Happy Passings

Recently in MICU we've had a hard time with families refusing to let their elderly parent or loved one die a peaceful and happy death. One 89 year old gentleman had made a will a few years ago and he did not want to be put on a ventilator. His son and power of attorney insisted we go against his wishes. He made threats of suing the hospital. He created havoc every time he visited; we had the nursing supervisor and security at the bedside at one time. He was placed on a ventilator and was not able to wean off. His son insisted he not be sedated. He was awake alert and pitiful at the end of his life. The son was suspicious we were trying to kill his father, the poor man wanted to die and he wouldn't let him. It was a very bad way to end a life, I hope his father comes back and haunts him!
It shouldn't be this way. Death is always sad because a loved one is gone but there are far worse things than dyeing, and we will all die someday. So I've had to remind myself of the more civilized passing’s I've seen over the years. My family is aware of my own personal wishes, I have a living will, I do not want to live beyond my time. You may be thinking that this is a sad and morbid post but it's nothing of the kind. The following are true stories of happy passing’s.
A few years ago I was working a night shift in MICU. We had a patient in his sixties who was in the terminal stages of his illness. A family meeting was set up with the family and his attending physician. His code status was changed to DNR (Do Not Resuscitate) he was made comfort care only.  His family had visited during the evening and his wife of 40 years was spending the night at the bedside. She asked me if she could get into bed with him because he always sleeps peacefully when she spoons him. I saw no harm in it so I helped her into the bed. In no time they were both asleep. About 4 am his heart rate started to drop and I went into his room to check on him. His wife was quietly singing and praying while stroking his head. I turned off the monitors so they would stop alarming and I let them be. I checked in on them again every half hour over the next few hours. On one such visit she said he’s gone but can I just lay here a while longer. I called their son and by the time he arrived she was up and ready to go. The paperwork was done quickly and the patient’s wife thanked me for allowing her to spend the time with him. Really I should have thanked her for showing me how to give dignity in death.
We had a lady admitted for respiratory distress and pneumonia. She had just returned home from a cruise with friends and had a wonderful time. When I first saw her sitting up in bed, holding court with family and friends, in full make up and perfect nails I thought ‘what’s she doing in ICU’. When she said jump family and friends (actually everyone) said how high. This was a lady who always got what she wanted; she could be demanding at times and was on the call light regularly. Over the next few days her condition rapidly deteriorated. She was put on a ventilator but she refused sedation. It was a full load taking care of her and the massive entourage of family and friends. When the time came to discuss tracheostomy because she was not successfully weaning off the ventilator she decided her time was up. With family and friends at bedside she insisted on removing the endotracheal tube and stopping the ventilator. She was alert and fully aware she would die. The tears and pleas of all in that room could not change her mind. So her next of kin agreed to let her go as she wished. No sedation she wanted to be in her senses to the end. She was dead in 15 minutes, peacefully quietly with no drama and on her own terms. I was in awe of her strength of character. 
We are mortal and as nurses we see death and accept death, it's a part of life. I don't know if it necessarily makes us better at the end of our own or family members life but it certainly did for one patient we had a few months ago. Her husband was a Hugh character and plied the nurses with boxes of oranges and food; he brought us in a ham one weekend. His wife must have told him feed those nurses and they'll do anything for you; which of course we did. That family was loved by all and they were a pleasure to care for. In her final hours it was beautifully sad and dignified as it should be.
My most memorable Palliative ICU patient was the Golfer and his family who sat around his bedside holding his hand, comforting him and helping in his care. They discussed his various games and wins over his sons on the golf course. The hole in one in a tournament, that cost him dearly in the clubhouse because he had to buy a drink for everyone. At the end it was my pleasure to help them on the 19th green, dignity in death and a celebration of life. 
Dora Meulman

Nurses Hangover

Nurses Hangover

It’s past midnight and I should be in bed because I’m exhausted. I’m more than half way through a bottle of wine and I’m finishing it before I go to bed so I’ll sleep until morning. Today at work got to me in a way I haven’t been in a while, when you’ve been a nurse as long as me you get a little hardened to life’s hardships and problems. It’s necessary that you get that way or you would never survive. So today got me bad it’s like I was a student, a new grad, crying my eyes out sad and upset.
I had a 29 year old cancer patient; he has been through rounds of chemotherapy, tests, procedures and it’s clear it’s a losing battle. He’s in ICU because his heart rate is 180 and he’s febrile and septic. We are in Interventional Radiology to check the patency of a nephrostomy tube and also in ultrasound to do some ultrasound guided biopsies of nodules in his groin. We’ve been off the unit for hours. They need him prone. It hurts to move. He’s crying and saying he’s done he’s had enough because he knows he’s not going to make it anyway.
So later he says Dora I need to talk to someone. Tell me I can take it. I know when they’re saying Hospice it means that’s it. We spend the next 3 hours talking, him crying, me crying, both of us crying. It put me so far behind I didn’t get home until all hours; I’m off tomorrow, thank God. My heart is heavy tonight, we agreed that all that matters is the here and now, doing the best we can now because that’s all we have, today was all that counted because you never know what will happen tomorrow. Except I know I’ll have a hangover :(
Dora Meulman

Family Centered Care

Family Centered Care

It’s been a tough few days in MICU, young patients dieing before their time from freak bug bites and infections. We’ve had Lifeshare underfoot a lot harvesting organs from heartbroken families, it takes it’s toll, our acuity is high right now.
Today one of our more stable patients family members were adding to the stress. Sometimes I miss the old days when we had set visiting times. Family members would come visit, stay a short while, they would be respectful, the doctor was God and the nurse was an angel lol. Now we have “Family Centered Care” with open visiting times. I have gotten used to it and for the most part I like my patients families. Most are fine people and I know what it’s like to have a loved one in ICU. (My son was in ICU in London’s Kings College Hospital last November after sustaining a head injury following an assault while on vacation, but that’s another story)  I put them to work if I can, give them something to do like mouth care, I get them to help with turning etc.
Anyway this patient is having trouble swallowing so he’s NPO. His daughter say’s ‘he’s thirsty can’t he have nothin’ to drink’. So I explained about him aspirating and we’re feeding by the nasogastric tube and giving him IV fluid and I offer to swab his mouth etc. But he says he’s thirsty so I’m giving him some water. There’ no getting this women to understand. OK try with some water and of course he starts coughing and choking.
So then his wife comes in. She’s a very large lady and smells like an ashtray. She plonks herself down in the chair and within minutes is on the call light. Can I have a blanket it’s cold in here. OK I’ll get you one. Can you get me some water I need to take my medicines, OK I’ll get you some. Where’s the phone, how come ya”ll don’t have a phone in this room. This is ICU our patients are usually too sick to talk on the phone. (we do have them available but we don’t leave them in the rooms routinely). Can you turn down all these bells and noises I can’t even take a nap in this awful chair, do you have a better recliner. No Mam the recliner you have is the best we have.
Then she calls and says can you get me a “guest tray” they got me guest trays when he was in the hospital before. I’m a diabetic and it’s been 2 days since I had anything to eat and my blood sugar gets low. So I say we have cafeteria’s on the first and third floors open 24 hours a day. I don’t have any money today and I got a guest tray last time. Now I know from experience it’s easier to just get a friggin’ guest tray for this women so that’s what we did. It annoys me I could call my supervisor but I guarantee you she’d end up with a guest tray anyway and it would have been a drama.
Give them an inch and they take a mile my mother used to say, and that’s how it is for some folk.
Dora Meulman

My ICU Today

I’ve been a critical care nurse for years with a few years diversion to Aeromedicine as an emergency flight nurse (6 years). There’s not a lot I haven’t seen before but this week has been rough even for me. It’s been a 50% mortality week and the dying has been the easy part. I actually like helping families decide to choose DNR and withdraw care allowing their loved one to die with a little dignity. As a nurse I think it’s our strength it’s where we shine and the families think we’re angles. I get all kinds of wow cards from these families and it’s effortless for me, crazy but I like it. I should work hospice I’d be able to sleep at night every night.

The real challenge comes from patients like Todd. 40 years old he suffered a gunshot wound to the spine in 1995 that left him a paraplegic. He has been in and out of the hospital for years with various ailments, osteomyelitis urinary tract infections, sepsis. Stage 4 pressure sores to both lower extremities and the entire sacral area; I mean the largest nastiest pressure sores I’ve ever seen in my life. He’s had numerous surgeries over the years, refuses amputation.  He also has a urostomy and a colostomy. All made worse by his noncompliance. He suffers mental illnesses including personality narcissistic disorder, plus he is manipulative rude and a HUGH pain in the ass.

He was discharged 7 days ago following a 2 month hospital stay to his sister’s house because no facility will take him anymore. He has burned every bridge. He is now septic again from his wounds probably; his sister calls 911 and tells them not to bring him back. I talked to her and she is done with him.

So this is what I have all day. He’s hypotensive on a dopamine drip. When we first meet at the beginning of my 12 hour shift his urostomy bag is full (he wouldn’t allow the night shift nurse to empty it) he pulls both the colostomy and urostomy bags off and throws them on the floor, the bed is a mess and so is he. I find myself getting annoyed with him and then feeling extreme sadness for him. He’s lonely and scared and his mental illness is profound. He has no patience he yells and screams at everyone and then he’ll ask you to sit and watch TV with him and is a sweet child for a while. He’s sad and lost and hopeless. The wounds when he allowed me to  redress and clean them where so bad and full of maggots which is probably the only reason he’s alive.

I don’t know how he’s alive or where he’ll go next but he is one of the most pathetic characters I’ve ever met in my life. I can’t help him because he won’t meet me half way and help himself. Society has given up on him. This is not living.

Worse than Todd I spent 3 12 hour shifts with Ms C. a 44 year old who has suffered from Crohns Disease for most of her adult life. This is a manageable disease, but poverty and ignorance led to noncompliance and depression which all spiraled out of control for this woman. She had refused to eat and her main caregiver was her 16 year old daughter, a dim child with limited education but sweet. Also living with her was her 26 year old 450 lb plus son. He’s a piece of work doesn’t drive or work and visits the hospital rarely because he doesn’t have a ride. Most communication is by phone.

Miss C had been found unresponsive by a visiting social worker in a filthy diaper; it’s unknown how long she had been in this state. Her admitting albumin less than 1 and all labs crazy off the chart. Full on ICU support including gallons of blood products and fluids. When it’s clear she’s not going to respond, she’s in multisystem organ failure and her condition is grave, her son insists on more. Threatening to sue, talking like we can pull miracles out of a hat, where’s Dr House when you need him? She is on a cocktail of vasopressors with a systolic blood pressure of 60, MAP 30 and he wants us to try Adderall…he heard that was good for low blood pressure. Lord have mercy you sit around on your big fat ass and watch too much TV I want to scream at him. Are you looking at your mother here rotting in this bed? Look at her skin sloughing off blistered weeping so bad we can’t keep her dry. It’s insane we allow such ignorance to prevail because Doctors and hospitals have to cover their ass against such vermin. Does anyone have any balls here and do what’s right for this misfortunate woman? Of course not. It’s unethical, we needed an Ethics Consult but it wasn't going to change anything.

This is for me the worse part of the American Healthcare System. Somebody should have been able to allow this woman to die with a little dignity without the risk of being sued by her family. Forget the cost to the taxpayer for all this, as bad as that bugs me it’s not the main issue. We are not GOD we cannot save you if you don’t take care of yourself and help yourself. We did the best we could and it wasn’t enough. End of story.  

Dora Meulman RN

Sarah RIP

Yesterday my daughter Kerry put a message on my facebook wall, “today it is 8 years since Sarah’s death I can’t believe it has been that long. I still think about her a lot…” I was immediately transported back and overcome with terrible grief.

Sarah was one of Kerry’s best friends since she was 5 years old. They went to school together at St Joseph’s Convent in Reading Berks. England. We had lived in Reading for 9 years but had decided to move back to the US at the end of the school year.

Sarah had just had her 14th birthday she was a difficult child at times deep and impulsive. Her mother Jackie was a single Mom raising 4 kids since her husband had died of cancer. She was strict on Sarah who was her eldest child, she was grounded a lot it seemed to me for silly things that Kerry did all the time. It was none of my business so I said nothing.

Kerry was on a school trip to Spain. Sarah had not gone on the trip I’m not sure if it was because of the expense or that she was grounded for some silly thing she had done. It was a Saturday morning Sarah wanted to go in to Reading but Jackie wouldn’t allow her to go. She calmly ate breakfast went upstairs and wrote suicide notes to a few friends. Then she took all her mother’s pain meds that were in the bathroom. Her 7 year old sister found her some time later having a seizure and they called 911. She spent the next 5 days in ICU before she died.

The next few days are some of the saddest days of my life. When Kerry returned from Spain she was distraught. She felt terrible guilt for not being there for Sarah. She had threatened to commit suicide but no one believed her. Kerry was going to leave her and move to the States. Her suicide notes were full of pain and loneliness. I sat for hours on end with Jackie; strong Scottish women now overcome with the worst kind of pain and guilt. Reading those notes after the police allowed us to have them was pure torture.

Her funeral at the Catholic Church in Reading was so terribly sad. Her young siblings and mother sat up in front. Her white coffin and all her 14 year old classmates crying is a sight burned in my brain. There was not a dry eye in the packed out church.

The next few weeks were a blur, I worried constantly about how Kerry was feeling if she was forgiving herself for abandoning her friend. Her entire school was in shock and our last few weeks in England were just an endless sadness. I was glad when the time came to leave because it was like starting over for Kerry. She made new friends easily and settled in to life in the US.

Every year we remember 14 year old Sarah Gormon, gone but not forgotten. She would be 22 now. RIP lovely Sarah you could never have known how much you were loved or how you would break our hearts.

Dora Meulman

Lent

Yesterday Kerry’s friend Alden asked me on Twitter “are you giving up anything for lent this year?” I replied no I haven’t given up anything in years. Now I’m thinking why not. I think it’s good to discipline yourself occasionally and Lent gives us that opportunity.

When I was a child in Ireland it was expected and usually I’d give up candy, we call it “sweets”. I went to a Catholic girls school and the Nuns would be prepping us for weeks, now girls I hope you’re giving some thought as to what you’ll be giving up for Lent. The state of our souls was the most important thing to them; I think it got them brownie points from St Peter. On Pancake Tuesday every girl would be asked in turn around the class what they were giving up for Lent… Dora sweets Sister; Mary cakes Sister; Noreen sweets Sister; and it would be noted.  

Ash Wednesday would arrive and we’d all be marched to Mass. During the Mass everyone would line up like when you go to communion and the priest would put a cross shape using ash on everyone’s forehead.” Ashes to ashes and dust to dust”. That would have to stay there all day no washing it off.

Now there was no opting out of any of this. No notes from parents saying little Dora doesn’t have to go to Mass. That would never happen, the Nun’s ruled sometimes harshly, and the Priest was their boss. His only boss was the Pope, then Jesus and the Holy Spirit. That was how it was the Church ruled everything.

Later as I got older for Lent I’d give up alcohol, or movies or whatever I enjoyed, the point being it had to be a hardship. I haven’t thought about Lent for many years the Nuns would be horrified.  I’d currently like to give up work for six weeks but that wouldn’t count if you get my drift. The only thing I would miss and therefore qualify is wine.

I’m a weak women I’d need a few get out of jail cards. I have my BUNCO ladies that I’m hosting on Paddies day can’t do that without wine. I have Margaret’s bridal shower again can’t do that without wine. Plus I need one more as a backup. So here it is my challenge to you and me. Tell me what you’re giving up for Lent; you get to have 3 passes or excuses. On those days you’ll be allowed to break your fast. Are you in? I need encouragement to stop the DT’s J

Dora Meulman

Do no harm

I have been a nurse for many years and one could say I’ve been around the block a few times. I still love my job and I feel strongly that most of us who work at the bedside taking care of the sick are here for the right reason. I believe most Doctors think they’re doing a good job. Certainly all of our ICU Physicians in the Medical Intensive Care that I work in are wonderful dedicated and caring. Yet something is not right!

The numbers of Americans addicted to Prescription drugs has skyrocketed. Worse than that is the needless and inefficient use of medications.  We are poisoning people instead of helping them. We are killing not curing them. The Pharmaceutical Industry keeps churning out growing numbers of drugs. They advertising their medications on TV and even with the long lists of side effects people take these poisons. They’re advised to ‘ask your physician if this medication is right for you’. Primary Physicians seem to prescribe vast numbers of unnecessary drugs to hapless patients who will take anything they are told to take.

Why is this happening and who benefits?  No need to answer that was a rhetorical question. It’s very clear to all but the people who are suffering the consequences i.e. the patients. I have admitted people with some of the newer more expensive drugs even though one has to wonder if the old and proven drug wouldn’t have been a better choice. Pharmaceutical companies are making money and they line the pockets of Physicians who feel they are entitled to the kickbacks. It’s a very bad thing.

I had a patient recently admitted with malignant hypertension. She had a long medical history and a lengthy list of medications she takes every day. She admits she takes 2 mgs Ativan orally 3 times a day. Her urine drug screen confirms this. Yet that Ativan was not on her Med Rec and so it was not being given. Her admitting doctor says her hypertension is because she’s noncompliant with her medications.  I know that’s not the reason we have her on a Nipride drip and it’s obvious she’s in withdrawal. Where does she get the Ativan? She says the express clinics. No records of Ativan that’s not right.     

I see patients with Medication Reconciliation forms that are pages long. It’s out of control. We have to step back from all the pills and give patients other choices to get their health and lives under control. There is not a pill for every aliment, we need to educate and motivate our patients to healthier choices. We have to remember to ‘do no harm’. 

Dora Meulman  

Be nice please...Pretty please

You’ve heard the old saying one rotten apple can spoil the barrel; well the same is true with people. There is nothing worse than having to spend time or be around someone who is always whining and complaining. Nothing is ever good enough their glass is not only half empty it’s dry. Their stories or problems are the only ones they are interested in. They monopolize the conversation and their negative vibe brings everyone down, it’s all about them all the time. This is especially true in the workplace they can make a happy place a misery just by being there.

For a manager these people are a nightmare, they need to be encouraged to move on as quickly as possible before their poison spreads and infiltrates the rest of the staff.  Ignore them and before you know it you’ll have a mutiny on your hands. That’s because emotions are contagious. Badness can spread like a wild fire and the only way to douse it is to build a firewall.

In nursing we unfortunately see this person regularly. They have the power to ruin your lunch break if they happen to be present. It’s enough to give you indigestion and the only solution is to loose oneself on the web and tune them out. Making you antisocial but that’s better than crazy. I could feel sorry for them if I didn’t dislike them so much.

Is life really that bad? When you start your day do you intentionally think I will make all around me miserable today. Do you know you’re a sour tart or do you think that your ranting is a normal way to behave? I think it’s a habit, a rotten nasty habit that you’ve allowed to get out of hand because no one has had the balls to tell you to stop. It’s an attitude and it’s less stressful and much healthier to have a good attitude than a bad one. So be nice please...Pretty please.

Dora Meulman

Denial

Denial is a psychological defense mechanism in which confrontation with a personal problem or reality is avoided by denying the existence of the problem or reality. We frequently see patients in denial about their health problems. Just recently we had a patient in his fifties who ignored his sore toe. By the time he sought medical attention the toe was gangrenous and he ended up with a below the knee amputation. Post-surgery he became depressed and refused to follow Medical advice. This led to further problems and it was decided he could not go to rehab so he was sent to a nursing home to recover. He was at the nursing home exactly one week when he developed pneumonia and was admitted to the hospital in Septic Shock. That's when I first met him in ICU.
When a patient is first admitted to ICU we attach them to the monitors, we then assess them and they're seen by their admitting doctor. We receive orders to get blood cultures and other labs, start IV's, and give the medicines that have been ordered by their doctor. It's a very busy hectic time especially if the patient is very sick like this gentleman was. As nurses we are responsible for the admitting paperwork. This is a tedious task, none of us like it but it has to be done. So once the patient is settled we will generally get the family to assist us with this. This patient was sedated on a ventilator, he looked horrendous far older than his actual age. His 2 daughters in their mid to late twenties came into the unit. They both stood at the end of his bed in a state of shock. The younger one put both hands to her face took a big gasp and whispered Oh Daddy...she then bowed her head and sobbed. The older one trying to be strong bit her lip. They were a sad sight to see. I'm a seasoned ICU nurse but sometimes it just hits you like a bat. It was all I could do not to cry.
Refusing to admit the truth or reality of something unpleasant is amazingly common it's almost a defense mechanism for some. You see people with advanced cancers they admit they haven't felt well for a while, they've worried they might have cancer and yet have not seen a doctor. Often they haven't spoken to family members about it. It's like they think if I don't talk about this it will go away or get better on its own. The ulcer stinks to high heaven and they put on perfume or cologne to hide the stench. They use peroxide and an assortment of creams and portions and it continues to get worse. After a while they're too embarrassed to go see a doctor because they fear their reaction at letting it go so long. They don't want to be thought a fool. They live in denial a negation in logic.

Dora Meulman

Your Voice

Studies show that HOW we say things is four times more powerful than WHAT we say.

7% is what we say

38% is how we say it

55% is non-verbal

I am blessed with a unique voice. People know me by my voice it is a big part of who and what I am. My voice has evolved and been remade many times over the years. I was born in Cork City Ireland. The Cork accent is lilting up and down melodic and full of colloquiums. It's easy on the ear but difficult for non Corkonians to understand. My parents, no correction my Mother and Grandmother enrolled me in singing drama and elocution classes. They did not want me to sound ‘common’. I went to school in London and returned in 94 spending a total of 14 years in England. This changed the tone and pitch and made me aware of the power of the voice. Add on the Americanization and I have the voice I have today.

Now I can change this voice at will and do regularly depending on who I’m talking to. When I’m in Ireland you’d never think I left her shores. At home and with friends I have my conversational voice. It’s Americanized Irish and has been strongly influenced by my husband Jeff who’s from Michigan.  I turn on the English influence if I want to sound smart or posh. When I teach my fitness classes I tend to speak slower, and use fewer words, mixed with non-verbal cues. I think that works best for me. I would say people wouldn’t need to see me to know who was teaching. 

Margaret Thatcher took elocution lessons for years and managed to lower her pitch and mellow her accent. She knew the importance of her voice if she wanted to have authority among men. I'd say it worked pretty well for her

BODYPUMP is a static program like teaching a class of students or doing a power point presentation. The most powerful tool we have to create contrast is our voice. How we say things is more important than what we say. I could tell you that you smell and your pants are on fire with a smile on my face and a high pitched voice. Chances are you would smile back at me because you didn’t hear the words but the intonation. Every 3 months we launch the new programs for Les Mills at the YMCA. These Kickoffs are great fun and highly anticipated by the members. Some of today’s music can be offensive to members. I usually get to teach these tracks because people don’t hear the offensive lyrics or language when I teach unless I want them to.   

I have five voices when I teach to match the highs and lows of the material or music.

1: CONVERSATIONAL- In the low parts, talking with the class. It’s friendly and easy on the ear. It’s natural but would be boring if that was all I used.

2: BUILD - To create anticipation and excitement and let the class know they need to listen.

3: BIG – To power and motivate.

4: INTENSE – A strong challenging focused voice that’s success and results oriented but not aggressive. It’s inclusive. Think ‘you can do it’ rather than ‘just do it’

5: SILENCE - Let the music or slide speak. You say it best when you say nothing, hold the silence, pause and breath. Most of us spend too much time talking about nothing. Then when you talk, talk to the class.

Have you ever gone to a class or presentation and found yourself bored to death. Not with the material but the presenter. There just isn’t enough coffee to save you from this person. They know all the material and you want to listen and learn. The power point is brilliant and yet it’s dull and you’re miserable. I guarantee you that the presenter spent long hours learning the material and putting the slides together but didn’t record themselves to hear how they sound to other ears. It’s something everyone who is going to stand in front of a class should do. Your voice won’t sound like you think it does. It can be shocking but it will make you better. Teaching and presenting is a Performance Art it takes practice and more practice to Master the powerful tool of your Voice.

Dora Meulman