NursingZen

Nurses occupy a unique position…

Nurses meet the patient where they’re at…

As bad as it might sound to have to work every other weekend, it’s a relief compared to working on the weekdays. On my unit, the weekdays are always frenzied and sometimes terrible, but the weekends usually are a respite.

Tonight I worked with a nice, hardworking team and had stable, interesting patients. Of note were two patients who had never been hospitalized before.

**Mr. Lee (name changed) is a small, wiry elderly Chinese-speaking man with skin smooth as a baby’s. He came in, reluctantly, because of chest pain but has no significant medical history or problems. He takes no medications at home, has no hearing or vision problem, no dentures, no diabetes, nothing. “Wah!” (Cantonese for “wow”) was my response to him. He’s anxious about being in the hospital, agreed to come in only for observation, and declined the ordered medications that are “protocol” for our patients. I told him a little about the meds but I didn’t dispute him – after 79 years of not taking any meds, it makes sense that he doesn’t want to start now.

**Ms. Nelson (name changed) is a talkative woman with spunky short hair. She also came in reluctantly because of chest pain, has no significant medical history or problems, and takes no Western medications. She says she’s been successfully treating herself with complementary modalities and herbal medicines. She also declined the ordered medications. She expressed distress and anger toward the doctor who admitted her, saying that he has no conception or understanding of integrated or complementary modalities and that he scoffed at her anxiety toward the treatments he offered her. As she read her poetry, chanted her “Ohm”s, and listened to music, I understood precisely how alienated she feels from the way medicine and healing is practiced and communicated in the hospital and in our society.

For a split second, I felt “wrong” for not pushing these two patients to follow the hospital’s protocol of treatments and interventions, especially since I know that in my position I “represent” hospital-based medicine, but within the same split second, I realized that even though I’m a nurse in the system, I don’t need to agree with the perspective that medication and intervention are always good, for everyone alike.

In truth, I believe our society is too medicalized and our hospitals do not provide enough individualized care. As someone who has grown up in diverse family and social contexts, I believe in an integration of healing methods and perspectives. Some people might say that I’m working in the wrong field then, but suddenly I’m seeing quite sharply the “unique position that nurses occupy.” You hear about this “unique position” throughout nursing school, but it’s a great moment when you actually experience it. Certainly there are safety reasons to follow some protocols, but we can also use our judgment to fudge or work around them to “meet the patient where they’re at” — another banal-until-experienced nursing school mantra!

This week was finals week for the winter quarter. Next up is a week of spring break. Whoo hoo. Time has accelerated in recent months; if I think about it too long, I might panic, so instead I’ll just sip my caipirinha, marvel at the interminable feather-grey sky, and count my blessings.

Example of a blessing (as a pathetic way of summing up the 1st half of the year): I’m happy to say that doing the Master’s program part-time was the right decision for me. Yay. Inititally I felt pangs of regret and wistfulness when I saw my MEPN friends walking merrily to class together. Or if they were harried, they were at least present to support one another. Poor me was usually alone because I had only two classes that most others weren’t taking yet…

But by the middle of this quarter, I didn’t mind feeling out of sync because I knew I was moving at a speed that’s right for me. While the NP classes and clinicals sound exciting, I’m content to focus on general graduate classes while trying to get comfortable with this wholly consuming identity of “registered nurse.”

I almost can’t remember the life of writer-reader-a.k.a.-dreamer. This isn’t a sorry or wistful statement; it’s just fact right now.

Maybe being a nurse doesn’t have to be all-consuming or so damn serious, but right now I don’t know how else to do it, if I want to do it kind of well.

One month ago
I gave a patient Aspirin and Plavix, not realizing that he already received the once-daily dose at a different hospital before he transferred to the one I work at. A nurse told me about the error the next day and apologized for having to report it on a “Responsible Reporting Form.” I was shaken by the news – both of the meds reduce the blood’s ability to coagulate. Luckily, the doses were relatively small and the patient was unharmed. Still, I was kicking myself and terribly annoyed by the “med reconciliation” process, which I think is highly susceptible to errors.

One week ago
I gave a scheduled dose of 10 units NPH insulin along with a sliding scale dose of 10 units of Aspart – except that I didn’t actually give NPH; I gave Novolin 70/30, which I mistook for “NPH” and later learned is 70% Aspart and 30% NPH. This means I gave a patient too much rapid-acting insulin, which would bring his blood sugar down, fast.

Just as I was going home, the nurse who had “double checked” my insulin noticed that Novolin 70/30 was in the med room labeled with the patient’s name. She asked if I had given 70/30 or NPH.

The chain of errors immediately flashed before my eyes:
- I went to the Pyxis to get NPH.
- NPH was grayed out/not available in the Pyxis.
- I caught sight of a bottle of insulin on the counter with the patient’s name on it.
- I looked at the label and saw “NPH.” It didn’t register in my mind that there was also the word “Aspart” or that it said “Novolin 70/30.”
- I drew up the insulin in the med room and outside of the med room, asked a nurse to check my doses and co-sign.
- She didn’t see from what vials I had drawn the insulin.

And so there we were. Mild panic and disbelief as to why I gave 70/30. Didn’t I know the difference? The shameful truth is, I didn’t.

I notified the doctor, who was very nice. He ordered every-hour blood sugar checks for a few hours.

The nurse, while astounded by my ignorance, also kicked herself for not doing a real double check.

We also blamed Pharmacy for sending up Novolin 70/30 with the patient’s name on it.

I didn’t sleep well.

The next day I studied my insulins like I should have before. But I was also cursing and shaking my head – why is the naming of the different insulins so alike?

Thankfully, the patient was unharmed.

For a few days I was despondent and angry with myself and with the hospital system we work in. The errors were my fault, no doubt about it. But it’s also true that the hospital system, the “flow” as one veteran called it, sets the stage for us to make mistakes and take short cuts.

I’m still shaken up by last weekend’s mistake, but I’m also extremely motivated and determined to not make another med error again. I might even be a little paranoid now, but paranoia is probably a good thing in acute care.