Residency: When Your Patient's Wife is a Nurse
Procedures are a huge time suck. I never say no to helping other nurses, especially when it involves doing a Foley, or wound care, blood, IVs, or anything else that involves invasive equipment. But one day, a patient with altered level of consciousness arrived on the unit. He was also a c-diff patient so I had to gown up each and every time I went into the room (which was a lot cause he pooped about every 4 minutes).
...but he needed to have his Foley changed because it was time. So I went in there. But his wife was there, too. She helped my preceptor & I change her husband's diaper but then stayed when I opened my sterile field to insert the Foley.
"No no no! Put the iodine in the tray first. The TRAY FIRST!" She would screech over at me. Apparently, she's the director of staff development over at her nursing facility. How she became the director with an attitude like that, however, is beyond me.
She continued to scream at me and criticize my technique which was NOT helpful to me at all. NOT AT ALL. I couldn't cover my ears because I had my sterile gloves on. So I just took a breath, cleaned the penis with sterile technique and gathered my equipment.
"Let me have that catheter cover. I will pull it out, you just stay sterile! STAY STERILE!"
My preceptor was shocked and stood still. He couldn't get a word in edgewise because of the tone and rapidness of her shrill voice. I had to take a breath. He clearly wasn't going to help me, so I had to try to ignore the woman somehow.
"Hold his penis with your whole hand, not just the fingers!!! Lift it up! Feel the base with your pinky! ARE YOU LISTENING TO ME?!!!!??"
She clearly wasn't going to leave me alone, and all the blood was shunting to my mouth to try to keep it shut so that I wouldn't yell back at her. So again, I took a breath, and decided to compromise. I let her help me. This didn't stop her squawking, but at least it re-focused her attention on her husband rather than just on me. When I finally inserted the catheter, the husband squirmed and wretched in pain.
"WHAT ARE YOU DOING? YOU'RE HURTING HIM! BUT KEEP GOING! Don't stop. I SAID DON'T STOP!!"
Goodness. "Think, Howie, think." I said to myself. I had come across a rather large obstruction. I thought about anatomy and that the male's urethra is longer than the female's. So I knew I had quite a lot more tubing to go. But every time I tried to push through the blockage, the husband would scream so much that we had to close the door!
There was no way I was going to stop and do this all over again.
Then I thought about pathophysiology and remembered that men his age usually have an enlarged prostate (I think I remember reading this on his H&P). And patients with ALOC usually have a lot of infection and debris inside their urethra due to poor personal hygiene. So I made a decision to ignore the woman, ignore the cries of the poor man, and decided to retract just a tiny bit, and bore the catheter past the obstruction.
Watching the urine come out was like finding treasure. Inserting a Foley is one of the most basic nurses' skills but doing it while under pressure and still getting through felt like some sort of a miracle. The first few mL of the urine came out with red blood clots. Afterwards, the shrill woman kept badgering me about this & that. It was as if everything wrong about her husband was entirely my fault. I wasn't the one who gave him brain cancer. I was just trying to keep him alive. Even when I was about to take off my gloves, she accused me of touching the vitals machine with them. The room was already full of C-diff! What more was I going to do??
The terrible woman finally calmed down once she saw that I had successfully performed the procedure and that my IVs were infusing into her husband as planned. But before I could leave the room she continued to try to lecture me about proper technique.
"You need to never stop once you insert the catheter. Keep going and don't stop! You have to feel the base of the penis with your pinky! Nothing is wrong with his urethra! You just have to hold and SQUEEZE the penis straight out! Like this. Like this!" At this point she's wiggling her fisted hand back and forth like she was having a seizure.
"Yes, ma'am. I see, ma'am. Thank you for the lesson." I wanted so badly to show her the clot and maybe even point out that, as a male, I know a little bit more about penises than she does. Then when the intern came in, the woman was SO SWEET to him. The intern even said, "Oh, you know your husband has C.diff but even though we're not entirely sure, we have to put him on precautions just so we don't spread it around. You know, the nurses here *think* that they can smell who has C.diff but, hahaha, they really don't understand. (He didn't even know that the woman was a nurse). Ughhh--to BOTH OF THEM *eye roll*.
I held it inside.
Even my preceptor said, "Wow, I would hate to be her student. She does not know how to create a learning environment." No, she does not. But then I saw her fussing about the room and squawking at her husband too. Then I thought to myself--her husband of probably 60 years is dying in front of her eyes. I watched her talk to basically a living puppet. And then I felt sorry for her. But I still didn't want to be her friend, that's for sure. Seeing her like that was enough for me to at least pop in once in a while to make sure they were ok. She was never nice to me, and I would resent myself every time I went in the room, but at least I didn't feel spiteful. (Well, maybe a little. I'm writing this, after all.)
The patients here in med-surg aren't all that exciting, but I've learned quite a few nursing tricks that I can bring to my practice that will help me in my career. However, now that I'm warming up to juggling a few patients, I find that bureaucracy, emotional games, and even sexual behavior among staff are still rampant! This all takes up a lot of a nurse's time and I'm trying to learn how to stay efficient.
For example, we give a lot of IVPB antibiotics here. I usually hang around 10-15 a day. I don't administer, but I do everything including picking up from the pharmacy, priming the tubes, flushing the line, verifying the order, programming the rate, attaching the tubes to the patient. The only thing I don't do is pressing the 'Start' button on the Alaris. My preceptor was sick one day, so I went with another preceptor who was a lot less intense. He believes in charting by exception (thank God). He also prefers to switch tubes of the same piggyback med rather than starting with a whole new set. Therefore, I was able to save time by verifying the same medication, and continuing the infusion using the same tube and flush bag. If the pump alarms, then I know I have to change the tubing anyway. I also learned how to prime the secondary tubing upside down if I'm using the same flush. It's a very useful technique that I've only seen once before. It's a complete time saver!
We also mix a lot of insulin. This throws off my regular medication administration schedule because it's not just pills, it's taking the blood sugar and waiting for meals to come in. It puts me out of my normal routine and slows me down. So I either try to delegate it, or try to aggregate it with the rest of the meds, then just keep in mind that the patient will need his Aspart when the meal trays come in. I sometimes mix my insulin if the order requires it. This can be daunting since the bottle is shared between patients. Therefore, I'm not allowed to leave the med room with the bottle. Therefore, I always draw my insulin and label it so it doesn't get mistaken for heparin, saline, or other clear meds to push. I also got tired of forgetting which insulin is for what, and I found that insulin is almost always in my Kaplan tests.
Finally, since the Corpsmen and nurses are practically all in their twenties and thirties, there are a lot of hormones involved. I've been here long enough to understand some of the dynamics between who is dating whom (on the down low). It's interesting to see how it affects their performance, as well. All of the staff are still quite competent, but I can notice when some are spending a little too long in an empty patient room, hahaha. And I'm privy to that, as well. I'm very friendly and eager to meet people so I immediately extend my hand and start joking around with new people. I think some of the younger nurses and Corpsmen interpret it as a come-on. I'm pretty sure it's obvious that I'm gay, but maybe some new girls try hard to fit in right away when they come into the unit. I understand that it's like coming in to the same classroom where everybody already knows everybody and you're the new kid in town. It makes you very nervous and you want so hard to fit in. They also like that I'm only temporary and therefore not part of any particular clique. Eventually they get who I am, haha. Even some of the big young guys joke around with me and have started to grow their mustaches, too. They consider me part of their 'boys' club'. Sometimes they ask me for stories about what it was like when I used to be a Corpsman with the Marines (they are so eager to leave the hospital and enter the Marine Recon special forces and the SEALs). But then sometimes they also look at me like, "How did Howie ever mix with Marines?" Bwahahaha. They'll never know.
Jan 5One of my least favorite things is when a patient has a family member that is a medical professional. Sometimes even worse when the actual patient is the medical professional! It all depends on their personality really but I can't stand the pushy ones who think that you are doing everything wrong. I don't let anyone tell me how to do my job though.
I had a patient on a slew of IV medications and the patients wife was a nurse. Everytime I came to administer the medications she would literally hover over my shoulder watching like a hawk. Then she would always "remind me" to flush the lines. I wanted to knock her teeth down her throat because she would always say things in a demeaning and condescending manner. Then the patient would request his dilaudid and she would always say "no he doesn't need it." Of course I didn't listen to her and told her whether she likes it or not her husband has a very painful condition that requires narcotics if he requests it and if its time I'm going to give it. Like I said. No one tells me how to do my job. Of course after I administered it before I could even get the empty carpuject into the sharps bin she was all over me about checking his vitals.
Everyone would dread being assigned to this patient. He was on the floor a while too with a pretty nasty bowel obstruction and had kept getting infections post-op. He couldn't get discharged fast enough. Poor guy I really felt for him. He would always apologize for his wife's shrew like behavior. He on the other hand was a gem of a patient, genuinely sick and didn't like bothering the staff for anything.Last edit by Munch on Jan 5 : Reason: SpellingJan 6Always depends on the person, generalizations are never true. If a patient's family or friends are nurses it's helpful to ask about where they work or what job they do. Sometimes family members will say someone is a nurse, but the truth is that they actually do something else in the medical field. Sometimes they will be a nurse but work in another area of nursing and have no idea about what is happening to their family member and eventually the lack of control and lack of knowledge can cause them to overcompensate and be not so nice.Jan 8Good for you to remember the amount of stress the wife is likely to be experiencing and that this is likely to have had a direct effect on her behaviour. Tough as it is to hold your tongue, it is the kindest thing you could have done for both patient and wife in that moment. As a nurse, she likely felt that this foley insertion was the only thing she could control, everything else was beyond her control and, to some extent, beyond her grasp. Spouses/partners of patients who are health professionals stop being that health professional when they are dealing with the illness and/or death of their loved one. It is our job to remember that and treat them with the dignity, compassion and understanding we afford all patients and loved ones.Jan 9Like you said, these family members are stressed out from seeing their loved ones suffering and want to exert control within situations in which they have little control. Knowing this, however, doesn't necessarily make it any easier on the staff trying to care for their loved ones. Having a family member screaming in your face (especially one who thinks they know everything and wants you to do things exactly the way they would do those things) isn't helping anyone. There is a line between being an advocate and being so pushy that staff are irritated or nervous (and thus more prone to making the errors the family member was trying to prevent from happening in the first place). Sigh.
Sometimes I wonder if medical professionals are more prone to this type of behaviour because of our role as patient advocates. We also have medical knowledge and have seen things (or been a part of things) that have harmed patients. Add heightened emotions to this mix, and it's easy to see why these family members can veer towards being becoming "difficult."
In my experience, if the patient has a challenging family member, it is important to convey this to the charge nurse. The charge nurse can help by rotating assignments and offering support to the staff and the family member.
On a side note, I love when the patient aggressively proclaims that they are a doctor (telling anyone who will listen) and when you ask them what they specialize in, it turns out they have their PhD in a totally unrelated field (i.e. art history). Okay! Thanks for sharing with me that you are smart. But, I will still have to try and explain to you about this medication I am about to give you.Last edit by Simonesays on Jan 9 : Reason: spellingJan 9Maybe the poor woman was a better instructor when the patients weren't her own loved ones. Maybe she was just in pure melt-down mode and had no idea how she was coming across. I used to find it helpful (if I had time) to take these obnoxious family members aside and ask them how they were doing with all this. Sometimes it settled them right down to feel a bit cared about themselves and they became easier for everyone to deal with. Sometimes they were just PIA at baseline and nothing was going to change.
OP, it sounds like you're learning a lot and making the most of every situation. Kudos to you and wishing you a long, satisfying career.Jan 11Good job keeping it together and not going off on her I do not know if I could. "Here is his penis YOU do it!" Lol back to the unemployment line for meJan 26No, just no. I know that family members have a rough time coping with their loved ones and their illness. I've been there. But guess what? When my loved ones were hospitalized, I remained respectful of the staff and I didn't menace the nurses each time they walked in the room. It is possible to behave like an adult and treat people with common decency in the midst of a crisis.
But this woman's behavior was inexcusable? Disruptive at best and dangerous at worst. OP, you are better than I am. You DO NOT HAVE TO tolerate that kind of treatment. I don't care how upset this woman was/is. Your preceptor should have had you stop the procedure and then go get the charge nurse to have a gentle yet firm conversation with this woman. I feel like continuing this procedure under these conditions would open up a huge can of worms.
OP, you are not a doormat. It is possible to be respectfully assertive.
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