Knowledge puffs up

I learned an important lesson at work yesterday.
I was working at the detox center and I had a few sick patients. The doctor was scheduled to come at around 8 but she called me at 9 to say she would be in after lunch. I don't normally give the doctors too much trouble- I get everything organized for them and try not to call them on their cells, especially at night, unless it's an emergency. If I need a lot of orders, I try to group them all together in one phone call so I don't bother them too much. Suffice to say that by the time Dr. Michaels* showed up at 2:30, I had a lot of stuff to talk to her about. (*Names changed, of course, since I'm about to criticize her).
One of my patients, a young man withdrawing from morphine, had been in a car accident and sustained serious nerve damage to his left leg. He was barely handling the excrutiating pain when a buddy gave him a couple of dilaudid pills (similar to morphine) and he quickly became addicted. Now his life was falling apart and he was willing to do anything to get off the drugs. We talked about the pain together and I gave him regular tylenol and ibuprofen but none of it was really cutting it. There is a drug called Gabapentin that I told him about- it is very good for nerve-type pain and it is especially good in the withdrawal pain associated with opiate use. I told him about it and he said he'd be willing to try it. In detox it is one of the more commonly prescribed drugs by the doctors- it is non-addictive and fairly safe and I've had patients tell me that nothing helped their pain until they tried the wonder-drug Gabapentin.
Dr. Michaels came in and I was down the hall and I heard someone calling for me.
"Where's the nurse?" She demanded as I came into the office.
"I'm here." I said, and quickly pulled out all the charts for her to sign. I asked my nursing student (who was shadowing me) to go and get the first patient to see the doctor. Dr. Michael's scanned the orders sheet.
Stephanie had been on a regular dose of dilantin (a seizure-controlling medication) but the doctor the day before had forgotten to order it and I needed her to write it out for me. Kyle needed a physician's signature on his admissions form for a treatment program. James had a bad cough and was asking for his puffers and I needed an order to get new ones from the pharmacy. One of my patients came into the office just then, doubled over in pain and looking like he was about to throw up. While Dr. Michaels was signing charts I whisked him into the examining room and quickly gave him some gravol.
He kept the gravol down without vomiting so I took his blood pressure and opened the med drawer to get him some clonidine (a medication used for opiate withdrawal that takes away a lot of the pain and nausea). The poor guy hadn't had his dose yet that day, as he had been sleeping, and he was in rough shape.
Suddenly Dr. Michaels stalked into the room and stood there, in my way.
"I'm just giving him some clonidine." I explained, checking the dose of the drug.
"Can't you do this later?" She demanded, waving me out of the room.
"Okay?..." I shrugged at my patient and went out of the room. She closed the door after me.
I busied myself copying orders and then went to get another patient lined up to see her. As I was coming back into the room she was sitting with her back to me, and she called out, "Nurse!"
Now, I don't mind being called nurse by my patients, because most of them are sick and there are so many nurses they can't keep it straight anyway, and we're all wearing uniforms.... But when a doctor calls me 'nurse!', especially a female doctor, there is something very disrespectful about it. I felt my blood begin to rise, but I held my tongue and came over to help her.
"What else do you need me to sign?" She asked.
I sat down next to her and went over some of the orders, finishing with asking about the Gabapentin.
"Paul has had nerve damage in his left leg from a car accident and it's excrutiating. I was wondering about getting him some gabapentin for it."
She shrugged, ignored me, wrote something else on Paul's chart about sleep medication and shuffled the papers together.
"I'll leave this form for today, I don't have time to fill it out." I held out the clipboard with her msp forms that required her signature to be paid, and she signed it and went out of the office, putting on her coat.
She had been there for an hour but it took me two to process her orders and clean up the mess. I explained to Paul that the doctor hadn't ordered Gabapentin for him, so we'd try to manage with tylenol and hot water bottles, and the poor guy looked like he was going to cry.
Later that night, after a busy day, I was doing shift report with the night staff. The nurse coming on shift was a veteran- she is a kind older lady with an ever-present smile and a sense of humor. She took one look at Paul's chart and said,
"Why isn't he on gabapentin?
"I asked Dr. Michaels for it today" I said, "but she wouldn't order it."
"What?! We use it all the time for this type of thing! Why on earth wouldn't she order it?"
Suddenly the old nurse smiled knowingly.
"Heather, you have to learn how to talk to doctors." she said to me. "I've learned over the years, you have to treat them like a husband."
I wondered what the heck she meant.
"I know Dr. Michaels," she continued; "she's a type A personality, and from what I know of you, you are too. What happened today had nothing to do with the Gabapentin. It was a power struggle, pure and simple."
Suddenly everything began to clear.
"The way you treat a doctor and a husband," she said, "Is you never tell them what they should do or ask them for something directly. You always make it seem as if it was their idea first. I'll bet anything you said to Dr. Michaels, 'Would you please order gabapentin for Paul?'"
I laughed. "Of course."
"Well, what you should've said was 'I don't quite remember, but is gabapentin the drug you normally order for this type of thing?', or something like that, to make it seem like it was her idea first. If she thinks that you know more than her, or know what she should do, she'll do the opposite."
We all laughed together.
I thought about it all night, though. It shouldn't be that way, but it is. Dr. Michaels (and some other very talented doctors I've met) treat me like a dumb LPN. Part of me wants to look her in the eye and say, "I know what I'm talking about, I've been in college for 8 years and I was in medical school." But part of me also believes that you shouldn't have to get respect by showing off how much you know. If Dr. Michaels can only respect me for my societal rank in the healthcare field (or lack thereof as an LPN!), then it's not true respect. True respect has to do with listening to a person and considering their opinions simply because you believe they matter as a person, not because they have the initials LPN or RN or MD or PhD behind their name.
I remember in nursing school, a very wise teacher told me, "If you want to know something about a patient, whether or not their behavior is normal or how long the strange rash has been there, then ask the care aides. If you want to know where things are or you need somewhere quiet to nap during your break or you have a machine break down or the cafeteria is out of food, ask the janitor. Never underestimate what the people 'lower' than you know and are capable of. They will make or break your career.
I have the same issue going on with my nursing student. She's annoying and not super smart, but I learned something from Dr. Michaels that I can pass on to her in the way I treat her.
"We know that we all possess knowledge. Knowledge puffs up, but love builds up. The man who thinks he knows something does not yet know as he ought to know." I Cor. 8:1-2
There is no substitute for loving and respecting people. And if I truly care about my patients I'll have nothing to do with the hierarchy that demands I treat the people 'lower' than me as if they don't know as much as me. Instead, I'll seek to build them up however I can.... In doing that, people like Paul won't have to suffer needless pain.

Hullaballoooooo!!!!

The other day at work I had a crazy day. It started out kind of bad because I didn't sleep well the night before and I woke up early and it was cold and dark and I didn't feel very upbeat. I drove to work and sat through report with a coffee in my hand. I didn't finish my coffee until 3 in the afternoon, which is probably why things went the way they did. We were short staffed: the social worker was sick and I had a student to help me with things, but otherwise I was on my own.
There are many different types of people who come through detox, but if I was to divide them into the two most general categories, it would be alcoholics and opiate users. Alcoholics of course can be anyone from any walk of life and there is no real typical example. Opiate users, however, are usually working through quite a bit of pain. Physical pain issues underlying their addiction are often things like car accidents or work accidents that left them with excrutiating back pain or chronic migraines, so they started with prescription painkillers and things spiralled down from there. Emotional pain issues are often childhood sexual or physical abuse, loss of close loved ones, bad marriages, etc.
Whatever the cause, when you remove a painkiller from someone, their pain surfaces at an even greater level than before. As a very general rule, people withdrawing from opiates (heroin, morphine, etc.) are in a LOT of pain; thus they complain a lot and are very needy. Coupled with the fact that many of them have subsequently ended up in pretty crummy life situations, many of them have very poor coping skills and very difficult behaviors. Not to mention a high rate of mental illness (depression, bipolar, multiple suicide attempts, OCD, etc.)
A busy day in detox would be 5-6 alcoholics and 2-3 opiate users. I say this all to explain why my day was so busy: when I got to work I had 9 patients; 8 of whom were opiate users.
Some of them were very sick. One young woman named Karen (not her real name) was scheduled to leave that morning. She had made plans with a young guy named Mark to go to his home for a couple of days before heading to a treatment center. Staff tried in vain to dissuade them. She had complex issues that we weren't really able to tell Mark about because of confidentiality. She had multiple suicide attempts and was drinking everything from listerine to glue to methadone and anything in between. Mark was a gentle-hearteded guy and the alternative of her going to a women's shelter for two days roused his protective instincts. The morning was spent on the phone with her parents and his mom and trying to convince him to leave without her. Mark finally confessed that he felt trapped; although he wanted to help her, he didn't really want to take her home with him, but when he tried to tell her she couldn't, she sobbed and cried that she had nowhere to go and wanted to kill herself.
Meanwhile an older man, Jason, had taken his medication for hepatitis and was growing weaker by the minute. I wondered if he had a drug reaction going on. Another lady, Beatrice, was sitting on the floor in the hallway crying and swearing.
The fire alarm went off. My manager came bursting out of the office yelling for me to get everybody out and evacuate. She called 911. I grabbed the census sheet and rounded up all my patients out the door and into the parking lot. It was freezing. We huddled together in the cold waiting for the firetruck to arrive. Jason had a blanket wrapped around himself and he curled up in the dirt, covering his head. Some of the girls were crying. I didn't have a coat and I stamped my feet to keep warm and told them it wouldn't take too long, everything was going to be okay.
The main boiler had exploded and it didn't take the firefighters long to check it out and let us back in the building. But there was no heat now, and no hot water. Me and the student helped Jason up from the dirt and I began filling hot water bottles and getting extra blankets for everyone.
Mark's mom arrived to pick him up and we quickly pulled her into the nursing station and explained what was going on. Karen was such a basketcase that we felt the easiest solution for Mark was to sneak out quietly and we'd deal with Karen after he left. The student distracted Karen; my manager got Mark ready to leave.
Beatrice was still crying. Her room was near the nursing station and she was huddled on the floor under a blanket with an electric heater under it. Her roomate was distressed. "She's going to light the place on fire!"
"Beatrice?" I tried to coax her out from her tent. She jumped out, knocking a glass of orange juice to the floor. She began to cry, sitting down in the juice with her blanket.
"I feel so awful! I'm spilling everything!"
"It's okay." I reassured her. "I'll clean it up. Why don't you go have a cigarette, and then I'll give you something for the pain?"
I hate to recommend smoking, but for people in that much distress it went a long way to calm jangled nerves.
She got up and went out the room. Her roomate, lying on the bed, told me:
"Beatrice asked me for some money because she wanted to get a friend to smuggle some dilaudid in here for her. I don't even know what dilaudid is."
And so my day went. Karen yelled and cried for 3 hours before leaving. We phoned ahead to the women's shelter and asked them to put her on suicide alert. The crowing glory was just after dinner, I heard someone shout my name, and I raced out of the nursing station to find the night attendent holding Jason against the wall. He was white as a sheet and tried to throw an arm around my neck as he slipped to the floor. He was a big guy, about 250 lbs, and I ducked out of his grasp and instead pushed him against the wall as I helped him collapse slowly. Then I got my stethoscope and listen to his falling blood pressure, managed to get him into a wheelchair and then into bed, and then called 911.
The detox center is not an acute medical facility, so anyone that turns critical we have to send to emergency. The paramedics came and put him in a stretcher and whisked him away. As I was trying to finish my charting, Beatrice came in crying and saying that the night attendant had been rude to her in front of the otehr patients and she wanted to make a complaint.
I went home feeling a little stressed. Sometimes people say, "Oh, I could never do a job like that!" My answer is that I couldn't either, if I had to do it full-time. I'm sure I would burn out. Some days are laid-back and easy-going, others are just one giant hullaballoo.