Rhythm looks bad

Some reactions are ridiculously underpowered for the situation at hand. To say that I had a "busy week" would be like that. It reminds me of something that happened to me at my very first job in the cardiac ICU.

My patient was in and out of stable V-tach. This is a tricky situation if you work nights, because is the patient asleep or now in UNSTABLE V-tach? I moved the crash cart into his room and put patches on him early in the shift, and I resolved to monitor him like a helicopter parent. But I had 3 other patients who were up to mischief.

I looked at him or his monitor every few minutes. It was one of those shifts where you don't eat, drink, or pee for much longer than a person should go without doing those things. On one orbit I saw the V-tach return. I ran in and the guy was asleep. I rattled him and he acted like a normal person would on being rattled awake. Whew.

But I still got an EKG machine, from the other end of the unit, hooked him up, typed in all the info, and did a 12-lead; called the really unhappy cardiologist (I had one line filled with amiodarone and one filled with dopamine, as I recall); and bolused the guy with some cardiac drugs and followed some other orders.

Which I mention because all of this took, you know, some time. Imagine my surprise when I got a page after all that was done from the monitor tech:

 Yeah it was a fun night

"Check pt: rhythm looks bad."

RHYTHM LOOKS BAD? Yeah. And I had a busy week.

Body language: down and dirty

Body language is a part of communication I never paid much attention to before I became a nurse---specifically, before I ended up in highly emotionally charged situations in ERs, jails, prisons, and, currently, hospice. I've learned a few tricks and tips.

  • Make a basket. Meaning, don't fold your arms or shove them in your pockets; instead, fold your fingers or hold your wrists and let them fall down in a big loop. This is, for some reason known only to shrinks, a nonthreatening position.
  • Do a body scan. Of yourself. Force your muscles to relax. Force your voice to stop squeaking.
  • Do a situation scan. Is someone towering over you and shouting? Stand up. Are you trapped between the shouting person and an escape route? Move. Are you infringing on someone's space? Move back. Have you legitimately done something wrong? Apologize. Addendum: frequently it is not possible to tell what is causing an outburst. In that case, assume it is not about you. That makes it easier to deal with and is also true 99.9% of the time (I totally made that up).
  • Do a body scan again. It's amazing what making all your muscles relax will do to help many situations.
  • Avoid the following:
    • "I understand how you feel." Or variants, such as "I understand that this is frustrating." Do you? The angry person has no way to know. Better to say something less obvious, such as, "this must be very frustrating" or "I feel like you are really frustrated, but I may be able to do something to fix it." Much better than "I know how you feel." Clearly occasionally you may in fact have a good idea how someone is feeling, but I find that if you choose to share this, it's best not to start with "I know how you feel." It's like "calm down." Just don't say it. Instead say something like "when this similar situation happened to me, I felt this way...."
    • "Calm down." This has never made anyone calm down, ever, in the history of the world.
    • Talking to fill space. That's a thing people do when they're nervous. You don't want to appear nervous, so clam up. If you've asked a question, allow that horrible silence to drag on. And on. And on.
  • Move in to the discomfort. When people start getting mad, distraught, or upset in any way, our human instinct is to pull back. It can be as simple as leaning back in your chair or as dramatic as finding an excuse to leave the room. Go toward it. (Safety permitting.) If someone has a screaming fit, stay exactly where you are, relax your muscles, make a basket, and be silent for a while. Fits come to an end. Moving away from the fit will prolong it and give the fit-thrower an advantage. (Again, if objects are about to get thrown, all bets are off. Move.)
  • Do a body scan. This is the equivalent of, in nursing school, "wash your hands." Do it all the time. Are you shoulders up? Forward? Are you hunched over? Are you rattling your feet? Biting your nails? Twirling your hair? Stop it. Fold your arms in your lap, breathe, and LOOK RELAXED.
  • Pause. Just pause, before you respond. Allow yourself to say things like "I think we should have this conversation at another time," if possible. Often, you do get a say in when a conflict takes place. You don't have to accept every invitation.

I'll say that again because it was a miracle to me when I heard it. "Who offered you this ass-chewing?" said a supervisor once. I named the person. "Did you accept it?" he asked. I was dumbfounded.

You do have the ability to reject an ass-chewing or decline to meet an unmeetable need. There are often consequences, but you don't have to accept every invitation to an argument, ass-chewing, or guilt trip.

The idea here is to recognize and acknowledge power plays and how they are affecting you, or, occasionally, how your power plays may be making something worse. Are you antagonizing someone? It could be unintentional. But are you? Stop!

Is your energy feeding in to a bad situation? If you're clenched up tight, your voice is high, and your arms are folded, the answer is yes. If you are the nurse, the charge nurse, the manager, or just about anyone who's ever been in a conflict, fix that stuff and things will go better for you.

What if someone actually threatens you? This happened to me in the ER and corrections on a pretty regular basis.

Guess what? The same principles apply, whether a convicted murderer is treatening to kill you if she doesn't get her Tylenol RIGHT NOW or whether the checker at Wal-Mart is being snippy. The SAME.

Oh. And breathe. Especially if you're maintaining a silence, this can be super helpful.

Hope this helps!

Review: iPad Pro 12.9 UAG case

I don't know about anyone else, but when I buy a giant slab of glass, I immediately start buying cases to try on it. In this case, I found one pretty fast that I actually really like. It's the Urban Armor Gear composite case. I bought it at Best Buy for $79.99. I already had a Smart Keyboard and didn't realize that you can use them both, so, win.

It's supposed to be impact resistant and have some space-age materials, and you can read about all that on the company Web site. My liking for it is based on more practical considerations.

  • Weight and size. Whatever it's made of is super light, and it doesn't take up much room around the iPad. If you already have the aforementioned giant slab of glass, you becoming immediately interested in not adding much weight to it.
  • Grip. The iPad is slippery. All Apple devices are slippery. I like the skinny naked look for your average device, but it's only a matter of time before I drop them if they are unclothed. This case has grippy material and protects the back as well as keeps me from fumbling with it.
  • Built-in Apple Pencil clip. Talk about slippery. I love my Apple Pencil with a kind of deep panicked affection. In the same way I always know where my keys are, I have a kind of built-in radar for it. Still I fear losing it. It's both small AND slippery. This case has a rubber grippy clip on the side that it snaps in to.
  • Works with the Smart Keyboard. The case has a side on the smart connector side that you can snap off and hook up your Smart Keyboard, so it basically acts like a back case that allows a Smart Cover. I'm a big fan of the Keyboard, and this setup lets me just take it off if I'm reading or drawing or something and yet easily put it back on to type or cover the screen while it's in my bag.
  • Kickstand. Along those lines, the Keyboard gives you ONE angle for propping up the iPad, and it's a fine angle indeed. But if I'm not typing anything, the case has a kickstand that allows multiple angles. It's a flimsy piece of crap kickstand and I hope it doesn't snap off, but it does have a wide base to it and supports the iPad really well if I want it propped up low on a table, which I tend to do when I'm reading stuff that may result in some minimal typing, which I'll just do on the glass keyboard.

iPad, Smart Keyboard, and case weigh slightly over 3 pounds, which ain't light, particularly when my MacBook Pro weighs only half a pound more. It's all perception, though. The iPad setup FEELS much skinnier and lighter, and dragging it around without the keyboard shaves off weight and bulk.

More to the point, I'm not likely to pull out my laptop to do much of anything when I'm out and about, but as it turns out, I AM likely to pull out my iPad, even as big as it is. You never know when you'll want to sketch something or look at something on the big pretty screen. I do read a lot on my iPhone 6S, but if I'm going to be reading for a long time I prefer this big old two-column view. I know, that's weird, and it's just all a matter of personal preference. I'm probably as surprised as anyone else that I like this thing so much.

It IS big enough that my MacBook cases and bags are fine to chuck it in and tote it around without them looking silly and wasting a lot of space, but it's also skinnier enough that it goes in my regular (admittedly giant) everyday bag. It's like the size of a thick folder of paper, of which I have MANY in said bag.

I don't usually review cases, because I don't buy that many. They're a horrible ripoff so I'm a bit choosy. This one, however, is worth reviewing because it's so convenient, at least for what I want a case for. I recommend it despite the scary-flimsy-feeling kickstand on it.

It's not an emergency

Former ER nurses, it turns out, have a different definition of "emergency" than everyone else does. I will explain, then, what an emergency is and isn't.

In my world, emergency means you will quickly die if I don't do something about your problem. And by quickly I mean in the next few minutes. So basically, there are three emergencies, and only three.

  1. You aren't breathing.
  2. You don't have a pulse.
  3. You are bleeding profusely. It is an arterial bleed.

I'll also allow things that nearly invariably lead to one of those things in the next 5 minutes. If you're having such a severe asthma attack that a tiny squeak of air is still moving, I'll allow that. If you keel over in V-tach and still have a pulse for the moment, I'll allow that. Everything else might be a big problem. It might even necessitate some quick thinking and action. But it's not an emergency.

Here are things that are not emergencies.

  1. You forgot to tell me I needed to do something, and now you are behind. This applies even if it's shift change.
  2. The pharmacy closes in 30 minutes.
  3. Your patient "had" any sort of problem at all (emergencies cannot occur in the past tense).
  4. You think your patient might be about to [deteriorate, stop breathing, die, fall, choke]. (Emergencies cannot occur in the possible future.)
  5. You are vomiting. Vomiting seems to be often confused with an emergency and also for an activity that cannot be undertaken alone. "Oh my God, she's VOMITING!" OK, unless we're talking about a trauma victim on a backboard (thus invoking emergency #1), I don't need to attend this event.
  6. You have discovered a wound on your patient.

You get the idea. Note that the list of things that are not emergencies is much longer than the list of things that are emergencies and can be endlessly added to. Thank you for taking the time to read this helpful PSA!

Pseudoaddictive behavior

I learned about pseudoaddictive behavior at a pain management class a few months ago. Because I've been reading the new CDC opioid management guidelines, I've been pondering it again.

What is it? It's when people are undermedicated for pain so they start acting like drug seekers, only they're actually seeking drugs because they're in pain. Here is the common scenario presented in the class.

A patient gets pain medication every 4 hours, say. It is not a sufficient dose to last that whole time, so after 3 hours, he starts hurting and looking at the clock. He probably knows that he can have medication 30 minutes before or after the due time, so after 3.5 hours he's on the call light. The nurse is quickly irritated by this behavior and, often, reacts by withholding it. By the time the patient gets it, he is in really severe pain, so now he is going to be anxious about the pain returning and not being able to get his medication when he needs it.

Guess what? That's going to cause behavior that looks exactly like that of someone who just wants pain medication. This patient will ask earlier and earlier and get more and more anxious. He may insist on talking to the doctor and become angry and hostile. But he isn't "just a drug seeker." He's in pain and inadequately medicated.

The problem here is that in today's opio-phobic environment, anyone who asks for pain medication sets off alarm sirens in medical professionals. Oh my God, this person asks for his oxycodone every 3.5 hours! He's obviously addicted! No. It isn't obvious.

It's not hard to differentiate addictive from pseudoaddictive behavior. Increase the pain medication. If the patient is just drug-seeking, the behavior will not change. If he really is inadequately medicated, he will stop the pseudoaddictive behavior. But we can't help if we don't recognize this pattern and the possible reasons behind it.

Nurses and the crying dilemma

"For some reason, I felt the need to apologize for my tears as I’m still not sure if doctors are allowed to cry."

This quote jumped out at me from Death is part of medicine. I will never get used to it. (I AM used to it, but that's not what this is about.)

This crying thing has been an ongoing topic in my brain since I started nursing school clinicals. Before I was a nurse, I just didn't cry unless I was in physical pain or really mad. Almost always the "really mad" one. Then I found myself crying in the car after clinicals. That wasn't even so bad, but then I discovered that I'm a sympathetic crier.

In case you're not familiar with this, I mean that even if I'm not personally distressed by something awful that's happened, but someone else is and is crying about it, my eyes start leaking. This was a horrifying discovery to me. The nurse can't be crying! I thought. I berated myself about it and dreaded the next sobbing family member.

As often happens in nursing, a mentor appeared when I needed her and gave me sound advice: she said, "don't worry about this. It isn't about you. No one is thinking about what you're doing or thinking." What? But yes. It's true.

So I moved on from that and no longer care when I cry with people.

But then I became a hospice nurse and found that I actually do cry all on my own on occasion. I get attached to some of my patients. If you see someone several times a week for months at a time, it's SAD when they die. I don't cry at every death; in fact, it should probably be upsetting to me how casually I've adapted to being around so much death. But some get to me. This discovery bothered me too.

It's a little silly, because crying over a corpse is not a discoverable offense. I'm pretty sure the corpse is not appalled at my lack of professional detachment. But I feel like I somehow "should" be able to switch my emotions on and off at my convenience. It doesn't work that way.

Again someone popped up when I needed her, a nurse at a facility I spend a lot of time in. She busted me crying at a bedside, gave me a hug, and said, "it's hard for us too, isn't it?" She was crying. This normalized the whole thing for me.

So I don't apologize or beat myself up anymore for crying. Either no one is paying any attention because the situation is not about me anyway, or I figure I have a right to feel sad when people I care about die. I'm not superwoman. And no one expects me to be, except me.

Look no further for the best medical podcast around

I like podcasts. Always have. Now that I drive constantly, I listen to more than ever before, and when I find a fantastic one with lots of old episodes, it just makes me happy. Enter "Sawbones: A Marital Tool of Misguided Medicine" [iTunes link].

I thought I'd share because this is one of the ones where, when a new episode downloads, I squee a little bit. It's mostly about medical history. Stories of medical oddities abound, and the doctor part of the team really does thorough research.

If you're the time who likes weird stuff, check it out and enjoy.

Tech tools for nurse road warriors: Automatic

Even working in a hospital, where you go one place and stay there, you end up schlepping your office with you everywhere. My scrub pockets were always stuffed with an amazing variety of stuff. Working basically out of your car is a new challenge insofar as stuff you need and how to keep it easily accessible. I still have to take my office everywhere I go, but the challenges have transformed from what kind of clip best secures my trauma shears to my pants to which bag will magically accommodate any equipment I may possibly ever need while not being too giant to carry (does Tardis make nurse bags?).

Obviously, I have also nailed down some technological assistance. My iPhone is probably right up there with my stethoscope in being vital for my job. In addition to the whole "I'm on the phone all day long" thing—in fact, I have TWO phones, both of which ring regularly—it does some pretty cool extra stuff.

The first thing I did when I got this job was buy an Automatic. Actually, the FIRST thing I did was refuse to spend $100 on a mileage tracker and instead tried to track where I went and when all on my own. This failed massively. The urge to "just remember it and do it later" is too strong. Some case managers, my boss tells me, carry their clipboards around and write down where they've been and when as they go. Good for them. I end up at the end of the day starting at my time sheet and being absolutely unable to recall what I did and when.

Automatic is a widget that you plug in to your car dashboard (you can't see it) and it communicates with your phone via Bluetooth. Automatically. So you can see everywhere you've been and when. You can tag trips if you want. It tells you your weekly mileage and how much you're spending in gas for each trip. It also has an Apple Watch app that keeps track of where you're parked and how long you've been there, handy for parking meter issues. Reportedly it tells you what warning lights mean and lets relevant people know if you have a crash; happily I've not needed to test either of these.

iOS screenshot. Yes, I drive a lot.

iOS screenshot. Yes, I drive a lot.

This stuff is pure gold for road warriors of any kind. It syncs with a Web site as well, and I have had a few instances where I've needed to look back and see what time I was somewhere and was able to do it.

Another iOS screenshot

Another iOS screenshot

For real geeks, Automatic has an IFTTT channel. You can log trips automatically to Dropbox, Evernote, or wherever, or you can have your Wemo turn on the light when you get home, or you can even have an iOS Reminder created if your check engine light comes on, so you remember to call the mechanic. IFTTT has a lot of ready-made Automatic recipes, including some of specific and questionable use such as "Call my spouse immediately if I park in front of a Nevada brothel."

If you don't drive for work, you probably don't need an Automatic. If you spend as much time as I do in the car, you might. It really simplifies some potential drudgery.