The Q Word Podcast
“Nurse Donna”
Nyssa: Lisa, do you know what the term “OG” means?
Lisa: You mean an “original gangsta?” I'm really hip on terminology these days.
Nyssa: You do know! That's right. So I was caring for a patient in the emergency room one time who had some gang affiliations. This patient kept throwing around this term, “OG.” I was not hip on the lingo and so I was talking to one of the hospital police officers who used to be with the Gang Task Force. He was trying to explain to me what “OG” meant, and I was having trouble grasping the concept. And so he said, “Look Nyssa, if the ER had an OG, it would be Donna Brannen. And then it clicked. Okay, I got it. I got it. So Donna Brannen is the original gangsta, not “gangster.” Gangsta. Of course, she is the OG ER RN and so I knew she had to be our first interview. I'm so happy that she's here.Wanna say hi to everyone?
Donna: Hello, everybody!
Lisa: Hi, Donna!
Nyssa: So she was the charge nurse when I was a tiny baby new grad nurse. And she taught me and babysat me and protected me, as she has done for dozens or hundreds, probably at this point since then, and continues to do now. She's a night shifter- hardcore. Do not ask her to get up early in the morning. Right? And so she's had a lot of roles in our department. Mainly, it's the same role, just a whole bunch of different names. Assistant Manager, Assistant Director, Patient Care Coordinator, Charge Nurse, Flow Coordinator... I I don't know. All these creative names that they come up with for basically the same job. So Donna, I wanted to start by asking you: Do you say the Q word when you're on shift?
Donna: No, absolutely not. And I get really pissed when people do.
Nyssa: There you go. That's probably where I learned it from.
Lisa: Do you get pissed when people say it outside of the hospital?
Donna: No, it's fine outside of the hospital. Just don't say it in the ER.
Lisa: So you’ll say it right now?
Donna: No, I don't usually say it! Not really part of my vocabulary to be honest with you. It’s like, you know, it just won't come out.
Nyssa: Nope! I don't want to... I don't want to say it.
Lisa: So you don't have like a visceral reaction every time you hear somebody else say it, sort of, out in the real world? Do you have like a flinch response or something?
Donna: I probably do to be honest with you. I just go, you know, “mmm.”
Nyssa: Oh, yes. So tell me what is your favorite type of patient or diagnosis to care for?
Donna: I don't know that I necessarily have a favorite diagnosis. But I want you tore up from the floor up. I want you have half dead. I want you as sick as I can possibly have you and then be able to critically think how to keep you alive. Those are my favorite patients.
Lisa: Wow!
Donna: I know that’s sad. But it's the truth.
Nyssa: I feel that on a spiritual level.
Donna: You know, sepsis, it doesn't matter if you're having a massive MI. Arrest- that's short and sweet. But, you know, I want to be able to really think about cardiogenic shock, neurogenic shock. You know, the big hardcore sick is what I like.
Nyssa: Wow. So kind of the follow up question would be: Is there any diagnosis or patient that rolls in that makes you nervous? That you're uncomfortable caring for?
Donna: Truth is... No. There's really not. Bring it.
Nyssa: So can you tell me about a time- a patient case- that you can think of where you made a freaking awesome catch?
Donna: I've caught probably three Stevens-Johnson's in the last six months, which is an unusual diagnosis. Elderly males.
Lisa: Can you tell me what that is?
Donna: Yeah, well, it's not something anybody ever wants! Typically can be like an allergic reaction, but it's so significant that they slough their skin. And most of them end up in a burn unit.
Nyssa: It's like your body is burning it.
Donna: Yeah. It's like it's rejecting itself. And it can be fatal.
Nyssa: It is not pretty…
Donna: No… it’s bad.
Nyssa: Yes, very bad. So in your role as a mentor, and a leader, and a charge nurse, and a director, and a manager, and all those things that we've said that you have done in leadership, I know that you've had many critical conversations with people- with nurses or other staff members. Tell me about how you handle critical conversations. Tell me about how you would, if someone were new to one of those roles, how would you advise them to handle one of those kind of touchy situations? When you have to tell someone that they're not meeting the standards that they need to, or they've made a mistake, or one of those types of difficult conversations.
Donna: Well, I've had some nurses that really the environment wasn't for them. They could not function optimally. The problem in the emergency room is that if everybody doesn't function at a certain level, it really impacts everybody else that works there. And to me, that is totally unfair. I will give you every benefit of the doubt, I will work with you, mentor you, get people to surround you. I think it's really important that new nurses, especially, are surrounded with some experience. So they have a go-to person. But sometimes it just doesn't work out. Now I would not ever terminate somebody from their first nursing job. I think that's probably one of the most horrific things that you could ever do. They work so hard to get through nursing school, but it's okay to suggest, “You're not ready for this right now. You might need to go get some Medsurge, develop some critical thinking skills, and then come back.” Because in the ER, you're having to multitask constantly. And if you're a certain type of personality, that is very, very difficult for you. You get focused on one thing, and three other people can be dying, and you're still focused on not having gotten the four o'clock vital signs. This is not your gig. And it's okay to tell them that.
Nyssa: So what about the times when the critical conversation- it is in the heat of the moment- and emotions are running high. Maybe there's a patient involved, maybe there's family members, voices are getting loud…
Donna: You know how I feel about loud. I tell everybody, especially when we work multiple traumas, I want to hear a pin drop. Talking over each other is never good. I have a tendency when I’m miffed- everybody knows- I get very, very quiet, my voice gets very, very low, because I want you to pay attention to what I'm saying.
Nyssa: It’s terrifying…
Donna: I don't want any yelling, screaming, hollering. Matter of fact, I'm one of those women... I'm fine with a patient yelling or being foolish, but don't let another healthcare provider yell at me because somebody’s liable to get slugged. I just don't do it. You just don't do it. I have told nurses, “Did you hit your head? What were you thinking? Let's talk about this.” You know, so they pretty much know I'm pretty direct. But I think for the most part they know I'm not being critical. I'm just being real. And it is an environment where time is of the essence, most of the time. So I don't believe in wasting it. You know, “What were you thinking? Did you hit your head? Now, this is what we probably need to do to fix this.” I do not like writing people up. As a good friend of mine would say: it's a weakness. But I just don't like doing it. I don't know that it's productive. I used to keep a calendar and if I had to talk to you more than one time about something, I would then eventually say, “Okay, we talked about this on this day. We talked about this on this day. Now, I'm not talking about it anymore. I need you to sign this piece of paper. And you know, it's kind of like memory tonic. But I think generally if you just sit down and have a conversation and say, “Okay, tell me what you were thinking. What was going on in your head? What did you see?” Because they do have a story, and at the end of the day, as human beings, I think we all just want to be heard. And so you have to really become a good listener.
Nyssa: Yeah, there are two things that scare me when they get quiet in the ER: that's little babies and Donna. If you were precepting, or mentoring is probably a better word, a new grad nurse or a nurse who is new to the emergency room... Do you have some little nuggets of gold that you always tell them? Things that maybe someone taught you that you pass on to them that's just good? I mean, I know you have a treasure trove of them. Let's hear some of them.
Donna: Daylight will come.
Nyssa: Daylight will come! That's night shift talk.
Donna: I think the first six months of a new nurse’s career, they're going, “Please dear God, please don't let anybody die. Please don’t let anybody die!” Every time they walk in the door. And then they get to the point where it's like, “Okay, I got that part. I've seen enough resuscitations. I can get through that. I think just letting them know, listen, I will go up somebody's backside to get to you. It's okay. If you need me, you holler. But you've got this, you know, just remind them, what they've seen, what they've done, and that you're not far away, and that you're there for them. I think that really relieves a lot of that angst. There a million little things. It's like, “Don't pay attention to numbers, look at your patient. I don't care if your patient’s got a 120 over 80 blood pressure, but if they’ve got the “Q” sign, Houston, there's a problem.” I think as an ER nurse, it's nice to have those numbers, don't get me wrong, but you really need to look at your patient. The most important thing you can do is learn to do a good assessment.
Nyssa: So you are the staff nurse’s charge nurse. People would follow you right off a cliff if you ask them to. So let's imagine that someone has just taken on the role, newly, as a charge nurse. So they've been given this responsibility newly. Is there advice or thoughts that you would give them about taking the role of charge nurse?
Donna: Absolutely. Absolutely. Remember to be human. We all screw up. Don't hold it against people. You can't play favoritism. You have to treat everybody the same. Whether you like them or not. You can't act as to whether you like somebody or not. It can’t be personality.
There are a lot of things... You don't eat until they’ve eaten. Make sure that they know that you're there. You are constantly rounding: Tell me what you got. What's going on? What do you need? Make sure that no physician ever gets in their personal space. That's not allowed. Let them know that no matter what, you were there. That you'll take that bullet for them, if need be. That goes with families, sometimes they can be very hostile. You need to be willing to step in and go. No, you cannot run from confrontation. You can't avoid it. There are some hard conversations that you have to have with family members as far as what's appropriate, what's inappropriate, you know? Cursing at the nurses, that kind of stuff. You got to stand up for your staff. The bottom line, I think, to me, as a charge nurse: there's two major priorities. One is patient care. That goes without saying. That's why you're in the building- is to deliver good patient care. But the next most important thing is the staff. Your job is to take care of the staff. To see to their needs. And if you do that, and they know you do that, then you're right. They will follow you into hell. Because they know you're leading the charge. And that's the key. They have to know that, no matter what, you're in the trenches. You're working alongside. You're not too good to wipe somebody's bottom, you're checking off blood, you know, you're doing CPR, you're doing whatever it takes to get the job done. You're also facilitating what they need as far as equipment. If somebody gives them pushback, you're willing to get on the phone and go, “excuse me, what's the problem?” That kind of thing. And I think that's a huge part of this. That doesn't always make you happy with everybody else in the building. They have glossy 8x10s throwing darts at it.
Lisa: Could you tell me more about the kind of confrontations you might have to get into from time to time with doctors? A lot of my students here at Harvard are going on to be doctors in the future. I'd love for them to listen to this so that they know what they should keep in mind for what not to do when they become young doctors getting on to the ER.
Donna: Yeah, well, the worst thing you can do is piss off an ER or an ICU nurse because I will call you every five minutes to talk to you about somebody’s flatulence. You know, and I'll be honest with you, I've been doing it a long time so I don't have a problem dismissing a physician. I had one not too long ago. I had a patient that had been in a trauma that had a dissection. The attending trauma doctor was saying, “Donna, I need this pressured this. Do whatever it takes to keep it there. And trust me, I was doing that. But she required a lot of narcotics. And this young, little resident came in and he was trying to ask and I was like, “Son, I'm not talking to you right now. Get DA on the phone. I can’t have this conversation with you.” Because I didn't have time to get him up to speed. There are some physicians that can... they're like everybody else, they're just kind of figuring out where they are in the food chain. And that's alright. But I don't tolerate you being rude or just generally being a dick. That's not okay. I had a thoracic surgeon go at a nurse in the ER one time and he was being unmerciful. So I just physically put my body between him and the nurse and said, “If you have an issue, you need to talk to me. I'm your girl. I'll deal with her. You deal with me. That defuses a lot of things. Because there's something about this gray hair that works. They're just like, “Oh, dad gummit.” Like, What are you going to say to the old lady? I had a trauma doc not too long ago throwing a tantrum in a patient's room. Just young, immature. Just being a jerk. And so I waited until he walked out and then told him that they would have to surgically remove my foot from his ass if he ever did that in a patient's room again.
Lisa: I love it!
Donna: Every situation is different. And you got to get a feel for the physician in the situation. But at no time does anybody have the right to be rude or mean-spirited. That's not called for. And when that happens, it's okay to say, “You know, you're out of line. That was mean.” You know, I've asked a physician, “Do you talk to your wife that way? Because you certainly not talking to me that way.” I have a saying: I don’t sleep with you. You don't pay my Georgia Power bill. I'm not beholden to you.
Nyssa: One of the things that Donna has taught me and many, many nurses is that doctor's orders are merely a suggestion.
Donna: Yes! Amen! I tell them all the time: Orders, you know, when you give somebody an order, they feel compelled to carry this order out just because that's just your upbringing from when you were a little child. It came across like an order from your parents. You felt compelled to do it. Well, I teach babies, especially baby nurses. Orders are like suggestions. If it's stupid, don't do it. At the end of the day, we're all human. Residents get tired. They make mistakes. If there's something that you're not sure about, you need to question it. I had an ER physician years ago, he was a military physician, God love him. And they’re a whole different breed. They're not used to civilians feeling the need to question them. And I shared with him, the day that I fell under litigation for what he did or didn't do was the day he lost the right for me to question what he did or didn't do. And that's pretty much how I live my life. So you just need to remind them that they're dealing with all kinds of personalities themselves, and I will tell you, it's a statistical fact: positions that are light don't get sued. Even when they screw up, they don't get sued. So it pays to be a nice person. It just pays to be a genuinely nice person.
Nyssa: ...and not just to your patients. To your nurses.
Donna: Exactly. Especially to your nurses. Because at the end of the day, the public really knows who's keeping them alive. They're much more educated nowadays. There was a time when physicians you know, you got up from the... I'm even from the generation where you got up out of your chair to make sure a physician had a place to sit. Not so much me, but other people- I have to be honest. But we're past that now and we work as a team. And it truly is- it has evolved in that and it is so refreshing. I have worked trauma codes where they're looking at the trauma doc, they're looking at me, they're looking at the trauma doc, looking at me- it’s kind of like watching a tennis match. And then finally the trauma doc looks at me and says, “Donna, can you think of anything else?” People around you learn. They learn. And I think ER physicians and residents, they really want a safe place to land. What what I will tell you is: tell them do not get arrogant on their third year. Because invariably their first couple of years they’re your best friend and then when they think they know something, they get amnesia. It's like, no. It is. And I've had to share with them, “I was doing this job when you were thinking about getting your first piece of ass so you need to back up.”
Nyssa: Oh, my goodness! So Lisa, I want to show you something. I know this is not a visual medium, but I want you to describe what you see. Donna has a long history of a specific uniform thing that she does. Okay, I'm almost there. Can you see?
Lisa: Oh, are they sparkly clogs?
Nyssa: They are indeed. They are mismatched. Can you see that?
Lisa: Oh, I do see that they're mismatched.
Nyssa: So we have one flower power and one paint splash. And that is a hallmark Donna Brannen for the entire time I have known her. She has never worn shoes that match with her uniform.
Lisa: Okay… And how did that come about? And what is the superstition behind that?
Donna: There's not really a superstition, it’s just to remind people: don't take yourself too seriously, you’re not in charge of anything. We're just cogs in a wheel trying to make it go round and laughter- contrary to popular belief- is probably one of the best medicines around. People would look at my shoes and go, “Donna, do you know, their mismatched?” And I go, “Uh, huh.” I said, “You like that about me, huh?” Or patients, they just bust out laughing because they think maybe you woke up late and you just put the wrong shoes on. And I go, “No, I did that on purpose. And they let me be in charge. Are you scared yet?” And they just bust out laughing. So it's just to remind people. It’s something whimsical. Don't be too serious. It's not healthy.
Nyssa: So I know Lisa probably doesn't know this. Donna, you might not know this either. But there's a little bit of a rivalry between ICU and ER. There's a little bit of a rivalry.
Donna: Just a tad.
Nyssa: So if you were speaking to an ICU nurse, how would you explain an ER nurse?
Donna: Well, you know that picture that you see about the wires going every different direction and all over the place?
Nyssa: Yes.
Donna: That is an ER nurse. An ER nurse is able to see that chaos and make sense of it. And then you have this analogy of all the straight lines and everything's just perfect and everything is tagged and labeled... And that's an ICU nurse. Because that's the way they think. And that's wonderful. I'm glad they think that way. I did over eight years in an ICU.
Nyssa: You made it out alive.
Donna: Yes! And I saw the light. And I tell everybody that I'm a better ER nurse because of my ICU experience. But I was a much better ICU nurse because of my ER experience. Because I looked at my patients, I didn't look at numbers. And vice versa- they go hand in hand. The second thing is, is that they're more alike than they're different. They just have a hard time figuring that out. But at the end of the day, it's not even about that. It's about the fact that you're bringing them work, okay? Most of the time, if they've got an attitude, it's because- I hate to say it- you're bringing them work. It's just like ER nurses that have attitudes with paramedics. It's not because they're bad medics, it’s not because you don't like the paramedic, it’s because they're bringing you work. So it's really about wanting to get a paycheck without doing some work.
That's craziness.
Lisa: It’s good work if you can find it, but I haven't found it yet.
Nyssa: What, what do you think is the hardest part about being an ER nurse?
Donna: I think for most ER nurses it’s being able to juggle all the different hats that you have to be able to juggle. It's from going from a resuscitation where somebody just died- especially if it's a pediatric- and then going right into taking care of something else immediately. Because at the end of the day, you don't have a choice, you know? And I know that's difficult. And I think with time it gets a little bit better. I think you're able to compartmentalize it or put it where it needs to be. And everybody deals with things differently. I've been married to an ICU nurse for a long, long time. And Lee has to come home and he has to talk about it. He has to decompress. He has to tell me about you know, this V V or VA ECMO or this CRRT or, you know, this bad resuscitation, he has to talk about it. The minute I hit that clock, I'm done. I don't talk about it. It has to be a very unusual patient for me to go on and on about it because I just allow myself to be okay with whatever the outcome was and move on. For me, personally, I know there is a higher power. And all I can do is all I can do. And as long as I feel good about the fact that that's what I did, then that's got to be good enough. I had an ER nurse one time- I'll never forget it- they were bringing in an eight year old- it was a trauma. And she just had a meltdown. And I told her, I said, “Stop it right now. Get your shit together. Because at the end of the day, this is not your eight year old. This is her eight year old, and she needs you on your A-game. She needs you on your A game. This is her child. So if you can't do this, I'm okay with that. I'll let you step aside. But otherwise you need to understand. And I think that’s what you have to get when you're an ER nurse. You’ve got time to grieve and you've got time to have emotions- and I'm not saying those things are bad- I'm not saying debriefing is bad, I think that in all intentions they're wonderful ideas. You just don't always have that luxury. And I do have to talk about it. One night I had the charge nurse at that time- I think it was the assistant director- call me at two o'clock in the morning and said, “I need you now!” And I was up and into the hospital probably in 15 minutes. I blew every light going down Vineville ninety miles an hour because your charge nurse doesn't call you at two o'clock in the morning unless it’s bad. And so I sat straight up in the bed and Lee says, “What's going on?” And I said, “I got to go in.” They had just had five pediatric resuscitations and four of them died.
Nyssa: That's a legendary night in our ER, for sure.
Donna: Yeah, it was a bad night.
Nyssa: One of the worst of the worst.
Donna: Yeah. And you've got to be there for them. They've got to know you're willing to get up out of your bed and come. And they need to decompress. They need to talk about that. They need to deal with how their feelings are and how they were angry at the whole situation. And you have to be willing to listen to it.
Lisa: Yes. So you play a bit of, almost like the shrink on the ward, right? To have to listen to other people's concerns with it and make sure that you help them process their grief in a constructive way.
Donna: Sure, absolutely. But you know, what's more important? It's not even so much me. All the nurses on the unit do that for each other. That's the camaraderie and I tell them all the time, it really doesn't matter- and I've been in leadership- it really doesn't matter what leadership does. It doesn't. What matters is what we do for each other, that we're there for each other. That we will hold each other's hand, that we will back each other up. At the end of the day, that's what's important when you're working with a group of individuals. It just is, in my opinion.
Nyssa: I mentioned that you are a hardcore night shifter and I think always have been and I've heard you say before that day shift is a team and night shift is a family. Tell me about that.
Donna: Well, I think usually because it has to do with resources. You usually have less resources on night. So I think you develop this dependency a little bit more on each other to be there. When you do that for any extended period of time, it really does become like a family. You learn how this person is going to respond, you know what this person's reaction is going to be, you learn your physicians really well. You're able to buffer. And I think that's probably why day shift- poor day shift... they’re under a microscope. You've got clipboards walking around going, “Why haven't you done this? What are we doing here?” And you're having to stop what you're doing and explain something that's totally obvious to you, to somebody it's not obvious to. It diminishes your respect for that person. But there's constant- that constant intervention from somebody who doesn't do this and it's transient. I think day shift, they have a tendency to me, from what I see sometimes, to be a little cliquish. You'll have this group and you'll have that group and then you'll have this group and they're all really, really close. And they are close inside the hospital and they're close outside the hospital; which is wonderful. And you have that some on nights too- don't get me wrong. But I think it really boils down to just resources. Having to depend on each other a little bit more. Just because you don't have ancillary. You don't have other people that can go into staffing. It's it. You know? When you come in and there's 12 nurses, there's 12 nurses. You gotta lock and load.
Nyssa: Yeah. And I think that ER nurses have a culture of our own. ER night shift nurses have even a subculture of that because you guys sleep during the day and are awake at night and nobody gets that except for another ER night shift nurse. You know?
Lisa: So there's a lack of your bureaucracy at night because all the pencil pushers are at home sleeping in their beds?
Donna: Why do you think I work weekend nights? I got to really piss somebody off for them to come in at two o'clock in the morning on a Saturday!
Nyssa: I told you she's at Harvard! She read between all those lines and got that from that.
Lisa: I'm sitting here going, “Maybe I should be working at night because there's a lot of bureaucracy at Harvard that I might be able to avoid!”
Donna: And don’t get me wrong… I’ve played both roles and they're important, you know, you've got to have leadership. But you need a certain type of leadership.
Nyssa: Lisa, I was telling you about how sometimes when you are out in triage and there are no beds in the hospital, and there are no beds in the department, the mood in triage starts to escalate and people start to get very upset. And as one person gets upset, it becomes contagious. They're feeling frustrated, they're sick, and you get the picture... When I was a triage nurse and that was happening, oftentimes I would call Donna to come out and give a famous speech that she gives in triage. Donna, can you give us that speech?
Lisa: Oooo, the speech!
Donna: I tell them if you're shot, stabbed, run over, hit by a Mack truck, having a massive coronary or stroke, guess who's going to get the bed? This is life threatening emergencies. That's what we do and everything else we kind of work around that. They will get taken care of. I tell them I don't know how long it will take. I also explain to them acuity; the sickest gets the bed. And that's why we do a lot of labs and x-rays and those kinds of things now, to try to determine where you are, as far as this triage category. Most of the time, they just appreciate the fact that you've come out and spoken to them. It's all about reassuring them that you do care, that you do realize they're sitting out there, you do realize that they don't feel well. I think it's just about being acknowledged.
Nyssa: It works miracles for the rabble that is happening.
Donna: Yeah, for about 30 minutes, then you have to go back out there.
Nyssa: And do it again!
Donna: I wish there was a tape… they could just reel it through.
Lisa: It would probably lose its effectiveness relatively quickly. So I think a regular guest star on this podcast is going to be my kidney stone, which is the first time I ever had to go to the hospital in an ambulance because I didn't know what the heck was going on with me and why was in so much pain. There's an idea that if you get to the hospital in an ambulance, you're seen first and automatically given a bed. I'm beginning to assume that that's not correct.
Donna: That is not correct. And that's another thing that I share with them. And I tell them whether you come in through the front door, whether you are flown in whether you come in by EMS... the reality is: it's based on acuity.
Nyssa: But you're right. That is a very common myth.
Donna: That is very common. That's another thing that I teach baby nurses. That's a huge part of this. I share with them that this is not your emergency. It’s theirs. You need to let them have it. Okay?
Nyssa: Literally my next question.
Donna: And you need to acknowledge that because that is a huge part of this. The huge part of just being heard. You know, I tell folks all the time, you cannot measure people with your yardstick. You'll come up short. And the same thing goes with emergency. You know, my emergency may not be what your emergency is or what your emergency is.
Nyssa: So Donna famously has a little black book and every nurse would pay a lot of dollars to get their hands on a peek at that little black book. Tell me about the little black book- I heard it went through some changes recently?
Donna: Well, it's falling apart. I'm having to rewrite it. But I think it's silly for nurses to think that they have to have all that in their head. There are some things that you don't see every day- like a thyroid storm- how are you going to address that? Years ago I just started writing things down. Which presser, in my opinion, works better for- and not necessarily scientific- what I have seen work better in certain situations. You just jot yourself little notes about all these different things, different processors, different rates. I’m an old nurse, so drugs that I'm used to- we used to use dopamine for everything and I can tell you the dosage or how to figure the math dosage of dopamine and nobody does that anymore! It's all done on a pump. I think it's just pearls- things that you've seen. What do you want to see with a neurogenic shock? What do you want to see in cardiogenic shot? We had a patient, not too long ago, and I happened to be in charge. A baby nurse came and got me and said, “Donna, I'm in trouble. This patient’s in trouble. I need some help.” And this chick is 30 something years old, and she's got a heart rate of 150 and they got her on dopamine and I said, “Cut that shit off! Cut it off!”
Nyssa: Dopamine makes your heart rate go up... So if you already have a high heart rate...
Donna: It’s a positive inotrope. But if you've already got a high heart rate, and your heart is already failing- which I could figure because she had congestive heart failure- yada yada yada. I figured, “No... this is not good for her. Cut that crap off. She needs some dobutamine. Fortunately enough, the cardiologist walks in and the first thing he says is, “Do you guys have any dobutamine?” And I was like, “Score!”
Lisa: Vindication!
Donna: I like you, Doc! So, you know, those kinds of things. Things that I've come across, that I've seen. Burn formulas, fluid formulas, pressers... all those kinds of things right there at my hands so I'm not having to run to a computer and not having to look stuff up. And it's just built over the years adding this to that, this, and now it's pretty much falling apart. The pages literally are disintegrating so I need to rewrite.
Lisa: So this is something you keep in your utility belt then? Along with your alcohol wipes and your stethoscope?
Donna: It used to live in my pocket and I’d pull it out. But a lot of this stuff if you do it enough, you know the dosage. Like epi: 2-10 mics, nitro, whatever it is, high dose epinephrine. You just you do it enough. You just know what it is. But, you know, I'm old. So if you ever have a brain fart, I can just pull it out of my pocket.
Nyssa: Listen, if the black book ever goes missing, do not look for it with me. I don't have it.
Donna: Yeah, you got all that knowledge. You don't need it.
Nyssa: So another thing I will tell you, Lisa, about Donna is that she has a family full of medical providers. She has a husband Lee, who's an ICU nurse. What I want to know about that is: what's it like sleeping with the enemy?
Lisa: Ohhhh, Nyssa! Give us all the gory details!
Nyssa: Sorry, Lee!
Donna: I don’t really consider him the enemy. But I will tell you, I have a really good relationship with CV nurses because of Lee. I think that really buffers knowing that we are married, you know? I don't get very much pushback from the unit. And I think that has a lot to do with him. And he's got that philosophy, you know? Give me the report. Tell me what you can, I'll figure out the rest. Send the patient on up. And he's always been really, really good about that. Because as an ER nurse, you're multitasking, you're doing a gazillion things. And contrary to popular belief, you do feel bad when you're not able to get everything done that you want to get done. But you know, you got a charge nurse going, “Roll with that patient because I got somebody else sicker or as sick I need to have in that bed.” So I think that plays a part. But like I said, we have different ways of dealing with things. And I will say, my husband, he is very, very bright. He's very, very good at what he does. And I wouldn't take any of that away from him at all.
Nyssa: Absolutely. So they have a successful West Side Story kind of a thing. So as far as your kids go, they were destined to be medical. So Donna had a daughter who chose the ICU route and a son who is a paramedic, so he's in the emergency route. And I've worked with both of them in the emergency department before they were both medics and nurses. They're both great clinicians and great people, and so I reached out to them and asked them what they would say about their Mama... What Michelle said that you taught her- the one thing that sticks with her, especially that she uses in her ICU practice- is that there are things that are a lot worse in life than dying. Yeah, that's pretty intense. The other thing that she said, that is so true, is when the crap hits the fan, my mom is the one you want standing at the bedside. And that is true!
Donna: I paid her to say that.
Nyssa: No you didn’t! And that's whether you're the patient or the nurse... the bedside nurse.
Lisa: So wait, let me cycle around to the first quote... what qualifies as worse than dying? I mean, I think I know where you're going to go with that, but give me some examples of what you think would be worse than death.
Donna: We prolong it to the ridiculous. We've gotten really good at resuscitating patients who were basically dead. So now they're in a vegetative state. And we're feeding them, watering them, and turning them and watching, you know, you have them on so many pressures that their fingers start turning black and they get these giant decubitus ulcers because their skin is necrotizing because it's not getting any oxygen or blood flow to it. And so rather than dying a peaceful, natural death, it's all chemicals or a ventilator keeping them alive. And sometimes it's not because somebody is well loved or revered… sometimes it's because they're getting a paycheck. There are a lot of different dynamics. Typically, when you see somebody that says, “Oh, no! Save Mama!” or whatever, it's somebody who's living in California who hadn’t seen Mama for six years. And I've told some patients, “I understand this is about you. This isn't about them. And that's okay.” But we just all need to be clear about that. And a lot of times it's their sense of guilt or whatever they're reflecting on.
Nyssa: A missed opportunity.
Donna: Yeah, a missed opportunity. So I think as physicians, they don't need to relinquish the power of common sense. I'm not asking anybody to play God. But when you know somebody is gone, it's okay to let them go. And I'm not talking about the six year old. You know, I'm not talking about the traumas- I'm not talking about those. I'm talking about patients whose comorbidities have comorbidities. They're sick, they've been sick a gazillion times, they may have already been trached and pegged, you know, we're keeping them alive on a ventilator, were keeping them alive with lots of pressers. They have no quality of life and even if they do miraculously wake up, they're destined to be in some nursing home where somebody else is going to continue to turn, water, and feed. That's, for me personally, that’s not life.
Lisa: I feel like all the ‘Grey's Anatomy’s and ‘Chicago Hope’s and all of these television shows where somebody comes in with some, you know, inoperable disease, or they're on death's door, and they've coded several times and they keep getting brought back to life and then two days later, they're being wheeled out of the hospital and everything is fine... I feel like that's setting up people for the wrong expectations of what a medical professional can actually do in many situations.
Donna: Yeah... it's horseshit. Yeah, I remember when the code black came out, and somebody said, “Donna, what you think?” and I said “Horseshit.” I wish they would hire real, working nurses to go “Yeah, yeah... no, not so much.”
Nyssa: So I just want to go on the record at this point and say to you two, both of you, two of my dearest friends: do not ever let me lay there like that. Don't do it. I will come and haunt you both.
Lisa: Yeah, that's right back at you Nyssa Lyn.
Donna: So, I will say, the other part of this, if there's a silver lining to any of it, I think it allows people to have an open dialogue about what you do and don't want. I encourage people before it becomes an emotional issue. Before you feel like, “Oh, I'm killing Mama”, or “I'm killing Daddy”, that you have that conversation and you go, “Mom, what do you want?” My mother is adamant, matter of fact, when she travels- my mother's 87 and she's a live wire- she travels with a pendant that says DNR on it.
Nyssa: I cannot believe that your mother is a live wire… Unbelievable.
Donna: So that's the time to have that open dialogue with family and friends and say, “Okay, you need to let me know how aggressive…” Now my sister is totally the opposite. She's like, “Do whatever you gotta do, I'm coming back!” And I am not her medical power of attorney.
Nyssa: For that reason!
Donna: For that reason! She’s like, “You would pull the plug!” So my husband is.
Nyssa: So when I reached out to Morgan, this is the story that he told me: He said that when he was in high school, he had a teacher who was a favorite of all the students. A very influential teacher. And that just a few years after their class graduated, this teacher passed away sort of unexpectedly after graduation. One of his friends called the house- this was back when people had a home landline. She called the house to talk to Morgan about the news and sort of mourn with him and he wasn't home... But you were and you picked up the phone, and you're the one that she ended up talking to. He said that she came back to him and said, “Your mother told me something that I will remember for the rest of my life.” And that was: time doesn't heal pain. It only gives you perspective.
Donna: That's correct.
Nyssa: And this young lady, evidently, now works in a healthcare profession and the particular office that she works in deals with a lot of geriatric patients. They build relationships with these patients, and because of that, a lot of their friends are passing away, their loved ones are passing away. So she uses this piece of wisdom that you gave her way back in the day all the time in her job currently.
Donna: Wow.
Lisa: That's great.
Donna: It's the truth.
Lisa: That's actually good advice for a lot of other things, too. So I'm going to remember that one, I'm going to glom that from you for my students for when they start freaking out about not getting honors or getting an A minus on a paper…
Nyssa: Well it sort of flies in the face of what we normally say- that time heals all wounds. Yeah, no it doesn't. No, the pain is still there. But you put it in perspective.
Lisa: Absolutely.
Donna: Well some people come to terms with it, and some don't, and everybody's going to grieve differently. And I think for some people, the more this one person is the center of your universe, the harder it is for you to get past that. And it's just a reality. But I think you have to be respectful of that. But it doesn't. Time doesn't diminish. It just puts things into perspective. And the perspective is: I'm going to wake up tomorrow morning, I'm going to brush my teeth, I'm going to get dressed, and I'm going to do whatever I have to do to go about continuing to live. And if you don't want to, then you choose a different route.
Nyssa: So I kind of wanted to wrap this up with the thing that you always wrap up a shift with when you are the charge nurse. You always go on the overhead and say something to the staff. What do you tell them?
Donna: I usually say, “You were rock stars. You did an awesome job. Thank you very much!”
Nyssa: And what does that mean to the staff? You're the only charge nurse I've ever had that says that or does that.
Donna: Well, I think it genuinely let's them know that they are appreciated and that it was noticed. I think one of the sweetest things that you can do to a baby nurse, or to a new nurse, or even an old nurse- it doesn't matter who it is. When you observe them doing something, going above and beyond, when you observe them taking care of a really sick patient- it's always wonderful to say, “You know what? I watched you. You did an awesome job. You did great.” You have to reward them and that's all it takes. You know, don't get me wrong, we're in this to get paid. We've got Georgia Power bills, butt that will sustain them when a lot of things won't. Just the fact that you do notice, that you do appreciate it, and that you do verbalize it because people want to hear it. We want to hear at the end of the day that we're important, that we mean something, and that we matter. And it's always wonderful to acknowledge that. Because you're right! You do! And you have the right to hear it. But they need to know that they're appreciated. You're making $26 an hour and trust me, you got your bell rung and they couldn't pay you $56 an hour for what you accomplished last night. That’s the point that they want to hear.
Nyssa: My boss thinks I'm a rockstar.
Donna: That’s right.
Nyssa: So Donna, do you want to end it with a mic drop? Chunk it on the table sister. That’s an OG EC RN mic drop.
Bibliography
For a description of Stevens-Johnson Syndrome:
National Institute of Health. (2019). Stevens-Johnson syndrome/toxic epidermal necrolysis. U.S. National Library of Medicine: Genetics Home Reference. Retrieved from https://ghr.nlm.nih.gov/condition/stevens-johnson-syndrome-toxic-epidermal-necrolysis
Keywords
nurse, patient, Donna, ER nurse, ICU nurse, physician, ER, trauma, hospital, triage, charge nurse, shift