Twelve hours with nurse Esther Marania

[pickledpepperRN]

http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2003/11/09/CM69996.DTL

HEALTH CARE

California's first-in-the-nation nursing/staff ratio law goes into effect Jan. 1, 2004, meaning hospitals in the state will have to hire thousands of registered nurses. The law calls for one nurse to every six patients in general medical wards, and a 1-to-5 ratio by 2005. The objective is to improve patient care. But in the midst of a national nursing shortage, critics and supporters alike worry about how hospitals are going to comply and avoid penalties and costly litigation.

Statewide, hospital officials estimate the new law will cost hospitals $900 million a year. Jan Emerson, spokeswoman for the California Healthcare Association, said the mandate couldn't have come at a worse time. The state is providing no additional revenue to recoup the hiring costs at a time when 51 percent of hospitals are losing money.

The nurses union that sponsored the bill, however, credits ratios for improving patient care and reducing deaths in ICUs, which have had similar ratios since the 1970s.

"They've saved patient lives," said RN Jill Furillo, director of national affairs for the California Nurses Association. Furillo said 30 states are considering ratio laws similar to California's. The union blames the hospital industry for the shortage, saying they have replaced laid-off nurses with unlicensed staff, to the patients' detriment. "This law shows the shortage can be reversed. (Under the new law) whether you're in a rich or poor hospital, you're guaranteed an RN at your bedside."

Below is the story of one nurse's day in the trenches..

7:08 a.m. Friday

It's shift change at San Francisco General Hospital, and RN Esther Marania, who is beginning her 12-hour day, is busily taking notes on a sheet of paper that will serve as her patient cheat sheet.

Acting charge nurse Claudia Oates flips through a binder marked with colorful tabs representing patient room numbers. She rattles off the list of patients and their conditions: a man in Room 8 has a stab wound to the right flank; a 25-year-old in Room 9 has a bilateral mandible fracture and a swollen jaw; several doors down is a bridge jumper; a woman has an infected spider bite; an elderly woman with mental problems who loves oranges is awaiting placement at a long-term care facility; and a younger woman who overdosed on morphine needs dialysis.

The nurses seated in the Nurses Conference Room in Ward 5C are in their 20s,

30s, 40s and 50s. Their eyes are bright and alert.

Oates warns the team about an elderly Spanish-speaking man with alcohol- related dementia who last night used a door hinge as a weapon against one of the staff. He should have no sharp objects and is a high AWOL risk. The good news is the 38-year-old patient with AIDS has his appetite back and is walking on his own again.

The census on the unit today is 29 patients. It's a slow day.

Marania, 49, will have nine patients to share with her LVN partner.

Except for its Emergency Room and psychiatric unit, San Francisco General is already in compliance with a first-in-the-nation law that goes into effect Jan. 1 mandating that hospitals in California maintain a certain number of licensed nurses per patient.

The nurses on 5C like the new law because it means there will be more of them to handle the workload. The irony is that even though Ward 5C is already meeting the new standards, the nurses are constantly on the move. Coffee and lunch breaks are often skipped or heavily prized when they come.

The nurses ask a few questions, fold sheets of paper into pockets and they're off to gather more detailed reports at the patients' bedsides.

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Outside, the morning is overcast and chilly. The sun barely shows through windows. Inside Ward 5C it's warm, and at this hour still relatively quiet at the nurse's desk, save for the hiss of oxygen machines.

At Marania's side throughout the day is her LVN partner, Soledad Aquino. Together they are a tag team. Aquino, 35, is Marania's right arm, her safety net. One of Aquino's priorities is to be on alert for deviations in patient vital signs.

"Esther, I have Room 4," Aquino tells Marania.

"Thank you, Sol."

Marania enters her first patient's room, a man who speaks only Mandarin. He was a bystander who got caught in the crossfire on the mean streets outside the hospital. The man is awake, moving his eyes and arms, after having sustained a gunshot wound to the right side of his face. His vital signs are stable. The bullet penetrated his cheek and shattered his jaw before exiting behind his right ear. Doctors wired his jaw shut and sewed him back together. Marania is here to manage his pain. They communicate through made-up sign language. The only Mandarin Marania knows is the word for pain: tong.

"Tong?" she asks the man.

He nods, and holds up five fingers, touching the right side of his face. Marania decides he's comfortable enough for now. If it gets to seven or more fingers, she will give him more pain medicine.

In an adjacent room, a young woman, who the staff believes came in with wounds on her legs from injecting drugs, is complaining of itching underneath her bandages. The woman has been in the hospital since Sunday, and she's known for disappearing and being unruly with the staff.

"I need my itching medicine," the woman demands in a whining voice.

"It's not time yet," Marania says. The attention assuages the woman for now and Marania moves to the next patient, a man in his 50s who was hit by a U- Haul-type truck. His left leg was fractured; he has a history of diabetes and has signed the consent forms for surgery. His leg in traction, lying prone on a hospital gurney, a hospital worker wheels him out into the hallway and he is off to the OR. He will be back to 5C to recover later that evening.

7:54 a.m. Standing at the nurses' station, Marania opens her notes and begins to plan her day. Aquino will help her manage her more high-maintenance patients, such as the elderly woman with mental problems who loves oranges but won't get up to go to the bathroom without being reminded.

Marania doesn't have the luxury of focusing on one task. In her 23 years on the job - all 23 years on Ward 5C - she has learned to be patient and flexible.

"Mr. R wanted some pain medication," charge nurse Anita Enriquez tells Marania.

Marania hears shrieks of agony coming from Room 3. She finds doctors trying to remove the gauze packing on the finger of the woman bitten by the spider. The woman is writhing, digging her heels into the mattress of her bed, tears streaming down her cheeks. The doctors didn't notify the nurses in advance so they could administer pain medication before the procedure.

"Getting a morphine, darling," Marania says, walking quickly to a secured room on the ward where patient medication is stored. She punches her username and password into the Omnicell, a drug vending machine. The touch-screen device keeps track of which patient had which medication when and provides an inventory so the patient can be billed for the prescription.

Back in Room 3, she begins injecting the morphine into the woman's IV.

"It's going in, all right, darling," Marania reassures the woman. Once the syringe is empty, Marania puts her hand on the woman's shoulder. Slowly, the woman begins to relax. The doctors are able to finish their work.

8:08 a.m. Marania sits down to start care planning. She has time, given that Aquino is bathing patients and checking bedpans, vital signs and medications.

Raised in the Quezon City, a city about the size of Manila, in the Philippines, Marania immigrated with her parents to the United States in 1972, when she was 17. Her father, a math teacher, came first to the United States and decided the family could have a "brighter future" here. She has four brothers and sisters. Her mother, a home economics teacher, came later with Marania and her siblings.

Marania's elder sister, also an RN, nudged her into nursing school because she thought Marania didn't have a focus in life. Marania earned her associate of arts degree, worked for a time as a medical assistant, went to school in Los Angeles another four years for her RN license, and returned home to her parents in San Francisco, where she met her husband and began working on Ward 5C.

She quickly came to love nursing. "I started working here and found the patients made my day," Marania said. "They made me feel good. It also felt good to make a difference. I feel bad when I have to rush and be insensitive. I always explain that I am very busy and I will be back."

Working conditions have improved greatly since Marania started. In the 1980s, she remembers, it wasn't unusual to be in charge of 17 patients. "It was terrible," she said, ordering more medicines from Omnicell. "There was no patient interaction. All we were doing was pushing meds. There were no breaks. No dinner. You were lucky if you got 15 minutes to scarf your food."

With the ratios, "I find myself delivering better care," she said. "The new rules allow RNs to do the role of care planning."

But there is no guarantee everything will run smoothly. That depends on the patient's level of need and the busy-ness of the day. On "yellow alert" days - big fires, car accidents with multiple victims, when the emergency room is overloaded and diverting patients to other hospitals - Ward 5C is a blur of bodies, patients continually being discharged and admitted. It's affectionately known as "roller-skates time," Marania says.

A mother of three kids, two college-age and one in high school, Marania is looking at another 10 years in nursing before she can retire. By then, her youngest will be finished with college.

She earns about $78,000 a year, plus benefits, which include education days, floating holidays, four weeks of vacation accumulated after 10 years' service, and six longevity days. She's been married to the same man for 21 years, Rolando Marania, an operations specialist for Charles Schwab. They own a home in Daly City. Together their salaries are "just right" to support a family of five, put their children through college and have a little left over for her shopping habit - clothing and household items at Macy's.

8:29 a.m. "Seven Bed 1, Esther," a voice sounds over the intercom.

Marania knows Seven Bed 1 is the woman with leg wounds from shooting up. She has a high tolerance for pain medication. Once in the room, Marania decides to give her a little more morphine. A phone at the adjacent bed is ringing. That patient is sleeping. Marania wakes the elderly woman, saying, "Breakfast is here."

"Tell the doctor it's not enough,'' the younger woman with the leg wounds says in a shrill voice. She says her leg is still itching, a side effect from the morphine.

Marania goes into the drug closet and enters her user name and password.

"Let me pull a Benadryl,'' she says, speaking to herself. A drawer pops open and there's one vial with the anti-itching medicine.

8:44 a.m. Marania is back in the Room 7, where she helps the woman with the leg wounds urinate and checks her dressing. "You have to pull down your panties," she tells the woman, now behind a privacy curtain. "If you want to wee wee, you have to pull your panties down."

"I gotta do it on my own time," the woman says. "My daughter is nicknaming you Cheery," she said, pausing to pull her panties down. "She's into cheerleaders, and you're always so cheery."

Marania smiles.

8:50 a.m. Back at the nurses' station, Marania picks up a ringing phone. On the other end is "Miss Diana," a nurse on maternity leave who reports she is expecting twins and had to be admitted for observation. Somebody is bringing a flyer by Ward 5C so people can attend a baby shower.

8:55 a.m. Marania glides across the linoleum like a hummingbird, back to the room with the woman who has the spider bite.

"Did you have soup?"

"Yes," the woman says, with a grimace on her face. She vomits into a pink tub. The morphine, while keeping her pain down, made her nauseous.

"Lord have mercy, I came right on time," Marania says.

Marania helps the woman up to use the bathroom.

"I'm hungry," the woman says.

"You can't eat right now," Marania tells her. "It'll come right up."

9 a.m. Back at the nurses' station, Marania answers the phone, "Good morning, 5C, Esther."

She turns to a woman near the copy machine behind the desk, "Did you page somebody, Lisa?"

"Yes," the woman, a social worker, responds.

Marania notes the patient's vomiting episode on a form made especially for people with alcohol withdrawal. She found out the woman drinks a lot of beer on the weekends. She must be monitored for signs of withdrawal every four hours and, if necessary, given medication.

9:05 a.m. "Darling," Marania tells Aquino, holding the pink tub with the woman's vomit, "We have 300 ccs of bile material."

After disposing of that task, she begins preparing her patients'

10 a.m. IV meds.

"Thank God for new innovations," Marania says, mixing IV medications with a new contraption that minimizes the chance of error. "Twenty years ago, there were five steps to doing this,'' she says squeezing an IV bag filed with saline solution, which mixes with powdered antibiotics, making a squishing sound. "Imagine the errors that used to happen with so many patients. With the new ratios, we're not as overwhelmed with a lot of information at once. It works beautifully. It allows you to interact with the patients."

The man in Room 6, with the gunshot wound to the face, has finished his juice. Marania makes a note in his chart.

9:29 a.m. The patient with the spider bite, much calmer now, slowly sips her milk and takes a few nibbles of French toast with syrup.

Two and a half hours into her shift, Marania hasn't had a moment off her feet.

9:50 a.m.Time for a break.

Inside the Nurses Conference Room, head nurse Enriquez brought a homemade cheesecake to share, but she forgot to bring plates. Marania goes to her locker for paper plates. When she returns, she munches on pineapple bread and decides to have some cheesecake later.

"The nurses use up calories here," Enriquez says with a chuckle. "Whatever's on the table gets eaten to replenish lost calories."

The nurses talk about how at the end of a 12-hour shift, it's not uncommon to be so sore you feel like you want to cut your legs off.

There are a lot of sore legs in Marania's family. In addition to her older sister, her sister-in-law and her niece are nurses. Marania said she feels satisfied by her job because she is helping alleviate people's pain. She is frustrated on the days she can't attend to every patient the way she would like to. "On those days, I wish I had more time."

It's a challenge some days to remain upbeat, cheery.

Her youngest son recently was expelled from high school for participating in a prank in which he and his friends took pictures they shouldn't have been taking. It's weighing on Marania's mind, but she has honed her ability to separate work from home life.

10:09 a.m. Time to review doctor's orders. She grabs the green binder that contains the patient charts. The blue one contains care plans and the red medications. She learns one of the doctors didn't sign off on a patient's IV. She will have to follow up with the doctor.

10:13 a.m. Marania tries to determine whether one patient can take antibiotics orally to avoid having to stick him with a needle another time. The man has an infection on his leg that has spread to his bloodstream.

In Room 7 a patient with respiratory distress has had a bowel movement in her sleep.

"You didn't know you went?" Marania asks the woman, in a gentle voice.

"Uh-uh," the woman responds, with the sheepish look of a child who has been caught making a mistake.

Marania puts on green surgical gloves, gets a package of moist towels, draws the privacy curtain and begins cleaning the woman. She thinks out loud. Maybe the stool softener the woman is taking is too strong. She puts the soiled linens in a laundry bag, wipes the seat of the bedside toilet, measures the woman's urine and calls for the porter to come clean up.

10:25 a.m. The family of the man who was hit by the truck arrives to check on their loved one's status. Marania tells them he should be back from surgery by 4 p.m. The family thanks her, and Marania takes a few minutes to do some charting.

"Esther, 3-2" a voice bellows over the intercom.

Marania knows instinctively it's Mrs. C, the elderly woman who loves oranges. The hospital is "baby-sitting" Mrs. C until she can get placed at a long-term care facility.

"My goal is to manage their pain, keep them comfortable," Marania says. "I have to remind her every two hours that it's time to use the bathroom, or she will go in her bed."

10:45 a.m. The doctor is coming at 11 a.m. to check on the gunshot wound patient. Marania orders a Mandarin interpreter for the man. "What is today, Friday?" Marania asks, as she makes a note in a patient chart.

Marania is back in Room 3. The scent of citrus hangs in the air. The

lady wants another orange. Mindful of the fact the woman is diabetic, Marania tells her this is the last orange she's getting for a while. The lady smiles, thanks her and begins peeling the piece of fruit.

She tells the woman with the spider bite she would like to see her walk around later on. A young man who crashed his bicycle into a pole is not scheduled for surgery until the following Wednesday. A relative has asked whether he can be discharged and come back then, but Marania tells the woman the doctors want to keep him under observation. His cheekbone is fractured, and it could get worse.

10:52 a.m. "Good morning," Marania says, entering the room with the young woman who overdosed on morphine. The woman tells Marania she collapsed on her arm and was unconscious for several hours before a friend found her.

"I haven't been sleeping well," she tells Marania. Marania asks how she got hold of the drugs.

"I was being stupid."

"How did you get ahold of that?"

"On the street. I was being stupid. I didn't know how much to take."

"Why did you take it?"

"I was just being dumb."

The woman can have only one liter of water per day. Her kidneys went into shock from the overdose, and she needs dialysis.

"Let me know what we can do for you in the meantime," Marania says. "We're limiting your fluid intake because they're dilating you."

"Take a deep breath," Marania says as she holds a stethoscope to the woman's back.

"Any problems with the bathroom?"

"Nope. I pooped this morning."

Marania folds her patient cheat sheet into her pocket.

She learns the hospital interpreter service is backlogged and the Mandarin interpreter may not make it in time for the doctor to check up on the gunshot wound patient.

11:13 a.m. The interpreter arrives and Dr. Hop Le and Marania take him to the Mandarin-speaking patient's room. The doctor explains that he will have his jaw unwired and have rubber bands put in place so he can begin to eat solid foods. The repair was complicated and he may not have a perfect bite, but all the bones were reattached. The doctor's pager goes off. He asks the patient if he has friends or relatives to contact. The patient gestures for pen and paper and writes down a number.

11:24 a.m. Time to change the dressing on the man with the blood infection. Marania catches the man shuffling down the hall toward his room, IV in tow.

"Where have you been?" Marania, smiling, asks the man, who has been gone more than an hour. "You didn't go home and come back, did you?"

The man says he was out getting exercise. She notices one of his shoelaces has come undone.

"Watch your shoelace; you might trip and fall, darling."

The man is in bed and she begins checking his wound dressing. His IV has come out of his arm and she has to find a new vein to reattach it. She puts a tourniquet on the man's arm and begins feeling for a vein.

"Make a fist," she tells the man, "Not so hard."

She wiggles the needle into the man's vein. "Hurts?" she asks. "A little bit," the man says. She notices a lot of backwash - blood coming into the IV.

She begins humming.

"The catheter kinked," she tells the man. "No good. We'll try one more time. " She puts a pad down on the man's lap to prevent blood from getting on his bedding. "I'll be right back."

She has another task, runs into Aquino in the hall and asks her if she can try reinserting the man's IV. Aquino says she will handle it.

11:42 a.m. For lunch, Marania has brought leftovers from home - eggplant torta, rice, salad and a medley of squash, coconut and shrimp. The chatter runs from the gubernatorial recall election to getting exercise away from work.

Opinions flow.

Marania explains to a visitor that at a teaching hospital such as General, nurses have to go behind medical students and check their orders. It's especially acute in June with the wave of new students. "It changes every 10 minutes," she said. "Some of the stuff is really off the wall, the wrong dosages. We have to call to correct and it creates delays. The doctors aren't always reachable."

Marania is patient with the fledgling physicians. She once was a new nurse. She said she's grown a lot in the past 23 years. When she started, there was no formal orientation for nurses. Now, new nurses are paired with seasoned staff for 10 weeks. "I was dumped here from school one day and I had to learn hands on through making mistakes and through patient care. Real world."

After 23 years, she said she's able to foresee her patients' needs. She is also more tolerant. "I learned to anticipate what they are looking for and when to intervene," she says.

One of her greatest accomplishments, she said, is being able to impart her knowledge on new nurses in transition.

12:39 p.m. Marania confers with Aquino about a patient's penicillin and whether all the finger sticks that need to be done to check glucose levels have been done. Aquino is on top of things. "Having an excellent LVN makes your work a lot easier," Marania says after Aquino leaves the room. "Good communication should be there or it's a problem."

12:43 p.m. Aquino goes off to lunch. During her hour break, she will steal a catnap in her car. Scurrying to the medication room, Marania exclaims, "There's my premixed penicillin. Hallelujah!"

12:53 p.m. The man who speaks Mandarin is awake and has had the wiring taken out of his jaw. Marania asks about his tong. He holds up six fingers. She notes that he finished his soup. "Good job," she says.

Marania has been lucky in that she hasn't been seriously injured on the job.

She has only been stuck once by a needle. "Accidents happen if you're not paying attention," she said. "If you're rushing, doing a lot of things." She slipped and fell once in a puddle of water on the floor. She took a couple of days off and applied an ice pack to her bruised hip.

1:08 p.m. Back in Room 3, the lady is asking for oranges. Marania tells her they are all out of oranges. The spider bite patient in Bed 1, has one she doesn't want and gives it to the older patient, who smiles at the gift. Marania offers to cut the chicken breast sitting on the tray table in front of the woman with the spider bite. The woman can't handle a knife because her left hand is bandaged up. "It's pretty tender," Marania tells the patient and she cuts the meat, covered in gravy, into bite-size pieces. "It cuts nicely."

Back in the Room 6, the man with the gunshot wound to the face is experiencing pain at the site of his IV. "I'll slow it down," Marania tells him, although he clearly can't understand what she is saying. "The medicine is strong." She records on her cheat sheet that he finished two soups, lemon sorbet and two juices.

1:35 p.m. Back at the nurses' station, Marania is charting amidst a din of phones ringing and doctor conversations. Two CHP officers are using a phone behind her, discussing a patient who is under arrest. Marania hurriedly adds signatures, shorthand and initials to her records. The secretary is absent this morning. Marania is the only one answering phones. A patient walks by in pajamas that are hanging off his body like they would off a scarecrow. Marania rifles through the pocket of her coat, which has antibiotics, straws, pencils and pens in it. A Spanish-speaking social worker comes by to say hello.

"Good afternoon, 5C, Esther," she says, answering the phone. She learns the patient who ran his bike into a pole will have surgery Monday instead of Wednesday. She pages a nurse over the intercom to have a patient transported to X-Ray.

"This is a good time to do charting," she said, unfazed by all the activity.

One of the frustrations of her job is that the pace is so fast sometimes, she doesn't always have time to delve into a patient's history. Some have multiple problems. "It's important to know the origin," she said. When she gets a break,

she tries to look back in the patient charts.

1:41 p.m. The phone rings. It Marania's daughter, who says she's going to pick up her younger brother at 3 p.m. She also tells Marania she's going to Costco and asks what she should add to her list? Toilet paper and Kleenex.

Marania can catch her breath. The patients are fed and the man in Room 6 is resting. She practices the lecture she is going to give the woman with the leg wounds who left hours ago to go smoke a cigarette with another patient and never returned. Moments later, she walks down the hall, adjusting her bun. There's a pillow shortage. She's looking for a pillow for a patient.

1:54 p.m. Back in the room with the patient who only speaks Mandarin, Marania increases his pain medication.

2:30 p.m. Head nurse Enriquez is leaning on a cart full of charts. She's rubbing her eyes, and her shoulders slump. Marania disappears into the secured medication room.

"She's one of the best nurses in the hospital," Enriquez says of Marania. "She's in charge when I'm not here, and I don't doubt for a second that things will run smoothly. She's excellent with patient care. She is also very good with the doctors and families."

The rest of the afternoon, Marania attends to her patients' pain management,

she battles with the woman with the leg wounds who refuses to allow her to change the dressing on her leg and welcomes back from surgery the man in his 50s who was hit by the truck. The man's family arrives and is relieved he came through surgery OK. Marania sees that he has his dinner. He's well enough to eat solid food. Marania and Aquino monitor a drainage tube that is preventing fluid from building up around the site of his surgery.

6:39 p.m. Marania is back in Room 3 with the woman with the spider bite.

"Are you still nauseous?" Marania asks the woman, who has made a bandana out of a pillowcase to keep her hair in place.

"Not that bad." the woman replies. "The Jell-O helped."

6:55 p.m. Marania begins filling out her intake/output records, signaling that the end of her day is nearing.

Back in the room with the woman with the leg wounds from injecting drugs, the patient has to go to the bathroom. Marania helps her get up. Earlier that evening, the woman fought for 45 minutes while nurses tried to change her bandaging.

"She had her way," Marania recalls later.

"Joy, can you get me my cell phone and battery charger?" the woman asks, from behind the bathroom door.

"Who's Joy?" Marania answers. "My name's Esther."

"I'm sorry, can you bring me my cell phone and charger?"

Unfazed by the woman's faux pas, Marania goes to the bathroom and tries to fix the woman's IV that has stopped pumping fluid.

"Just press play," the female patient says.

Marania laughs. "Just press play," she repeats.

Aquino tells Marania Mr. R wants to sit up on a chair. He's moving his bowels normally.

7:04 p.m. "Thank God it's 7 o'clock," Marania says with a sigh. "It's almost time for me to go."

Enriquez tells Marania that the Spanish-speaking old man who used the door hinge as a weapon wants scissors so he can cut his hair. The three meet up at the nurses' station.

"It's prohibited," Enriquez says.

In Spanish, Marania offers the man several Bic pens. "Mi regalo (my gift)," she tells the man. The man opens a paper towel he had stuffed in the waistband of his pajamas and puts the pens inside and refolds the paper towel.

7:24 p.m. The sun has set. The ward is dimly lit.

Marania reports to the RN/LVN team that will take responsibility for her patients during the next shift. All her patients have pooped, relaxed and had dinner. She closes her purple binder, her charting finished.

The 33-year-old patient who came in with the morphine overdose is getting her electrolytes back on par, the Mandarin-speaking man is drinking well and his morphine is keeping his pain to a minimum. He's doing so well doctors may discharge him tomorrow. The woman with the leg wounds who has frustrated the staff is well enough to go home.

"She needs a lot of TLC. Poor thing," Marania tells the nurses.

7:38 p.m. Marania says goodnight to Aquino.

"Thank you, darling."

And the two go their separate ways, down the halls of Ward 5C.

Christopher Heredia is a Chronicle staff writer who reports on health and fitness. E-mail him at [email protected].