The Zen of Nursing

Life is not fair.

If you haven't noticed that by now, either you haven't been paying attention or you don't have enough birthdays under your belt.

Life was never fair, and never meant to be.

While whole religions have erupted from the minds of men to address this one issue, the fact remains, there is no divine justice wrought here upon the Earth.

I learned this lesson while I was very young, but had it reinforced by a decade as a newspaper reporter.  I saw cold-blooded killers set free, saw liars triumph and the honest punished for their honesty. Mendacity rules at all levels of power. Inhumanity and incompetence are promoted. Debased actions and bullying are rewarded. Being a reporter is to strive for truth in the face of lies. Journalists comfort the afflicted and afflict the comfortable.

In journalism, fairness is a watchword and justice is what every young wide-eyed new reporter seeks. Yet, the pay is barely minimum wage and you are disposable to your employer and community. After seven years at one paper -- winning awards and working 60 hour weeks, I was told to move on because the corporation didn't want to start paying reporters more than $18,000 a year.

"You've had too many raises," the executive told me from the hollow of his tailored suit. "You've reached the pay ceiling."

Everyone hates you when you tell them the truth anyway.

I had few illusions when I went into nursing.

Sure, there are golden moments when all is right. When your patients are healed by your actions and grateful for your kindness. Those moments must carry your for six months to a year before you might encounter them again. In the interim, the kind nurses will be cursed at and shat upon, denigrated and abused. They will work long hours and then be mandatoried over to work more -- punished for showing up to work.

They will cast themselves upon the rocks of the suffering and pestilent, the addicted and debauched, to be broken, yet to stand again.

At least the pay is better.

Moreover, as emergency room nurses we see the inequality of life's whims on full display. Children suffer, criminals get out of jail by malingering. The drunk driver murders children, then staggers away without a scratch. The kind die in pain and suffering while the cruel survive again and again. Sickness is not tied to sin.  The good die and suffer for no good reason. The gift of survival falls heedless of whether the recipient deserves another breath.

It is a hard lesson for a nurse to learn. The zen of nursing is learning to heal without judging, without a care about justice. Your job is to make the sick better, not to make the world fair.

No, there is no fairness in this business nor in life.

Yet in our larger lives, we must still strive for justice -- for justice is a thing wholly created by humanity. It is our humane reaction to the unfairness of life. Justice is the perfection we seek but may never attain. Striving for justice, fairness and equality are the only tools we have to battle back against the empire of fates that seek to pound us into submission.

The world is not fair.

It never will be.

Unless by our hands we make it so.

-30-

RED's Rules

Okay, I've been having to train new nurses lately. Not just new nurses to the ED. But nurses that are new to everything. I've been giving them my rules. Mine aren't as refined as the House of God rules, but I'll keep working on them. I'll take suggestions too! 

1. Bringing a crash cart into the room can ward off evil spirits.
2. Don't panic. If the airway is patent, get a set of vitals. It's useful information and buys you time to figure out your next move. Moreover, it makes you look like you know what  you are doing.
3. We have to treat all our patients, not just the nice ones.
4. The patient is not the enemy. 
5. There are many reason for people to be assholes - demanding, agitated, argumentative. Sometimes it is an underlying disorder of the personality that you have no control over. Sometimes it is because they are dying. Often they don't know what to expect and aren't used to being powerless. At the very least, it may be because you just met them on the worst day of their life. This is a good possibility given that they are in an emergency room.
6. You job is to try and be the best part of the worst day of their life.
7. The Emergency Department is an easy place for a nurse to kill people. If you don't walk into work a little scared of doing so, you probably aren't paying attention.
8. Err on the side of the patient. Over time, it is always easier if you do the right thing in the first place. That said, it is never too late to do the right thing.
9. Doctors will yell at you for doing the wrong thing just as they will sometimes yell at you for doing the right thing. Thus, it's easier to do the right thing. 
10. You are never the most important person in the patient's room.
11. Don't pre-anger the patients in triage. Don't argue with patients in triage ... just nod your head and get as much information as you can. Let the doctor piss the patient off or do your discharge teaching right before you send them out the door -- not in the triage room.
12. The one time you don't do what you always do, you will get burned.
13. If a patient says they have esophageal varricies and their chief complaint is "vomiting" they need two large bore IVs -- even if their vitals are perfect and they look the picture of health. 
14. Chart like your license depends on it.
15. EKGs are cheap, undetected MI's are expensive. If you ask yourself: "Should I get a 12 lead?" The answer is always yes. 
16. Check blood sugar on anyone with altered LOC.
17. You patient's blood pressure will drop about ten minutes after you start the IV antibiotics and just before you admit them. 
18. Don't DC an IV until the patient is dressed and in the wheel chair ready for discharge.
19. Don't argue with drunks or crazy people. 
20. Some people suffer from undiagnosed UAD (Underlying Asshole Disorder) 
21. Don't take it personal. They don't know you, and with any luck you won't see them tomorrow. 
22. Leave 'em better than you found 'em and you've done your job. 
23. Nurses don't work for doctors, they work for patients.

Nurse Jackie, Flawed Nurse, Good Show

"The Truth About Nursing" has a different take on "Nurse Jackie" as well as a more detailed analysis than my visceral reaction. Their conclusion:

On the whole, Nurse Jackie has the potential to alter the public image of nursing more profoundly than any Hollywood show of recent decades. Even on ER, by far the best major show for nursing so far, the profession was never more than an occasional supplement to the real action, which was dominated by the heroic physician characters. But Nurse Jackie is an unusually compelling, witty character who works at center stage, dispensing expert physical and psychosocial care, saving and endangering lives, raising nurses' and physicians' level of play, deceiving herself and those who love her, making dubious moral choices--and presenting a radically different vision of what a nurse is.

Read the full review here: Nurse Jackie: Henchman of God

Nurse Jackie Review

For a while I've been waiting for a decent TV show that shows the world what nursing is really like. Nurses deal with so much on a daily basis, you'd think it'd be a cinch to come up with a drama where nurses are intelligent professionals, not bed-pan changers and foils for genius-doctor's frustrations. Shows like "House" eliminate nurses entirely, while most other doctor-driven series give us doctors doing many of the jobs that nurses do every day. 

So when I saw "Nurse Jackie" advertised, I decided to give it a chance. Edie Falco certainly looked like the ED nurses I work with (aside from the tight-fitting designer scrubs). Maybe she'd be a modern cipher for modern nursing. We need such a person to give the world a window on the demanding and challenging profession of modern nursing. 

Alas, she's a foul-mouthed, pill-popping, ethically challenged, cheating-on-her-husband "saint."  In other words, in an effort to smash old stereotypes about nursing, the writers have gone to the opposite extreme. This could have worked, but I couldn't help feeling that the writers are being lazy.

There's an old joke among writers. Whenever you see a quote from Webster's Dictionary leading off a story, you know the writer has run out of ideas and stopped trying before the first word. 

That's the impression I get from Nurse Jackie.

In an effort to try to make the lead more "relatable" and human, they fell back on old crutches - drug abuse, infidelity, moral ambiguity, questionable ethics. Instead of the "Hooker with the Heart of Gold" the new  cheap plot driver is a outwardly respected lead character with a multitude of sins -- "Saint with Skeletons in the Closet." Load up all the vices you can think of and you'll have lots of plot lines for future episodes. Particularly for female leads, this seems to be the easiest way to make the protagonist interesting. TNT's got a lot of these shows right now. 

Oh, and the only male nurse is gay. Gee, didn't see that one coming.

Don't get me wrong, I'm all for showing the ethical challenges of medicine and the human side of women professionals ... but why do they always have to be drug and booze addicts? Why does every strong married woman have to be cheating on her husband? Aren't there plenty of challenges in the nursing profession without trying to embody all the worst traits in the lead character? Here's a plot twist, show a hard-charging female professional with her act together. That'd be a something new! I work with and know a lot of these women. I don't know how they Hell they do it.

Other problems with the show? They appear to be working an a converted church or museum instead of a modern hospital. I work in a Catholic hospital -- the daily prayer is piped into all the rooms -- and I can tell you that there are no 20 foot tall murals of tortured saints covering the walls. Sure there's a chapel and a giant cross in the lobby but the nuns don't giggle and tour through the ED in their habits pointing at patient's genitals. 

There are plenty of details to make your eyes roll too -- the trauma patient in a soft-collar was a joke, right?Just a way to telegraph how little the writers know about their subject? No head to toe trauma assessment? Trust me you can still kill 'em tragically in lots of other ways. 

 And where are all the other nurses? It's a busy ER and there are no techs? No wonder she's working 80 hours a week! You'd think that after years of ER, a big budget show would at least one or two technical advisors to help get the simple things right.

Anyway, the show is a good opportunity for Edie Falco to get attention for her dramatic abilities. I'm sure she'll win an award or something. Sadly, we'll still be looking for a modern representation of a modern nurse on television. Apparently there are a number of shows in development, so I'll skip Nurse Jackie and keep looking.

Also see the Emergiblog's review of the show.