I’m sorry to my high school teachers. I’m sorry for skipping class and saying I would never need algebra, biochem or liquid biology.  As it turns out, I need all these things. Algebra comes in very handy when trying to figure out how many pills my patient needs to get the right dose of medication, or how many drops of IV fluid per minute will get the correct rate for IV medication and fluids. Biochem, well, that was a dumb move on my part, to think that I wouldn’t need biochem in nursing. Turns out that is pretty much what your body is=biological chemistry, the citric acid cycle, the glucose cycle, Blood gases, electrolytes, etc . As for liquid biology, it is essential I understand the difference between isotonic, hypertonic and hypotonic IV solutions in order to make sure my patient gets the fluid exchange they need.  I need to know all about those to understand my patient’s condition and be able to be a good nurse to them.  Truly, the only thing I didn’t really need was English class. 
 
 
So, I’m on nights on a busy surgical unit. My friend NewGradRN goes into a room to take vitals on Crabbypatient in with some broken vertebra, non surgical. This lovely person was in a private room because his yelling and cursing kept up all the other the patients.  The door is closed, presumably so we can’t hear him yelling at his poor wife. She immediately comes back out and slams the door shut. Then politely enquires of our charge nurse “so...what do we do if we walk in a patient having sex?...hypothetically speaking”
SuperCharge “You go back in and tell them to STOP”
NewGradRN “yeah..I’m not gonna do that...but you can”
So, SuperCharge goes in and yells at them to stop, this a hospital, not a cheap hotel.  They stop! He gets moved back to a ward room shortly after that. During all this, I’m at the desk, tears streaming down my face. When NewGrad comes back and sits down, I say “you know,  if you can do that with a busted back, you can go home
 
 
I think it’s great that we’re putting more money and supports into the community, and I think it’s awesome that we want to send people home first. My ward has always had the philosophy that home is best, and we need to respect the patient’s wish to live at home, even if it is at risk. However, we have a multi-disciplinary care team for a reason, and it’s not to sit with our thumbs up our asses.  If our entire team assesses and feels that this patient cannot live at home, even at risk, perhaps you should listen to them. We know what the community supports are, and we know what our patient needs.  To stand there and say that we have (HAVE) to send the patient home with the max supports “just to see” is insulting. You are implying that we are not doing our assessments properly.  You are implying that we, their health care providers, do not know our patient as well as you do. You, some figurehead that came to one meeting, think you know the patient better.  And our hands are tied, because we have no choice, we must send every patient home first. Full Stop.  We have to let them fail at home first, and then come back to us in much worse condition. This is what healthcare is now, black and white, no grey areas for people to be in.
And then when they get re-admitted, we have to look at we what WE did wrong. How we failed. Perhaps it's not us, perhaps it's a system failure? Maybe there's a problem with the community?  Maybe you should have listened to us and not sent the patient home in the first place. 
They keep touting the successes of their program, despite the fact it hasn't even been around long enough to get significant data. And, as my stats teacher would say "Correlation does not equal causation."  You can make anything correlate in your favour. 
But, as people keep reminding me, healthcare is a business. f it is a business, this is a terrible way to run it. No other business would send something out knowing it would fail. Cities don’t build bridges know that they are going to collapse, just so they can build the right one next time. Companies don’t send out parts that they know are going to fail, only to re-do it right the next time.  Its insanity, it makes no sense and it ends up costing millions of dollars. Although I accept that healthcare is a business, I will not accept putting my patients at risk. I will always stand up for my patients, no matter how many people I am standing against.  
 
 
“ICU just sluts around with everyone”
“not really a hot stroke, more like a lukewarm stroke”
“....that looks like an anus”
“we’ve been getting a lot of vagina flaps..and nothing smells worse than a vag flap gone bad”
“he was just moaning so you would come over and he could look at those big boobies”
“well, you could put comfort care patients in as pending discharges”
 
 
I found out one morning that there was a patient on my ward with a troponin of >200. Was in ER yesterday, had a diagnosed NSTEMI, as well as pneumonia.  The lab did not call to inform us of this, which is odd, since they called when it was 4.43. We called the on call doctor who ordered repeat blood work and a STAT ECG. Lab tech came, drew the blood, ECG tech came and informed us of a new policy that elevated troponins were not considered stat any more, and that it should have been put in as urgent. I explained that this was critically high, and was told it didn’t matter. “There is only a few of us, and we can’t go to all these false stats” At this time, I looked at the conditions for stat and randomly picked one that applied to this patient.  I respect that I’m sure they get a lot of “false stats”, but I feel like my (and the doctor’s) clinical judgement should play some part.
So, eventually we get the repeat and it is still >200. By this time her BP is going down, she is on 80% HFFM, and slowly desatting into the high to low 80s Call the covering doctor (different than on-call person) and get an order for....Normal Saline @75. No extra blood work, no calling CCU. He needs to come up and review the chart first. An hour later she starts to fill up with fluid and her resp rate goes into the high 30s, we call again and get an order for lasix and IV morphine. 3 hours later he shows up, orders some more stuff, and then leaves. Never lays eyes on the patient, never talks to me, and doesn’t talk to the nurse.  One of his orders was to put her on 4LNP. From 80% HFFM. What?? She’s not comfort care, she’s still full medical management, but I guarantee that putting her on 4L will kill her. 

I want to reach through the phone and strangle him half the time. 

 
 
One of my favourite columnists writes about the "Price of Admission" for being in a relationship. In order to be happy, you have to accept their faults. I think a similar principle applies to nursing. 
I currently have a bruise on my arm about4cm (2inches) in diameter. This was given to me by a patient I was trying to insert a foley into. He had been peeing blood for a few days before coming to the hospital, a CBI had been running, and he pulled it out. He had advanced dementia and didn't speak English. In his mind, he was defending himself. He punched and pinched me as I was inserting the foley. There was already two other staff members trying to stop him from doing that, but, as I've learned, people can be incredibly strong when they think they are fighting for their lives. When it comes to that, I generally don't have a problem with it. I've been called some pretty horrific names by confused people, and I can shrug it off, because they don't mean it. Either they think I'm trying to hurt them, or they have some head injury that takes away that filter most of us have. They just say whatever comes into their heads. I accept this as the "price of admission" for being a nurse. 
What I can not, and will not, stand for, is when people are rude or ignorant to me on purpose. I have been whistled for, snapped for, had suggestive comments made, been  yelled and screamed at and more. This type of abuse would get you banned from a restaurant, arrested on a plane and kicked out of  a store. This does not just come from the patient, either. This comes from the family as well. I have made it clear to families and visitors what kind of behaviour will not be tolerated on my ward. I have actually gone so far as to have visitors removed from wards I've worked on in the past. 
There is the price of admission, and then there is abuse. Nobody deserves to be abused in their workplace. 
 
 
I’d like to talk about a problem that’s sweeping the nation: New Graditis. New nurses graduate and seem to think they already know all they need to know about being a nurse, and don’t need to ask any questions or get any help. And God Help You if you offer a suggestion or point out something they may have done wrong.  They refuse to see that other nurses may know more, or have a better way of doing things through, you know, experience.
These nurses scare the ever loving shit out of me. They have no clue how little they know, and how dangerous their lack of knowledge really is.  I came across more back home than I do out here, but I still come across the odd one. I have no idea how to tell them without being “that bitchy old nurse”. I’m afraid the only way they’re going to realize is if they almost kill someone, but who would wish that on someone?
There is also the opposite (sort of) problem, where older, experienced nurses who think they know it all and have nothing left to learn. They refuse to accept criticism or feedback from younger nurses. They tend to go on about how different nursing was and how it’s so terrible now and it was awesome back then.

I guess my point is that nursing is a job where you cannot stop learning. If you do, you need to quit and go find something else to do
 
 
My ward is not geri psych, a stroke ward,  an ortho rehab floor,  a garbage bin for palliative patients that ICU needs out because we’re busy and the surgeon doesn’t want anything to do with because they’re not surgical anymore (I know, long),  a step down unit (ironic, considering other people consider us just above a rehab floor), an easy floor, or a “vacation”

My ward is busy, chaotic, a zoo sometimes, a wonderful place for your loved one to be, full of nurses, who love the geriatric population and an amazing place to work.

 
 
Nursing is an amazing career to have. I have endless possibilities stretching out in front of me. I can change jobs every 3-4 years and have that work in my favour.  I make a difference in people’s lives, and inspire people to take care of themselves.  I am in a career where the education opportunities are endless, and learning will be life long.  My job however, sucks balls on a regular basis. We are in a huge bed crunch on a daily basis, and I feel like my voice is lost in a sea of everyone else. Someone else’s area is always the focus of the day, and making sure they have beds is always more important. We’ve had our overflow beds (our overflow beds are 8 beds, btw. Other wards are 1-2 beds) open for a year solid. Nobody seems to notice anymore.  But every day I see;  I see my staff struggle with the weight they are carrying, the strain of these eight extra patients.  I see my nurses burnt out because we are constantly asking them to work extra shifts, stay a few more hours. I see my PT, OT, Dietitian, SW, CML and rehab assistant working tirelessly, thanklessly to make sure that the patients are taken care of.
I do not work in a flashy critical care area. I do not work with young people. We do not get donations from private organizations. We are an afterthought, generally speaking.  Everyone assumes will get by, because we always do.  

Yet every day I go to work and smile and laugh and try and make sure the team I work with know I see them, that I see the difference they make. 

 
 
I work closely with doctors on my ward. Most of them are wonderful, caring people who understand and respect my role in patient care. They understand that they are looking after a small percentage of the patients on my ward, and I always have to look at the big picture. Some of them, however, think that I do nothing but their bidding. 
A young woman came in with a palliative brain bleed. I only had a ward room available. This is far from ideal. In a perfect world, these patients would always get a private room so the family can be with them and grieve in private. In reality, all my privates had people with some pretty serious infections that could pass on to everyone if they were in ward.
The doctor promised, in this order:
A bed on the palliative care unit (not gonna happen, they take from the community first)
A private on my ward (again, not possible)
After admitting to my ward, promised palliative care would come see them today (consults usually take 48h to happen)
A private on my ward because he "just sent someone home from a private, so you should get it. I wrote an order for it" (has no bearing on where I put patients, and we had a patient with diarrhea and vomiting that needed to be moved to a private)
So now I have a distraught family on my hands, cleaning up his mess and essentially being the bad parent, telling the kid he can't have a pony. In the meantime, I had been talking to the other charge nurses trying to secure a private room. I also was having a discussion with the family, who said "so, what you're saying is my mother dying isn't a priority" I almost burst into tears. 
I eventually did some moves, thanks to the other amazing charge nurses I work with, and got her a private room. 
Where was the doctor when all this was happening, you ask? I have no idea, but not backing me up, that's for sure.