Add low sodium vegetable juice to red lentils in a 2-to-1 ratio. Bring to a simmer. Add more liquid as necessary. Season to taste with what you like. Takes about 30 minutes...enough time for your rice to cook. It's nutritious fast food when you just don't wanna. I added frozen spinach to another batch to give it color. Serve with naan...or Wonder bread.
Friday, February 12, 2010
Wednesday, February 10, 2010
Going Bareback**
One of the unique aspects of nursing is that you are likely to work side by side with someone who has been practicing vastly longer than you have. Nursing is not a profession where long years of experience automatically translate into management. Many nurses do not want management because it takes them away from the bedside. Instead, they are compensated with other perks of seniority such as first dibs on shifts and holidays, the option of choosing whether or not to interact with problem families, and the license to practicing nursing the way they learned it, no matter how long ago that was.
Now I love working with nurses who have been around forever. They have done everything and they have seen everything and for the most part they are happy to share everything they know with you, so long as you come with an appropriate attitude. This doesn't mean you grovel, but it does mean that your bachelors degree does not trump their diploma and 20 years on the floor. While it is said that nurses eat their young, this had not been my experience…or maybe working 15 years in the software industry with ex-military folks who didn't care about my hurt feelings was good preparation for nursing.
Case in point, my new manager, Kyle. About a month into my first job, I was transferred from the acute care unit to the ventilator unit. I don't know how much input Kyle had into this decision, but it was the Director of Nursing's will that I replace the nurse who was transferring to another facility. I could see immediately that everyone loved April, the nurse who was leaving. Meanwhile Kyle had not acknowledged my presence even after a week of orienting to the unit. I wasn't sure this was going to work out so well. Even after April left, Kyle barely spoke to me. He would talk to the respiratory manager and the lead nursing assistant when he wanted to know what was going on. I said nothing. I was determined not to fail what was clearly some test of my metal.
While the day shift is undoubtedly the lighter of the shifts, I think it is the hardest shift to transition into. If anything weird is going to happen with a patient, it happens between 12am and 7am. There are simply less people in the building to help you if something bad happens, your access to doctors is diminished, you can't get STAT anything. Most 911 calls happen on the 11pm to 7am shift. When you come on for the day shift, you have to catch all the events of the last shift and help finish some of the work. Things like IV dressing changes, catheter changes, certain blood tests get left for the last minute. In order to move the process along, I follow the nurse coming off shift to give her a hand and get report.
On this day, I was following Maggie, a forty year nursing veteran. Maggie is tall and wiry with a whisky voice from too many cigarettes and a tanned hide from too many afternoons on the golf course. She started working the night shift after her husband died. There was something I admired about the candor of her grief. It was raw, but not maudlin. "The wee hours are when I miss him most," she would explain. "By the time I get out of here, it's morning and I have the day ahead of me." She had certainly figured out a way of making the best out of a bad situation.
"Come help me change this catheter on Mrs. Gillian," she said, waving me into the room. "She's just so big, I can't possibly move her on my own." Another thing about Maggie is that she is blunt in a way that we're not anymore. What used to be an "alcoholic" is now a "history of ETOH abuse" and what used to be "an overweight patient that requires two staff to move" is now a "bariatric" patient. There is no mean-ness in Maggie, she's plain-spoken. But it's jarring to hear the forbidden words made flesh. Call it what you will, at five feet and 250lbs, Mrs. Gillian was a big woman.
So I followed Maggie into Mrs. Gillian's room. It's still dark outside and the fluorescent light is on over the sink. This combined with the flickering of the TV makes me feel like we are working clandestinely. Mrs. Gillian, who is conscious, but unable to communicate except by grimacing, sweating profusely and breathing against her ventilator is expressing her displeasure. Her breathing on the ventilator makes a noise similar to a donkey's bray. It is dissonant, patternless, and echoes in my head on nights when I can't sleep. It sounds like pain to me.
"Did she push this thing out?" I ask, starting to feel a little dizzy. Her breathing was so uncomfortable and she was using so many muscles to breath against the ventilator, she expelled the catheter. The golfball sized balloon that would normally keep the catheter in place was still in tact, laying at the foot of the bed. "Oh yes," Maggie responded while pulling a new catheter out of its wrapping. "She does it all the time. I don't know why we keep putting new ones in. She's got to be in agony. But then she has these bed sores, so I guess we keep doing it until the doc says otherwise." Maggie continued unwrapping the catheter. She checked the balloon by inflating it just a little and then she lubed the tip. She cleaned Mrs. Gillian's perineal area with the cleaning swabs that come in every catheter kit. Then I rolled Mrs. Gillian to her side so that Maggie could approach from behind, something they don't teach you in nursing school. It's not the "official way" of inserting a catheter, but it's how you do a big patient on an air mattress when the target area is obscured by folds of skin and legs that are clenched shut.
Just when I think I cannot hold Mrs. Gillian steady anymore, Maggie is done. I roll Mrs. Gillian onto her back and straighten out her bed clothes. Something was wrong. Maggie hadn't been wearing gloves. I know I saw her wash her hands but the pack of sterile gloves was laying on the mattress with the rest of the used kit. No way, I thought, she couldn't have. But she didn't. Maggie was washing her hands again as I cleaned up the rest of the kit. "Thanks for your help," she said as she walked out of the room.
I washed my hands and went out to the nurses station, which was abuzz with the morning's activities. In the background a respiratory therapist was opening a bag of chips. "I brought food!" she announced. Maggie sailed over to the bag. "Thank you so much. I'm starving," she said. She reached into the bag, pulled out a handful of chips and walked away. "No chips for me," I thought to myself.
Just then, Kyle picked up the bag of chips,"Who brought these in?" Kyle asked, enthusiastic about free junk food so early in the morning. He grabbed a paper towel and was about to pour some out when I said "I wouldn't eat those if I were you." Kyle looked at me as though I was the junk food police. "Why not?" he retorted. "A certain someone inserted a catheter bareback this morning then had their hands in that bag you've got there," I stated matter of fact-ly and then turned back to Amy, the desk nurse. "Bareback?" Ken asked? "Yeah," I said, without looking up from Amy, "no gloves." A muffled squeal escaped from Amy, "Ooooh, she did that for you too?"
Kyle held the bag of chips by his fingertips and dropped them into the trash. As he breezed by me on his way to morning meeting, he said, "Bareback…I like that."
Kyle stopped ignoring me after that.
**Names are changed.
Now I love working with nurses who have been around forever. They have done everything and they have seen everything and for the most part they are happy to share everything they know with you, so long as you come with an appropriate attitude. This doesn't mean you grovel, but it does mean that your bachelors degree does not trump their diploma and 20 years on the floor. While it is said that nurses eat their young, this had not been my experience…or maybe working 15 years in the software industry with ex-military folks who didn't care about my hurt feelings was good preparation for nursing.
Case in point, my new manager, Kyle. About a month into my first job, I was transferred from the acute care unit to the ventilator unit. I don't know how much input Kyle had into this decision, but it was the Director of Nursing's will that I replace the nurse who was transferring to another facility. I could see immediately that everyone loved April, the nurse who was leaving. Meanwhile Kyle had not acknowledged my presence even after a week of orienting to the unit. I wasn't sure this was going to work out so well. Even after April left, Kyle barely spoke to me. He would talk to the respiratory manager and the lead nursing assistant when he wanted to know what was going on. I said nothing. I was determined not to fail what was clearly some test of my metal.
While the day shift is undoubtedly the lighter of the shifts, I think it is the hardest shift to transition into. If anything weird is going to happen with a patient, it happens between 12am and 7am. There are simply less people in the building to help you if something bad happens, your access to doctors is diminished, you can't get STAT anything. Most 911 calls happen on the 11pm to 7am shift. When you come on for the day shift, you have to catch all the events of the last shift and help finish some of the work. Things like IV dressing changes, catheter changes, certain blood tests get left for the last minute. In order to move the process along, I follow the nurse coming off shift to give her a hand and get report.
On this day, I was following Maggie, a forty year nursing veteran. Maggie is tall and wiry with a whisky voice from too many cigarettes and a tanned hide from too many afternoons on the golf course. She started working the night shift after her husband died. There was something I admired about the candor of her grief. It was raw, but not maudlin. "The wee hours are when I miss him most," she would explain. "By the time I get out of here, it's morning and I have the day ahead of me." She had certainly figured out a way of making the best out of a bad situation.
"Come help me change this catheter on Mrs. Gillian," she said, waving me into the room. "She's just so big, I can't possibly move her on my own." Another thing about Maggie is that she is blunt in a way that we're not anymore. What used to be an "alcoholic" is now a "history of ETOH abuse" and what used to be "an overweight patient that requires two staff to move" is now a "bariatric" patient. There is no mean-ness in Maggie, she's plain-spoken. But it's jarring to hear the forbidden words made flesh. Call it what you will, at five feet and 250lbs, Mrs. Gillian was a big woman.
So I followed Maggie into Mrs. Gillian's room. It's still dark outside and the fluorescent light is on over the sink. This combined with the flickering of the TV makes me feel like we are working clandestinely. Mrs. Gillian, who is conscious, but unable to communicate except by grimacing, sweating profusely and breathing against her ventilator is expressing her displeasure. Her breathing on the ventilator makes a noise similar to a donkey's bray. It is dissonant, patternless, and echoes in my head on nights when I can't sleep. It sounds like pain to me.
"Did she push this thing out?" I ask, starting to feel a little dizzy. Her breathing was so uncomfortable and she was using so many muscles to breath against the ventilator, she expelled the catheter. The golfball sized balloon that would normally keep the catheter in place was still in tact, laying at the foot of the bed. "Oh yes," Maggie responded while pulling a new catheter out of its wrapping. "She does it all the time. I don't know why we keep putting new ones in. She's got to be in agony. But then she has these bed sores, so I guess we keep doing it until the doc says otherwise." Maggie continued unwrapping the catheter. She checked the balloon by inflating it just a little and then she lubed the tip. She cleaned Mrs. Gillian's perineal area with the cleaning swabs that come in every catheter kit. Then I rolled Mrs. Gillian to her side so that Maggie could approach from behind, something they don't teach you in nursing school. It's not the "official way" of inserting a catheter, but it's how you do a big patient on an air mattress when the target area is obscured by folds of skin and legs that are clenched shut.
Just when I think I cannot hold Mrs. Gillian steady anymore, Maggie is done. I roll Mrs. Gillian onto her back and straighten out her bed clothes. Something was wrong. Maggie hadn't been wearing gloves. I know I saw her wash her hands but the pack of sterile gloves was laying on the mattress with the rest of the used kit. No way, I thought, she couldn't have. But she didn't. Maggie was washing her hands again as I cleaned up the rest of the kit. "Thanks for your help," she said as she walked out of the room.
I washed my hands and went out to the nurses station, which was abuzz with the morning's activities. In the background a respiratory therapist was opening a bag of chips. "I brought food!" she announced. Maggie sailed over to the bag. "Thank you so much. I'm starving," she said. She reached into the bag, pulled out a handful of chips and walked away. "No chips for me," I thought to myself.
Just then, Kyle picked up the bag of chips,"Who brought these in?" Kyle asked, enthusiastic about free junk food so early in the morning. He grabbed a paper towel and was about to pour some out when I said "I wouldn't eat those if I were you." Kyle looked at me as though I was the junk food police. "Why not?" he retorted. "A certain someone inserted a catheter bareback this morning then had their hands in that bag you've got there," I stated matter of fact-ly and then turned back to Amy, the desk nurse. "Bareback?" Ken asked? "Yeah," I said, without looking up from Amy, "no gloves." A muffled squeal escaped from Amy, "Ooooh, she did that for you too?"
Kyle held the bag of chips by his fingertips and dropped them into the trash. As he breezed by me on his way to morning meeting, he said, "Bareback…I like that."
Kyle stopped ignoring me after that.
**Names are changed.
Tuesday, February 2, 2010
Before You Go
When I do nursey stuff, I work in a ventilator unit. I say "when" because I used to do it full time. Now I do it part time and every time I work, I remember why I can't work there full time. When the house is full, I am responsible for up to 13 patients. On any given day, half of those patients are in a persistent, vegetative state, one fourth are "awake" and one fourth have an actual hope of going home. Of those folks who are "not awake" some are DNR/DNH (do not recussitate/do not hospitalize) and those who are not, should be. DNR means that if I find you unresponsive, I will not initiate any life saving measures such as CPR and I will not send you to the hospital. Do not hospitalize means that if you have something wrong with you like lethally abnormal electrolytes, we will try to manage the situation in-house, but we won't send you to the hospital. It is one of the steps the road to hospice or comfort care.
This weekend, I cared for a woman who was actively trying to die. It is a privilege to care for people in this state. Sometimes you're the last touch they feel, the last voice they hear. If you are the last bridge between this world and the next, you always hope you made the "here" better for them. This woman was in agonizing pain when the morphine wore off. It hurt when I wiped her mouth or repositioned her hand. So my job for the day was to make sure the morphine didn't wear off.
By now, we all know that hearing is one of the last senses to leave when someone is dying. In my practice, I recommend the patient be surrounded by family talking about the positive things that are happening. If the TV is the patient's only company, I make sure it's tuned to music. What a patient should not be hearing is "I don't want to send my mom to the hospital for a blood transfusion, I already told that stupid doctor that!" What we have here is an ambivalent son. He doesn't want his mom to suffer, but he doesn't want to let her go.
At this point, I suggest we step into the nursing office. I explain that the Responsible Party (the person who has legal authority to make health care decisions on a patient's behalf) canceled the "Do Not Hospitalize" order on Thursday and with blood work as abnormal as this patient has, I have to follow the orders of the on-call doc unless the on-call speaks to the Responsible Party directly.
(It should be noted the the on-call doc has NEVER seen this patient and practices medicine in such a manner as to keep the patient safe and not get sued. I leave it as an exercise to the reader to decide the order in which these occur.)
At this point, the son is actively trying not to wring my neck. He is frustrated because he knows he argued his step-dad into canceling the DNH order earlier in the week. Step-dad knows the score and understands that his beloved is not going to recover and is suffering. Son is not ready to let go of his mother. Who is? I tell the son that I will not send his mom to the hospital if he will help me get the step-dad in touch with the on-call. It's the only way. Son gets on the cell phone - it goes to voice mail. Step-dad is on his way home, somewhere between Philadelphia and the Poconos.
Finally we are able to get the step-dad connected with the on-call and a new DNH order is obtained. End of shift, I go home.
But I'm still thinking about work. What happened here is mostly avoidable. Mom is probably in this situation because she did not have a living will. Without the living will, this family had to go to court to decide that the spouse and not the son would would make decisions on behalf of this lady. This case is not isolated. Many of my patients are not married to their companions. But without any document indicating who should make decisions or who should execute the decisions you have already made, you will be kept "alive" until your heart gives out (not a good death), some other party will choose for you, or your companion will have to go to court to "prove" that you are a family.
You don't have to be married and you don't need a lawyer. For a few dollars, organizations like Five Wishes provide living wills in simple language. All you have to to is fill it out, get it notarized, then give it to your doctor or make sure your companion has it. The red tape in a nursing home is ten-fold. Your family has enough to worry about with you in a coma. Before you go, do them a favor and execute a living will.
This weekend, I cared for a woman who was actively trying to die. It is a privilege to care for people in this state. Sometimes you're the last touch they feel, the last voice they hear. If you are the last bridge between this world and the next, you always hope you made the "here" better for them. This woman was in agonizing pain when the morphine wore off. It hurt when I wiped her mouth or repositioned her hand. So my job for the day was to make sure the morphine didn't wear off.
By now, we all know that hearing is one of the last senses to leave when someone is dying. In my practice, I recommend the patient be surrounded by family talking about the positive things that are happening. If the TV is the patient's only company, I make sure it's tuned to music. What a patient should not be hearing is "I don't want to send my mom to the hospital for a blood transfusion, I already told that stupid doctor that!" What we have here is an ambivalent son. He doesn't want his mom to suffer, but he doesn't want to let her go.
At this point, I suggest we step into the nursing office. I explain that the Responsible Party (the person who has legal authority to make health care decisions on a patient's behalf) canceled the "Do Not Hospitalize" order on Thursday and with blood work as abnormal as this patient has, I have to follow the orders of the on-call doc unless the on-call speaks to the Responsible Party directly.
(It should be noted the the on-call doc has NEVER seen this patient and practices medicine in such a manner as to keep the patient safe and not get sued. I leave it as an exercise to the reader to decide the order in which these occur.)
At this point, the son is actively trying not to wring my neck. He is frustrated because he knows he argued his step-dad into canceling the DNH order earlier in the week. Step-dad knows the score and understands that his beloved is not going to recover and is suffering. Son is not ready to let go of his mother. Who is? I tell the son that I will not send his mom to the hospital if he will help me get the step-dad in touch with the on-call. It's the only way. Son gets on the cell phone - it goes to voice mail. Step-dad is on his way home, somewhere between Philadelphia and the Poconos.
Finally we are able to get the step-dad connected with the on-call and a new DNH order is obtained. End of shift, I go home.
But I'm still thinking about work. What happened here is mostly avoidable. Mom is probably in this situation because she did not have a living will. Without the living will, this family had to go to court to decide that the spouse and not the son would would make decisions on behalf of this lady. This case is not isolated. Many of my patients are not married to their companions. But without any document indicating who should make decisions or who should execute the decisions you have already made, you will be kept "alive" until your heart gives out (not a good death), some other party will choose for you, or your companion will have to go to court to "prove" that you are a family.
You don't have to be married and you don't need a lawyer. For a few dollars, organizations like Five Wishes provide living wills in simple language. All you have to to is fill it out, get it notarized, then give it to your doctor or make sure your companion has it. The red tape in a nursing home is ten-fold. Your family has enough to worry about with you in a coma. Before you go, do them a favor and execute a living will.
Subscribe to:
Posts (Atom)
