, and was a little nervous about the whole experience.

He didn’t seem concerned that that the dead might rise and that we would be forced to fight a zombie (although I’m sure it was in the back of his mind). His main concern was how to handle the body respectfully, and how the patient’s family were. After reassuring him that my patient had had a dignified death, where her family loved her enough to let her go, rather than insisting that we violate her with every piece of high-tech equipment that we can bring to bare, the wardie was fine. A dignified death, that lacked tragedy and highly-strung grief was somehow OK, and not scarey at all.

This got me thinking about the nature of death and it’s associated grief; and how death, itself, doesn’t affect me, but the grief felt by families does. At the same time, Ten out of Ten wrote an entry on his blog that describes what I was going to write (though much better that I reckon I would have):

I am not saddened by death. It’s just part of my workday, occurring sporadically, occasionally in tragic fashion though much more typically the end result of too many years or poor health decisions. I used to feel a sense of disquiet, but this has long been displaced by ambivalence through emotion-numbing repetition. I remain unfazed, and simply move on to the next task at hand.

I am saddened by grief. I dread telling people a loved one has died, all the more so when they are unprepared. I dread the reactions, the sadness and anguish and tears and while I can’t comprehend the full extent of their pain, I feel a small part of it course through me.

I wonder if I’ll be numb to this someday too.

Original post here.

I hope that I don’t become numb to this pain.