Fledgling Nurse, Part 10: About Pain Medication

Another raw one this week.  

Sometimes, when I'm getting report from another nurse or when I'm sitting at the nurse's station, one of my peers might comment with a heavy sigh that "oh, they just want their pain meds."  On some instances, it's simply a letter-of-fact--that is why the patient is calling based on a previous conversation or as a general understanding of the main core of the patient's needs.  However, other times it is not meant that way.  In the latter, there is a heavy implication that at the very least the patient doesn't need the medication; at worst, the implication is that they're a drug seeker.  

And I'm trying to find a succinct way to ask people to stop that, because they don't know that they're talking about me.  I've struggled with how to even begin to voice that, how to tell my peers that it sends me immediately back to those places, where I was sick and miserable and told in different ways by my healthcare providers that I was not believed nor worth their time.  I see a specific glimpse of my hospital room at Mayos, and I feel my muscles pulling into a quiet guarding, aiming to protect me from an unknown but still very real threat.  My body remembers those places.  A simple statement or attitude toward a patient regarding their pain medication, and I'm there emotionally in those spaces, if only for a split second.  The sympathetic nervous system is triggered and can take a bit of work/time to talk out of it.  It is not completely debilitating anymore--it may not even register on my face--but it is a portion of my energy for the day that I now have to refactor, snatching from the emotional energy I would otherwise have for the day.  PTSD is a real bitch, sometimes.

I was a patient in pain.  I knew without a doubt that my nurses talked about me that way.  I know this because a couple of them told me to my face on a few occasions, including multiple instances of explanations that they wanted to see how long I could go without the pain medications and, once, in these words:  "You don't need this."  I had abscesses cropping up, the effects of sepsis pooling in pockets around my organs.  I'd get a new drain placed to allow the purulence an exit or a few times fistulas burrowed an exit for themselves, and, lordy, I am struggling to find words to explain what that actually feels like, to have an infection literally carve its way out of your body over a course of days, weeks.  One of those tunneled its way toward my reproductive organs which was a special kind of uncomfortable.  Another was nearby and did not close until several months after the proctectomy and permanent ostomy placement--the inflammation did not subside quickly, having run uncontrolled for months and months as we needed time for the right medication combination to find control again.  

I was twenty-five and twenty-six in this specific stretch that comes to mind.  I was very courteous and pleasant to my healthcare staff when they were in the room, and I did my crying when I was alone.  So, no, I did not look like I needed it--I had become accustomed to a high degree of pain, but that did not mean it was not present or unfelt.  In certain periods, I had also become quite tolerant of pain medication, meaning that more was needed to have an effect.  I remember being lectured about a PCA pump, and I don't know if it's reality or not that I remember that individual being frustrated about having to set it up.  I had a family member hide the clock in the hospital room because they felt I was watching the clock rather than actually listening to my own body--I was not, and the clock was replaced later that day.  I remember wondering if I needed to show it better in order to be believed, but A) I was already feeling vulnerable enough and B) it felt duplicitous when I wanted to establish mutual honesty.  I remember agonizing about the decision each time the medication was available again, whether I would ask or try to last a bit longer this time.  When I finally did, I heard my voice trying to make assurances that I was not a drug seeker.    

In nursing school, we are taught that a patient's pain is what they say it is--there are places where I weigh my options available to a patient based on their symptoms and what they are telling me, but I do not doubt that their pain is present.  Pain is subjective.  There are some objective markers, but I am acutely aware of that internal struggle that I see some of my patients go through.  Being in pain for too long has physiological effects and otherwise can discourage patients from doing activities (e.g. physical therapy) that they need to heal.  In other words, untreated pain--be it physical or otherwise--delays healing.  While I have had hospital staff that have made me feel lesser, I have also had nurses that understood it was important to get ahead of the pain again, to catch-up before we could start talking about weaning down.  There were those that said they would be back with the medication and proved true to their word, that made me feel seen and heard.  I want to be one of these.

I see myself in my patients, a decided bit of transference.  This is both good and bad.  For every person who has been told when facing adversity that they have "a good attitude," I would not want to talk you out of that mindset, but I would affirm a hundred times over that it is still okay to have a low moment, to take space to grieve as it is needed.  One does not lose their "good attitude" status by simply being human.  [There's all kinds of good advice for the people with "poor attitude" that I don't feel a need to dig into that today.]  As result, I am very intentional in my practice to ensure that I honor my patient's pain.  Being sick is exhausting business.  I won't say that there are not drug seekers in the hospital; however, the fear of being seen as one can interfere with treatment in its own way.  I'm sure I have more to learn on this yet, too.  I will also need to decide whether I bring it up directly with my peers (compared to this gentle scream into the void).  And regardless I will need to perfect how I manage my emotions when that triggering does happen, how I acknowledge and unclench in those spaces.  

Startled Aloneness

In therapy, we have been discussing sympathetic nervous system responses:  in other words, fight or flight kinds of reactions.  Specifically, the discussion has been to clarify that there are more than just those two responses.  Adding to fight or flight, freeze I think is the easiest to accept on the list.  When faced with a significant stressor--something traumatizing--freezing in place is a very real response, whether it's physical or mental.  This can be momentary or last for a bit longer, depending on the circumstance and the individual.  Another is a fawn response.  A fawn response is the individual becomes much more of a people pleaser in order to protect themselves.  I've seen this response toward doctors, where a patient confronted with some startling news becomes almost overly considerate and receptive to anything the doctor has to say.  Persons who are threatened either verbally or physically might make themselves smaller, figuratively or literally by changing their body positioning or backing down from a stronger stance than they'd previously had.  As a hypothetical, a confrontation with someone becomes more heated and interpreted as dangerous because the confronted individual has raised their voice or, in an extreme version, thrown a bottle at the wall; the person bringing up the charge in question begins to back down, walk back some of their verbiage, not because they think that they were wrong but in order to keep themselves safe.  

The one that I want to discuss today is a startled aloneness.  

Without knowing it, I was referring to this feeling almost exactly in a previous post.  Something happens.  And then in that moment, all that is present is an acute sting, a feeling of being deeply, deeply alone.  As though one were in the bottom of a deep well with barely a shaft of light to see an inch out.  Suddenly and wholly alone.  The feeling is both the suddenness as well as the isolation, the shock as well as the despair in one clean bolt.  It's jarring.  And the shock can linger, even with the adrenaline ebbs away.  Remembering that sense of being alone, that can stick.  

My interpretation of the pit

I find places where this kind of response hits tend to be moments of significant pain, be that emotional or physical.  Pain has a way of making us feel very, very alone.  Pain is so subjective--we know that we are the only ones that can feel that depth and breadth of it, hence that particular kind of alone.  The internal black pit of alone, the one that has a gravity-inducing ache, that's the one I mean.  That's the alone that lingers after.  And when it hits suddenly, transported to that pit in a moment, that's it.  That's the feeling. The shock and the impossible weight in the same moment.  

It's reassuring to know that I am not the only one to experience this, that someone else knew it enough that it had a burgeoning clinical category.  Oddly enough, it makes one feel less alone.  And it's nice to have a name for it.  

Fledgling Nurse, Part 9: The Hospital is Weird

Y'all.  There are all kinds of strange things that happen in the hospital.  There are SO MANY things that I cannot say because they involve patient specific circumstances, but, oh, there are many other stories that can be shared without any specific identifiers, from both my time in clinicals and on the floor.

• Patient was complaining that there were snakes in their room.  We reassured them a great many times that we checked under the bed, the bathroom, the blankets and all else that there were no snakes.  Patient was still concerned.  One brilliant member of our team made some "snake repellant" and sprayed it around the room.  It was some quality stuff, apparently.
• A patient was unfortunately not going to be discharged that day as planned.  They were understandably disappointed.  I stayed with them for a few minutes, as they processed that grief, including asking what they were most looking forward to when they got home.  They proceeded to tell me about the special relationship they had with their four-year-old granddaughter, how she seemed to simply know what they were feeling and was a beautiful, comforting presence.  I replied, "Sounds like she has a lot of empathy--maybe she'll grow up to be a therapist."  The patient sighed heavily and said, "No, she's going to be a pole dancer."  I couldn't help but burst out laughing--evidently, as they explained this four-year-old was in a stage where she simply did not want to wear clothes.  
• Walked by a room and noticed a patient standing at the front of it by the trashcan.  And then it clicked that this was not their room, that it was a room of a patient that had discharged about an hour and a half earlier.  I approached them, asking them if they needed help getting back to their room...and noticed that they were adjusting their waistband.  Sure enough, they had just peed in the trashcan.  From there, it was time to continue to convince them to go back to their room.  Just staying calm and not reacting and trying to not argue while attempting several persuasion tactics.  
• A couple of folks ending the call-light conversation with "I love you."
• We have a machine called the Pyxis that has various drawers with cubies inside them that lock and unlock for your selected meds.  One day, I was with my preceptor when they received a call from another nurse:  "I'm stuck.  Come to the Pyxis."  She hung up with some confusion but walked swiftly to the Pyxis; I followed.  We rounded the corner and saw the other nurse shut her jacket in a Pyxis drawer, and she could not yank it out nor manage to take her jacket off.  Of course, at that point we were not much help, laughing with her about the absurdity of being stuck in the Pyxis.  Once we had collectively regained enough sense to actually solve the problem, we pulled the same med for the same patient (and then canceled it) to get the same drawer open again.  She was freed, but, naturally, we had to tease her about it for the rest of the day.
• I had a day lately where I was feeling a little off, the kind of day that includes dropping things more than usual and running into doorknobs.  Right at the end of shift, I had a patient that hadn't peed all day and the doctor had ordered a straight cath in order to drain their bladder directly.  I had not used this particular tool we had for this process very much, so I asked another nurse for another set of hands and eyes.  This process involves wearing sterile gloves and then not touching anything that is unsterile, i.e. pretty much anything.  Once your gloved hand touches the patient, that cannot touch the part that is going inside them again.  This means, too, that putting them on without touching them everywhere is a skillset, because touching the outside of the sterile glove with an unsterile hand contaminates the glove.  So.  The goal is to get one glove on enough to help the other hand put it on fully--sterile to sterile is fine.  Putting on a tight glove one-handed is difficult, let alone on a low dexterity day.  So, I had the thumb on the wrong side in one glove, two fingers in one hole on the other, fingers in the wrong hole, and basically I turned to the patient like a giant squid, spending about as much time fixing my rubbery appendages as I did on the actual procedure point.  And then the straight cath bag flowed backwards and soaked the patient's bed a fair bit.  Sad squid hands.
• Had a patient call me into their room.  I asked what they needed.  "My name," they said.  I clarified, "your name?"  "Yes," they agreed, "I dropped my name."  I told them that I was pretty sure they still had that, pointed out that it was on the whiteboard.  "Oh.  Can you bring it to me?"  "I sure can't--the whiteboard is attached to the wall."  "Oh.  Can you bring it to me?"  I then pointed out that they also had it on their wrist, on their hospital band.  They asked that I bring it to them, too, and after three or four attempts, eventually we connected together that they did, in fact, already have possession of both their name and arm.  

It's a sampling, to be sure.  I daresay I will continue to collect more.  We have to treasure those moments to laugh, partially to protect against those other moments and also because it's too absurd not to.

Fledgling Nurse, Part 8: Boundaries and Abuse

I sat down to listen to a patient one day.  They were angry, frustrated that they had been suffering the effects of an illness for over a year and a half, now, with multiple trips to the emergency room, a gamut of tests, poor empathy responses from work/landlord/family/the world in general, familial stress, arguing with insurance, and the very real anxiety of the looming bills yet to be revealed.  This particular patient clarified several times that they were not mad at us, the nurses and techs, just that they were tired.  I sat down with them to listen for a while, validating the hell out of their feelings--that is a difficult place to be, that not-knowing space.  I want to think that they felt better to get some of that off of their chest--they were at least visibly a little less grumpy.

But this patient had not been particularly harsh to any one of us.  Not very conversational, maybe, but not outright rude.  I cannot say the same for other patients.  

"A Lapse in Perspective and Empathy," a short story:
Scene, nurse enters patient room.

Patient:  (clearly annoyed, sighing dramatically) "I put on my call light twenty minutes ago.  What took you so long to bring that water?"

Nurse:  (sets the cup of water down) "Oh, one of my other patients stopped breathing.  So sorry to keep you waiting!"

I have been intentionally hit in the face, smacked a few times in the arm, pinched, kicked, threatened, yelled at, called a number of names (variants of stupid and incompetent are favored choices), and once was patted on the butt like it was a compliment.  And I've only been a nurse since August.  I daresay every nurse or CNA has at least one story.

The bulk of these were confused persons with varying degrees of dementia; some were patients that fit into that category of "I feel out of control so I'm going to pick a fight to reestablish control."  So logically I know that some of my patients are not angry with me, that I just happen to be a convenient place to focus their anger; I can also recognize that some patients are demonstrating poor boundaries as part of a wholly valid medical reason.  That does not make that behavior okay.  Both the recognition that the behavior is affected by certain factors and is inappropriate exist in the same space.  It's also possible that the individual in question is simply an asshole.  

Yet, there is culture to accept a degree of this abuse.  I have the option to press charges, but whether I have cultural approval to do so is a different question.  From management, I have been told that I have the right to feel safe, that I don't have to be a martyr.  In the same breath, there is an unspoken pressure that there are some places I just need to have a thick skin, and it's difficult to calculate how thick this is supposed to be.  The thick skin is only needed because the microaggressions and then outright aggressions are common, again, because there is a culture formed in this environment, which means that patients know on some level that they can get away with it, becoming a self-perpetuating cycle.  Realistically, too, I know that patients with advanced enough dementia are likely waiting on placement in a facility, where they will be making decisions based on scores of how directable, violent, etc. the patient is, meaning that I might delay some options (certain medications, for example) or bend more than I might otherwise to not affect their chances.  

I have set boundaries with patients, a "I will not be spoken to that way," or "I will call security if we need to" and "I'm not going to engage in that argument."  I have also sat down and said directly, "I don't think you're actually mad at me--what's on your mind?" and start the conversation to the deeper places, find those actionable components from there.  I have also admittedly gotten caught in some of those unproductive arguments, attempting to persuade a confused, suspicious patient for the better part of forty-five minutes to do something (roll off a soiled pad, take their medication, sit back down because they have a history of falls, etc.).  There are times when I have to keep trying, because it is about their safety, and yet their agitation continues to rise as I continue to press, attempt a new angle.  As such, I'm working to refine some of these boundaries, because leaving these rooms six kinds of frustrated and an hour behind does not serve my other patients.  

There are circumstances where a patient has an order for medications that will help decrease agitation--when the patient is a danger to themselves or staff, it is an unfortunate but necessary option.  There are many specific checks and steps to creating these orders, not something that I can dole out because I find someone annoying.  If they cannot or refused to be talked down, again, we have to protect both them and ourselves, meaning that we are no longer asking.  And I usually call security for an assist (the presence of a uniform sometimes changing their demeanor immediately), since an agitated person is also not going to appreciate a shot in the arm.  I would much prefer a one-time dose of something than allow something to escalate to needing locked restraints or the patient falling and injuring themselves or any of the staff getting injured.  I have some cognitive dissonance on when it is okay to use these--I don't want to give someone a shot in the arm that doesn't want one, nor potentially make them more upset by doing so, nor inadvertently alter their options in placement.  Simultaneously, again, this is what the medication is here for, I want to protect the patient from themselves (as well as my fellow staff), acknowledging that allowing agitation to progress further is its own kind of negligence.  On a personal level, I don't have time to be threatened--I pick my battles with patients, but this is a steadily solidifying line.

"What not to do," a study

I shouldn't have to absorb abuse from my patients, whether they're in their right minds or not.  I acknowledge that an unspoken norm to expect this abuse exists, but I also recognize it is an unacceptable norm that needs addressing.  Of course, if it was an easy answer, we would have already figured it out by now.  For myself, I am working on setting cleaner boundary statements, that I am not there to absorb their anger for example, or that I will refuse to engage.  For patients that can be engaged, I can give them a space to vent what they're actually upset about instead of accepting passive-aggressive digs all day.  In other places, I become almost overly professional, stripping out my personality--if I'm going to be seen as a service then I will only be a service--which protects me.  For patients that are unable to engage due to dementia, temporary confusion, or other reasons, I pick my battles--I'm not terribly annoyed that they're pulling the sheets off their bed if they are not putting themselves in danger of falling; I will bring them a fresh ice water every hour if that helps them stay calm and feel they are attended to; I will wait to give them their daily medications until they are eating breakfast rather than wake them up to take them when I think it's more convenient.  

There is grace for a patient's circumstances; there is also recognition of my own emotional and safety needs.  I will not win a prize at the end of the day for absorbing X amount of patient frustration.  It will not make me a better nurse to fail to stand up for myself.  As a culture, it is important to challenge the idea that it's okay for certain workers--any workers--be receive a degree of verbal or physical abuse, whether they're ED staff, teachers, food service, or whatever else.  Right now, we're seeing a lot of discussion about teacher's autonomy in the classroom, but I can also remember when I was student teaching a conversation with a parent that was furious that we scored their child a zero on a project that the child openly refused to do, how rudely they behaved in that moment--in other words, the disrespect to the career is not a new thing, though it does seem to be continually getting worse.  And for food service staff, well, there are too many examples of those to count, and I will never understand why an incorrect drink or burger is a reason to go nuclear on someone.  

In short, we as a culture have collectively allowed this to happen, by not correcting the behavior.  That's an overly simplified statement, to be sure, particularly when we factor in the medical caveats in the hospital setting.  My goal in my practice is to ensure that the boundary is set, for my sake, the patient's sake, and the patient's family's sake.  For the patient and their families, an escalation of the situation will not have the excuse of ignorance, that they were unaware they had crossed a line.  For myself, reaffirming the boundary is an act of self-compassion, one that helps me make tough but necessary decisions and ultimately enforce them.  For my peers, I don't want to hand any of them over to a situation they don't feel safe in either by not deescalating where I'm able to or hesitating too long to call for additional hands.  I am testing my own balance between being gracious to the circumstances while also ensuring it is not at the sacrifice of my own needs.