Confounding Outcome

The e-mail arrived from the nursing board of review. 

Dear Ms. Davis,

As was recently discussed, your unprofessional behavior of January 25th, 2023 has been brought before the board.  Please know that the board takes these concerns very seriously and, given the code of conduct signed by each employee upon hire, it is the expectation of this board that  said code will be honored. 

It has been noted that you have had an exemplary career as a Registered Nurse for 41 years to include nomination for Nurse of the year 2014, Awarded Employee of the year 2005 and, voted most compassionate by your peers.  The board has also considered the numerous letters and e-mails of support received on your behalf. 

While the aforementioned accolades are admirable, the reported behavior warrants consequences, and those consequences are designated as follows;

At that point I had to stop reading.  41 years of nursing down the drain.  I honestly had no control and, still,  no idea what came over me that day. 

Looking back I know I had taken on too much but what nurse working these days isn’t?  The back to back shifts, the pounding by upper management to meet productivity, the never ending open shifts due to sick calls, leave of absence and just plain leaving.  I can only speak directly for my job in Home Health but I would bet the hospital and every other section of healthcare is feeling it too. 

I remember waking up that day with the head pressure that wasn’t really a headache but was enough of an ache to make me consider calling out.  Given that I had picked up that day to cover another nurse who turned up COVID+, I didn’t really see how I could call out.  I had worked with symptoms much worse than head pressure, not that management ever would care about that. 

I remember looking at the schedule of patients that day, most of whom I had already seen so was (at least) grateful that I knew what I would be up against.

Mr. Brown, who had severe,  end stage COPD,  but refused hospice because he was sure the doctors had the diagnosis wrong.   He would have to be the last patient of the day because his continued, excessive cigarette smoking meant I would walk out of his house smelling like I was the chain smoker. I also had to remember to call ahead and ask him not to smoke while I was there for his visit as well as make sure he had not taken down the “Oxygen on premises signs,” repeatedly posted.  Just another idea that Mr. Brown thought was TMI.  He worried that his smoker friends might stop coming by if they thought he would blow them up. 

Mr. Atkins, with his new below the knee amputation site.  Despite having been on Home Health service for 2 years, no amount of wound care,  teaching and reviewing potential bad outcomes had stopped him from making poor dietary choices, “forgetting” to take his insulin and conveniently losing his glucose testing machine.  All efforts to try and get him into a higher level of care having been shot down by his adult children.   Can’t keep taking advantage of the money the patient has if he goes in a skilled facility.   Those places do not come cheap. 

Then there was Mrs. Hudson, what a sweetheart!  100 years old and, even with painful, limiting arthritis, still up and as independent as her body would allow.  She would need a little follow up to see how her new pain med was working for her and if the safety equipment physical therapy had put in place was helpful. 

The 4th and 5th patients were new but the chart review did not look good.  A 36 year old with advanced cirrhosis of the liver but only recently confirmed. Orders from MD to check patient’s home for an old prescription of Antabuse and, if found, encourage the patient to dispose of it in the presence of the RN.  Based on the medical work up, it was too late (AT AGE 36!) for any help from Antabuse. Patient number 5 was a 45 y/o, female with newly diagnosed Multiple Sclerosis. She would need teaching on how to inject her MS medication and education on disease progression. 

After doing all of the review, calling to schedule the visit times and  loading up the car with the supplies for the day, it was time to head out and do my job.  

I had not even gotten out of my driveway before my work cell started ringing. The screen identified the call as our team scheduler.  I answered the phone and heard,  “Hey, I know you already have a full schedule but I have a call from a patient near your area who has a plugged catheter.  Could you swing by and help her out with that?”  

Her voice is firm, daring me to say no.  From her perspective we must all be out here riding around in our cars with all the time in the world and patient visits are just a hop in, hop out kind of activity.  My vision seemed to get a little fuzzy and, right after she stopped speaking the world turned upside down.

When normally I would have taken a deep breath, shelved my irritation and said, “sure, put them on my schedule” instead what came out was “Why not?  I’m a pack mule only partially loaded.  Go ahead, heap that one on my back and let’s see if my legs will stay up long enough to get to where I need to go!”

Shocked at what had just come out of my mouth, I disconnected the call, sat in the running car for a few minutes and contemplated calling the scheduler back to apologize. Instead,  I just put the car  into reverse and started driving as if what I had done was no big deal. 

If my insane behavior had stopped with that I might have gotten away with just an apology, and probably would need to offer to take EVEN MORE patients to make up for it, but my opposite day did not end there. 

Driving to the first patient’s house was slow going. Traffic was terrible!  I showed up 20 minutes late, and even though I was normally a little early, and reliable for visits, the caregiver opened the door and gave me a dirty look.  I just ignored her and started asking if there were any concerns she had about the patient.  She mentioned that his stump dressing seemed to have an odor to it and I assured her I would check it.  I entered the patient’s room just in time to see him slide the nearly empty liter soda bottle behind the head of his bed.  Trying hard to ignore the obvious I asked him how he was doing and started my assessment.  Vital signs all in range and then time to remove the old dressing and check out the surgical site.   The incision did not look good and yes, it did have an odor.  After cleaning the wound and re-dressing it I asked the patient if I could review his blood sugar readings.  As I went back through the glucometer I could see that he had not been checking them as ordered, the last reading being 2 days prior.  After taking a few minutes to check a blood sugar, the result showed up as 422-way too high for a morning reading.  

The futility of trying to heal a wound in the presence of a poorly controlled blood sugar hit me hard and whatever madness had been unleashed on the scheduler earlier was still bubbling around my brain and my mouth.  I asked Mr. Atkins if he had been following his diet and taking his insulin; and his other prescription medications.  With a smirk he said, “well,  you know, doing the best I can” at which time I turned and pulled his bed further away from the wall and was absolutely shocked to see 6 empty liter soda bottles, candy wrappers and a box of partially eaten cookies.  As I gathered up my equipment my mouth opened  and out came, “well if that’s your best I guess you can plan on losing that other leg next or, maybe even better, have the big, fat heart attack or stroke that will come your way since you can’t be bothered to get your blood sugar under control!”  

What was happening to me?!

That was not me!  For 41 years I had been the model of support, endless and repeat education, patience, empathy and tolerance.  

Forcing my lips together I ran out of the patient’s room, past the shocked caregiver (who no doubt heard what I said) and out the door.

I threw my bag and laptop onto the back seat, put the car into gear and just started driving. 

Was I losing my mind?  I thought back to times when I had heard doctor’s say shocking, inappropriate (but really amazingly honest) comments to patients, AND GET AWAY WITH IT!  

There was that time Dr. Smack refused to see the patient for his yearly cardiology follow up because the patient had disclosed at check in that he still was smoking cigarettes at a pack a day.  It was my job to walk in and tell the patient that the doctor said , you can either stop smoking or find another doctor because he is done wasting his time on you.”  

Then there was Dr. Hittem’s comment, to the 400 lb. patient, as he walked into the exam room, “it’s been a year since I last saw you and you are still fat.”

It was all so shocking, so un-PC and so needed but that is not how modern medicine works AND, I AM NOT A DOCTOR!

Within minutes my work cell started ringing again but this time it was my supervisor.  Afraid of what might I might say next, I opted not to answer and let the call to voice mail. 

Deep breaths.  I just need to take some deep breaths and calm down. 

I knew nurses who had mental health breakdowns, turned to recreational drugs or hit the alcohol pretty hard but I had managed a long career without anything more than a strong, dark chocolate addiction.  I need to get a grip!

After waiting about 20 minutes I felt better and decided to call Mrs. Hudson to let her know I was running late.  She answered on the first ring.  After I identified myself she said, “your office called and asked me to tell you to call them as soon as possible.”  I didn’t respond and she asked me if I was alright.  Not wanting to worry the patient I told her I was fine and was just having a busy morning.  She seemed to sense something was wrong and said, “how about you come see me tomorrow or the next day.  I am doing fine.”  Her thoughtfulness was close to overwhelming and, trying choke back tears I thanked her and promised I would call with our next visit plan by the end of the day. 

Knowing I had no choice, I called into the office and asked to speak with the supervisor.  She came on the phone right away and asked me to return to the office immediately.  Trying to down play what I knew was a serious situation I told her I was fine and just needed to give back a patient or two so I could get back on track.  I guess I didn’t sound convincing enough because she repeated her instructions, and further stated that all of my patients for the day would be reassigned to another nurse. 

When I didn’t respond right away she asked if I heard her and, instead of calmly saying yes I said, “of course I heard you! I’m not deaf.”  Arghh!!! After hitting the end button I knew I was in over my head.  With no choice left, I got in the car and fully intended to return to the office however, my car seemed on auto pilot and instead took me home. 

Pulling into the driveway I was in a panic.  I didn’t want to lose my job, didn’t want to end my career like this and didn’t want to be thought of as the nurse who lost her mind.

Entering the house I went straight to my bedroom, lay on the bed and closed my eyes.  I had to figure this out but what to do?  

While laying there my mind was racing as it tried to figure out the problem.  For some reason I remembered a Dr. Seuss book that I used to read to my children, called Wacky Wednesday.   “It all began with that shoe on the wall.  A shoe on a wall shouldn’t be there at all.”  I remembered all the odd things that popped up on the different pages with instructions to the children to try and find what looked out of place.  There was a line where the narrating child said, “I got scared” but patrolman McGann reassured him that it would soon be over.  Sure enough, after finding the 20 wacky things left, Wacky Wednesday ended, “I even got rid of that shoe on the wall.”

I desperately needed this day to end.

With my mind on fire I decided it would be safer to just stay put and after a very long time I fell asleep. I woke some time later to  darkness and the sound of the front door opening.  From the front room I could hear my daughter calling me. She sounded worried. I called back to her that I was in the bedroom and, after walking in and asking me if I was okay, she told me my supervisor called her to check on me. 

Not knowing what else to do I told her all of the insane events of the day.  I told her I had no control and for every normal thing I tried to do I seemed to be compelled to do the opposite.  I explained that I didn’t have any warning of the things I said or the actions I took and, even me being in bed rather than making dinner or some other useful thing was nothing close to my usual. 

Once I finished talking she had a funny look on her face and I asked her if she thought I was coming unhinged.  That made her laugh and she explained that, while she was listening to me, it crossed her mind that the kids came home from school  that day with activities completed for Opposite Day.  

As much as I appreciated her trying to comfort me I could not wrap my head around a grown woman suddenly having been bewitched by a silly named activity day. I had nothing left in me and knew tomorrow I would have to face my supervisor. I thanked my daughter for checking on me, sent her home and went to bed. 

The next day I woke feeling anxious but clear headed. I called the supervisor, explained that insanity of the day before and waited for the worst but it never came. She shared with me that the scheduler called to report my outburst and, thankfully, the scheduler knew it was out of character for me. Mr. Atkins caregiver called in to report me too and that was when my supervisor knew something was way off.  She was very kind, told me she understood that something went wrong but also had no choice but to report me to the board of review. I could tell from her voice that she felt terrible about it but, it was protocol. 

As I re-opened the e-mail from the review board, and continued reading only to see that,  instead of firing me or putting me on mandatory leave the board responded in a shockingly opposite way. 

“Based on our thorough review of the complaint against you, and having weighed all other evidence presented, the board has petitioned and been granted, permission for you to have 3 months of paid time off, with no use of your PTO bank.  Furthermore, the board wants to recognize you for your consistent dedication and loyalty so will be granting you a $5 an hour raise effective immediately. It is clear to this board that the events of January 25th, 2023 were an aberration, resulting in  an urgent convening of the members, 

As I read and re-read the e-mail I was stunned beyond words.  I could not believe my eyes but there it was in black and white. Given how the recent events had been I decided to print the letter off. Who knows, I might wake up tomorrow and find out I had hallucinated the phenomenal response. 

Picking the letter up off of the printer I scanned the words again, and just as my eyes finished confirming the good news, a little chill came over me while reading the board signatures followed by the date, January 25th 2023.