A Different Run; Or How Not to Do A Medication Pass

Yesterday I came to work with the goal of becoming more organized on my run, and was beginning to settle in for the day when one of the nursing assistants looked at the schedule and said, "you're on South today, Arlene." I looked at the schedule, which had many entries crossed out, in disbelief. That horrible sinking feeling when you know that you are going to be far out of your comfortable and familiar routine. New "on the floor", I can barely do my own med run in an organized manner. Because of a severe staffing shortage of nurses, I and another nurse from the long-term care side had been moved to the more active Medicare side of the building, where neither of us had ever practiced. Although we recognized that our assignments were the best solutions to a difficult problem, we felt as if we had been hijacked. I was assigned to a very active and challenging run, and the other nurse not only had an unfamiliar run, but had to split a run with another nurse, taking 30 instead of 20 patients, mostly "tube feeders" and very time-consuming.

We met with the Director of Nursing to clarify our assignments, and I helped the other nurse accept our difficult situation. Later it turned out that, like staff who work double shifts, a meal tray was provided for us, in recognition for accepting a difficult assignment. This was welcome, as I knew there was no way we would have time for a lunch break.

As it turned out, I had three tube feedings to start at a specific time, one person with one IV antibiotic to run and another person who had two IV's during the shift, as well as seven people who needed their blood sugars checked before dinner and at bedtime.

Despite an excellent report from the outgoing nurse, the day immediately went to chaos trying to relieve "Lucinda" of her horrible pain from back abcesses. One of her as-needed medications, oxycodone, had been allowed to run out, and she was screaming that she needed relief NOW. I phoned the pharmacy and learned that, since this was not a new prescription, they would not allow taking it from the emergency "E-Kit." Fortunately there is a team of two doctors who take turns every week visiting the facility every day, so the doctor wrote a prescription for Dilaudid. More time on the phone with the pharmacy, obtaining permission to pull the Dilaudid. Unfortunately, only one med cart set of keys had the key to the narcotics E-Kit, and none of the nurses assigned to those carts knew which set of keys had the narcotics key, or what it looked like. I went from one to another nurse, borrowing their keys and trying them in the locked cupboard. Finally I phoned the Director of Nursing, who was still in the building, who found the appropriate key and obtained the Dilaudid for me. It was well after 4 PM and I hadn't done any of the seven before-dinner blood sugar tests on that hall, or delivered more than a few medications.

For the next seven hours I had three interruptions for every patient I visited. I discovered that multiple family members come in the back door every evening at different times, setting off the alarm. Lucinda's bariatric bed broke and the maintenance man came in, who ended up waiting for someone else to come in who could help him repair the bed; the repairman had to come down from Lynnwood to Puyallup on a Friday evening, completing his regular route as he came. Lucinda was transferred from her bed to a "shower bed" constructed of giant-bore PVC pipe, to a regular bed; then ultimately back to her own bed after it was repaired. None of this could have been comfortable.

Later in the evening, personnel from a mortuary came in the back door, with business on another hall, setting off the alarm every time they entered or left. I kept receiving phone calls about residents I knew nothing about. The entire shift was total chaos. When the night nurse came in, I enlisted her help to finish up the medication pass [fortunately I only had about two people left to see.] As a crowning touch to the evening, the night nurse placed the cart keys in the top drawer, and one of us locked the keys inside the cart. Fortunately, on another set of keys there was a key to the business office suite. By some miracle, the DNS' office was unlocked, which had a spare key to the cart.

It was a horrible feeling to scrape by, just barely getting the medications delivered and blood sugars and insulins done, feeling so frustrated and incompetent. I have to say that everyone was alive at the end of the shift, and I did not make medication errors, and the evening came to an end eventually. I would not want to repeat it.

There is a reason they call it a medication "run."

Epilogue: When I turned on my phone after I came home, I learned that while I was at work, my mother had died.

The Divine Physician

The All-Knowing Physician hath His finger on the pulse of mankind. He perceiveth the disease, and prescribeth, in His unerring wisdom, the remedy . . . The remedy the world needeth in its present-day afflictions can never be the same as that which a subsequent age may require.

~Baha'u'llah

The Prophets of God should be regarded as physicians whose task it is to foster the well-being of the world and its peoples, that, through the spirit of oneness, they may heal the sickness of a divided humanity. To none is given the right to question their words or disparage their conduct, for they are the only ones who can claim to have understood the patient and to have correctly diagnosed its ailments. Little wonder, then, if the treatment prescribed by the physician in this day should not be found identical with that which he hath prescribed before.

~Baha'u'llah

Man can never hope to attain unto the knowledge of the All-Glorious unless and until he ceases to regard the words and deeds of mortal men as a standard for the true understanding and recognition of God and His Prophets.

~Baha'u'llah

Behold how contrary are the ways of the Manifestations of God, as ordained by the King of Creation, to the ways and desires of men!

~Baha'u'llah

Free?

Was offered a free newspaper at the grocery store the other day. "Why not? It's free!" he said. "No, it's not," I said. "Yes, it is," he said. By that time I was out the door to load up my groceries, so I didn't stay around to play yes-it-is/no-it's-not. When you give your information to them, which is required to receive a free paper, you are selling your information. For seventy-five cents.

Last time I did this, probably some time in the 80's, I didn't realize I would be looking forward to ten years of solicitor's calls from the News Tribune every six months, usually from someone in Dallas. At this time they had passed the legislation requiring solicitors, if you told them to stop, to stop calling you. Which the News Tribune steadfastly ignored. I would say, "Last time you called, I asked you to stop phoning you. But now you are phoning me again. Which is against the law." "Oh, I'm sorry ma'am."

I also have a card with Safeway. These grocery store cards [all except for Fred Meyer, which works differently] are always promoted as a way to save money at the store. To pay regular grocery prices, it's required to get a card. It's not a save-money card, it's a fail-to-let-them-gouge-you-card.

I always hated the intrusiveness. In the beginning, at Safeway, they would always address me by name at the checkout counter. I go to the store expecting to be anonymous, and in fifteen years I have never gotten used to being addressed by name by a grocery clerk. Except for Mrs. Jackman in the neighborhood store in 1960. Addressing me by name does not make you Mrs. Jackman. It makes you intrusive.

"Don't call me Mrs. Fritz," I would snarl. "We're just being friendly. We're required to do that."

I still have the same card, but a different phone number [fortunately still memorized, for when I forget my card.] I also have changed names at least twice. So when they call me "Mrs. Fritz" it is no longer my name, so I just smile.

Don't even get me started on "Drive safely!" Now I have more manners [slightly] I no longer reply, "What do you think I am? A moron? I'm going to drive out there and see if I can't hit a few light poles."

Notes on Studying the Kitab-i-Iqan

Studying the Kitab-i-Iqan [The Book of Certitude] by Baha'u'llah in the Wilmette Institute online course, Dr. Moojen Momen presented quite a list of suggestions for themes to study:

The Station of the Manifestations [my favorite theme in the Iqan]
The Proofs of the Manifestations
The meaning of Divine Sovereignty/Divine Kingship
How did Baha'u'llah introduce clergy, as a class, in the Iqan?
What is meant by human knowledge?
What is meant by divine knowledge?
What is the difference, and which one is more acceptable?
What are the veils standing between us and God?
The subject of tests. "Do men think when they say 'we believe' they shall be let alone and not be put to proof?" After having tests, we will become stronger and stronger in our faith.
God is unknowable, and everything you thought you knew about God is actually knowledge of the Manifestation.

Gems of Divine Mysteries

I'm taking an online course on two books by Baha'u'llah: Gems of Divine Mysteries, and the Kitab-i-Iqan [Book of Certitude.] I would like to share a little bit from one of the themes of the Gems.

Baha'u'llah asks:

What hath prompted the divers peoples and kindreds of the earth to reject the Apostles whom God hath sent unto them in His might and power, whom He hath raised up to exalt His Cause and ordained to be the Lamps of eternity within the Niche of His oneness?

He answers this in five sentences which I will sum up: 1. People fail to fix their gaze upon the testimony of God; 2. They follow the footsteps of the abject and foolish among the leaders and divines; 3. They refuse to see with the eyes "wherewith God hath endowed them." 4. They desired things other than God hath desired for them; 5. They cling to the outward meaning of scripture.

Done

My career as a resident care manager at "Mountain View" is kaput. I was so busy trying to keep up with things that no earthly human could really keep up with that I didn't even notice my 90 day probationary period was up, until I was called into the DNS' office and learned that I will not be kept on in that position.

She will do a couple of things for me; extend my probationary period two weeks; offer me an evening position working on the "floor", doing medications and treatments and MD calls and all that. So that keeps the wolf from the door, but there went my Mon thru Fri days, there went my free evenings and weekends.

This news came on the brink of me finally getting The Cold that many at work have been getting, keeping me home for two days. I don't dare ask for more off.

On Call

I was on call at "Mountain View" from 8 PM Friday to 8 AM Monday. Friday I had gone out to dinner, then gone to bed late [for me] about 10:30.

Friday: 11:19 PM.
My first call came 11:19 from the evening and night nurses on an allegation, which I walked them through: yes, you have to send home the staff member [which would put them short an aide and be a severe inconvenience]; yes, chart on the patient and put her on alert; yes, initiate an incident report; call police? At this point I had them phone the Director of Nursing and she informed them that the whole thing stemmed from a previous allegation which has been disproved, no sending anyone home--wait, have they clocked out--and no incident report. I get to sleep somewhere around one AM.

Saturday: 10:05 AM.
Received call from the weekend nurse manager that a night shift nurse called in, and that the usual practice when that happens is to split up a run so two instead of three nurses could cover it. The only nurse to call, according to "Janet", is someone who is pregnant and probably wouldn't come in. We decide to leave it at that.

Saturday: 8:09 PM.
Received call from "Mary" about newly readmitted Mr. Burpee calling out loudly for no discernible reason for the last three hours, despite morphine and Ativan, until his wife got there. It's a male room: can the wife stay there? I said she can visit and when they do personal care, leave the room. Resident is not supposed to go back to the hospital. I ask if Haldol is available, suggest calling the MD; it turns out that they don't know who the on-call doctor is for the MD. I suggested calling the MD's cell phone and apologizing and asking who the on-call MD is. I call back to follow up in an hour and it turns out that Mr. Burpee is now quiet and they opted not to phone MD.

Saturday: 9:35 PM.
Received call from "Laura" night nurse asking who is coming in to replace the nurse who called off? I explained what Janet had told me, to split the shift, and that we had agreed not to fill the vacancy. Laura said that when she was manager on call, she always came in to fill a shift, and was I going to come in? I said I hadn't been planning to, and she became angry and said, "Thanks for all your help!" Clunk.

Saturday: 9:50 PM.
Received call from evening nurse, "Francisca", who said she had phoned Janet to ask Janet to call Laura about the staffing issue. I said that I hadn't slept well last night and I had trusted what Janet told me about splitting the run and I wasn't prepared to work.

Saturday: 10:05 PM.
Received a series of texts from "Alison" the DNS clarifying that I did not call people to try to fill the night shift because I trusted what Janet had told me. Alison said I should notify the facility that the census is low, try to get people to stay late &/or come in early, and offer to go in. I found a day shift nurse to come in at 4:00 AM, dressed for work and came in to help with the night shift from 11:30 PM to 4:00 AM. When I got there I apologized to Laura and said what Janet and I did wrong, and that if I had been in her place I would have been angry too. She was very gracious. I learned to use the facility's very weird glucometer, gave several people their meds, almost all of them through gastrostomy tubes, and unplugged a recalcitrant tube which clearly had not been flushed after the last feeding. I went home feeling somewhat heroic.

Sunday I slept till 8 AM when I thoughtlessly answered a call from a phone solicitor, dozed till 10 AM, gave up and showered, spent time on the internet, and was downstairs eating lunch when the phone rang again.

Sunday: 1 PM:
Received a call from Janet that an evening shift nurse had called in and she had not been able to replace him. My heart sank. I swore. I went through the 7 Stages of Death, "DABDA": Denial, Anger, Bargaining, D-something, Acceptance, and Death. [Wait, that's only six. Guess I need to bone up.] I packed a lunch and dressed and went to work. I worked on the cart on my wing, having gotten an excellent report and worked out a game plan with the day nurse, and had to deal with severe staffing issues for the CNA's [there had been four call-in's.] We had one able-bodied aide and one on light duty for 30 residents. It required a show of force to the other side to get them to trade an able CNA with our light-duty CNA.

I was checking blood pressures, blood sugars, and popping pills out of bubble packs until I was able to take a lunch from 7:30 to 8:00, completed an incident report on a skin tear, and very ready to go home by 9:30 PM. There was only one medication I couldn't find and I found out it was at the bedside, where the resident's family members administered it. The family was very nice about it. About 8 PM I received a call from the hospital asking if I would take a readmission and I was very firm and clear in my "NO!"

After report and counting with the night nurse, and still on call until 8 AM, I instructed her not to call me during the night unless there was a chain saw massacre.