nurse at large: who wants to know?

If you’re a patient and you know what’s good for you, you won’t get sassy during an interview with anybody in the health care industry.  Every interview is run by a gatekeeper and your compliance is key:  in fact, being compliant is one of the most important skills you bring to the table.  You will answer the same questions again and again and again; at some point you’ll be tempted to ask whether anybody is reading the answers.  Don’t these people talk to one another?  Where is all this information going?  Who wants to know?

My experience as a patient tells me the interview/assessment system is very brittle, especially in outpatient settings.  I’ve literally been told by licensed health care staff I need to answer a question because they have to “fill in the blank” before they can move the computer form to the next screen.  The pain scale scenario I described in an earlier post is just one example of how the health care industry shapes information gathering to suit a very particular matrix; there are lots of other examples as well.  Backed by research and clinical trials, information-gathering systems are rigid and mandatory, designed to yield specific types of profiles.  It’s easy to see that, over time, the shape of the information determines the shape/presentation/ behavior/expectations of the patient as well as the practitioner.

Lots of ethical questions arise in this context.  I’d like to look at one simple question, one every practitioner can and should ask of himself at frequent intervals:  What am I going to do with this information?

We, as nurses, need to remember every question we ask increases the patient’s vulnerability.  Sharing deeply personal information is not without psychic cost.  Repeating the details of an assault,  describing a complicated birth, reciting the list of medications that ultimately didn’t work may be simply “medical history” to YOU, but to the patient they are her life story.  Patients share this intimate story believing it will advance the process of their care.  Will it?

Several examples from my own experience:  I’ve been asked my surgical history dozens of times.  Certainly, as a “pain patient,” my response to surgery is relevant.  However, NOT ONCE have I been asked any questions about my surgical experiences (such as responses to anesthesia, use of pain medication, recovery time, etc.).  What are you doing with the information?  Similarly, I’ve been asked to used the 1-10 pain scale rating system hundreds of times.  NOT ONCE has my answer prompted any immediate nursing intervention–it literally hasn’t mattered if I rated my pain a “3″ or a “15.”  My answer has been recorded, sometimes with a noticable arch of the eyebrow, but nothing else has happened.  And, frankly, what are you doing with THAT information?  If somebody has been in pain for five years, what do you make of the numbers on that scale?

You don’t have time to discuss the metaphysics of all your questions with every patient–I know that.  But please at least have them clear in your own thinking.  Maybe you just need to fill in a blank.  Maybe you’re actually checking for inconsistencies, trying to “trip up” somebody you think is gaming the system.  Maybe there are some questions you’d rather avoid (history of domestic assault?  spiritual beliefs? to name two big ones…) and you’re just recording the information in case somebody else wants it.  Maybe you’re practicing defensively, gathering information so nobody can come back and sue you.  Get it straight in your own head, even if you’re not going to share all the underpinnings with your patient.

No matter what kind of “model” you use in your practice, you need to remember all patient information is ultimately subjective.  Patients have hopes and expectations, some outside the limits of the industry’s ability to intervene.  You may think it’s impossible to practice in a sea of ambiguity, that structures and algorithms are necessary to process data in a usable way.  Maybe you’re right.  Yet, the anxiety produced when needs meet resources is the place where nursing care begins.  You might have to step outside the box.

nurse at large: pain, schmain

Describe your pain.  Is it burning?  Crushing?  Constant? 

My pain is a huge iron anchor from a battleship, half buried in ice slag somewhere in the Arctic, surrounded by toxic waste drums leaking caustic fluid onto it, burning and freezing, heavy, impossible to free.

So, it’s burning? 

My pain is a tiny, naked animal dangling in the open maw of a giant shark, brushing against the first row of razor sharp teeth, frozen in fear of the crushing bite, curled against the raw wetness of the shark’s breath.

So, is the pain crushing or burning?

My arm is the rope stretched between opposing tug of war teams, being pulled in both directions with immense force, then drenched with gasoline and set alight.

No need to get all medieval…(growing impatient).  Rate your pain on the pain scale from 1-10 with one being no pain and 10 the worst pain you’ve ever felt.

I don’t know.  Sometimes I think it’s the worst pain possible, but then it gets worse still.

Rate it from 1-10.

I really can’t.  I don’t remember what the baseline was like.  I have no idea what the upper limit can be on any given day.  I’m in pain all the time.  After a few years, the pain scale doesn’t mean anything.

1-10, please.

[At this point, I say "9".  You just want to fill in the blanks on your paperwork.  So be it.]

And you, the clinician, at this point are starting to have an opinion about me.  I’m being difficult.  Uncooperative.  Possible drug seeking behavior.

I was once a clinician, too, and I know how it goes.  In your mind there is a matrix of pain/behavior/intervention/resolution for many, many typical conditions.  A woman is in labor–you expect certain levels of pain at certain intervals, certain interventions will help relieve it, eventually it will resolve.  Same with a fracture.  Gunshot wounds.  Headache.  Different situations, different timelines, but they all follow a curve in your mind and when someone moves off that curve, you have an opinion.  Your opinion, as mine used to be, is that the problem must now be “psychological.”

A lot has been written about chronic pain.  I don’t need to review the literature here–I’m sure a lot of it is useful and accurate.  But I’d like to briefly explore the way your expectations harden your experience with a patient in pain.  I want to somehow convince you of the “realness” of constant pain and urge you not to be afraid of it.  I want to help you recognize that at least some of your patients in pain are brave and tired and appreciative of your affirmation, even if you can’t fix them.

For now, let’s just say I think the pain scale approach is fairly useless in the long term.  Pain is a thing some of us have to live with.  As we go along, we develop ways of coping with the amount of pain that can’t be relieved.  Please don’t be so skeptical.  Help us find ways to make daily life easier, to conserve our limited energy, to help focus our scattered concentration. 

We’ll return to this topic again soon.  Right now I think I’ll lie down on the heating pad for a while.  It’s a 10.

nurse at large: got cane?

 

When do you jump out of bed and say, “I’m buying myself a cane!”  Why do you need one?  Frank Lloyd Wright apparently needed a cane for pointing at things, but most people have other uses in mind.  When I was a nurse in clinical practice, I would have put the cane issue in the mobility category, done an assessment, consulted the physician, and made a referral to physical therapy.  Maybe I would have helped procure the cane, reinforce cane walking instructions, and assess the patient’s adaptation to cane life.  The real world, though, runs a little differently.  Sometimes people just amble out and buy canes on their own, willy- nilly.  I was one of those.

I bought my first cane when my gait started getting, to put it technically, all wanky.  I wasn’t sure my legs were going to do what I thought they were, so I went to the drugstore and bought one of these medical-supply grade canes.  I immediately felt better.  The cane provided some stability, a little pause where I could rest for a fraction of a second and compose myself for my next move.  I learned the first DIY cane lesson:  it helps take the pressure off.  Walking, when you’re uncertain about your balance or your position in space, is a tense ordeal.

Eventually my physiatrist and the physical therapist got involved and I received cane walking instruction.  However, they didn’t really delineate my cane use parameters; they left me “free-ranging.”  I started to understand about having good days and bad days mobility-wise.  I realized there would be times I’d need the cane for a few minutes, but otherwise be OK.  That’s when I bought the purple print fold-up cane.  Walking with a cane really slows you down and takes up one hand (that otherwise might be holding packages or opening doors).  Also, a cane is unwieldy when you sit down in your theater seat or on the bus.  The fold-up solves a lot of problems.  Plus it looks cool.

I don’t yet have a cane with flames on it like Dr. House’s.  I do, though, have a handsome black Italian “walking stick” I received for Christmas a few years ago.  I save it for special occasions. 

The tip of the cane plus your two legs create the three points of a plane.  Geometrically speaking, that automatically provides stability.  People see you with a cane and they give you extra space; they also lower their expectations of your ability to navigate complicated patterns.  With extra stability, space, and time you can carve out your wanky gait without as much worry about falling or getting hurt.  This is an excruciating business, actually.  I know some people are militant about how being “disabled” shouldn’t keep one out of the mainstream, but the mainstream is pretty daunting when you can’t swim at the same rate as the other fish.  When you see someone walking with a cane, be aware he is using a load of mental energy to get from point A to point B.  It’s OK to give an encouraging smile.  And I think it’s always OK to hold the door open…