The weekend between the call for a repeat mammogram and the actual appointment passed quickly.  I stayed busy with family to keep my mind away from the unknown.  Being a person who compartmentalizes emotions, denying anxiety was easy to do.  So, it took my by surprise when my sister and friends rearranged their schedules to escort me to my appointment.  I told each of them that I could go alone.  After all, it would be panicking if I brought along a companion, wouldn't it?  I wasn't sure what to do.

On Sunday, however, I received a blessing.  A mom, Kay, at a birthday party my daughter attended happened to be a Technician at the very Breast Center I was to revisit.  We talked, a lot.  She eased many of my fears and promised to be there with me every step of the way on the day of my exam.  She even confirmed that bringing a pal was not a bad thing.  I went home happy, relieved and armed with information to get me through the next couple of days.

Wednesday came quickly.  I told everyone, especially myself, that I would be in and out of there after a few pictures.  I was so sure that I sent my husband off to work and brought my sister to the appointment, mostly because she insisted.  (Truth be told, I was more than thankful for her persistence.)  Before we went inside, I looked at her and said, "We will be back in this car by 9:40, guaranteed."

I signed in at the desk and waited.  My heartbeat stayed steady.  My sister and I even noted that I was not the only person who brought along support. 

Kay greeted me with a warm smile.  As she showed me the original pictures and the "area of interest", my palms began to sweat.  There was something there.  Even I could see it.  But what was it and when would I know?  I took a deep breath.  It was going to be okay because it had to be.

After the pictures, which a little more uncomfortable than the first time, I had to wait.  No big deal.  Kay had told me the Radiologist needed to review the films.  I got ready to get dressed.

Kay then reappeared.  She was not smiling but she wasn't exactly frowning either.  I needed to go to ultrasound.

In my head, I heard the words again, "Do not panic."  My heart didn't listen, it began beating a few beats faster.  I smiled at my sister, more thankful than ever to have her there.

Ultrasounds are strange tests.  So much of what appears on the screen looks like a blob of nothing.  And mostly, that's what I saw.  Kay pointed out numerous structures and differences in brightness, but she never said anything about one large black spot that kept reappearing on the screen.  She stopped, measured, marked and frowned.  I reached for my sister's hand.

I did not panic.

A few more swipes of the transducer and the black splotch became front and center.

"I think that's a lymph node," Kay said.  "The Radiologists prefer to see an ultrasound in real time.  I'll be right back."

I panicked.  Sobs escaped me before I had the ability to control them.

"Is that normal?" my sister whispered.

"I don't know!" I wailed.

"It will be okay.  It has to be."  My sister stroked my face.

"I'm fine.  I'm fine.  I need to pull myself together."

The Radiologist, entered the room.  I felt like a fool shaking his hand with my sweat soaked palm.  He nodded and touched my leg softly.  

"Do lymph nodes belong in breasts?" My voice was shaky.  I didn't care.

 Both he and Kay nodded as she continued probing my breast.  When she stopped at the node, this time she talked about it.  The node had a perfect kidney bean shape with a distinct lighter color in the middle.  Blood supply was normal in and around it.  The spot on the mammogram was this lymph node we were viewing.

My whole body relaxed.

The Radiologist asked me a few questions about my family history and then reassured me multiple times that I was fine.  As a matter of fact, he did not see a need for follow up in six months, unless something changed.

Finally, I was relieved.

After I was dressed, Kay escorted me to the exit and I hugged her.  There was no way for me to thank her for her kindness.  

My sister and I got in the car and let out huge sighs of relief.  We even laughed for the first time that morning when we noticed the time.  "9:47," she said.  "Only seven minutes past your prediction." 

It took me a few days to recover mentally, but when I did, I knew I had to share my story.  Once I started talking about it, many women came forward with their own stories of angst.  And each one made me realize that none of us have to go through this alone.  

My doctor informed me this summer I was of age to receive my baseline mammogram.  He paused for a moment in the hallway and glanced into my eyes.  "You've always had lumpy breasts, right?"

I nodded.  Before he closed my chart, I caught a glimpse of a circle he had drawn on an image of a breast.  I swallowed hard, but decided he would have told me if he thought something was wrong.

A few months went by.  I was sorting through some papers and found the form my doctor's office had given me regarding my baseline mammogram.  The kids were back in school.  I now had the days to myself.  It seemed right to schedule it.  I even chuckled to myself when it was booked for October, Breast Cancer Awareness Month.

 The exam itself was  quick and painless.  The environment was warm, relaxing, and inviting.  The technician educated me about breast health while positioning my body for the x-ray and again when showing me the pictures she had taken.  As she pointed out various details she said, "Do not panic if we call you back for more.  Dense breast tissue, which is common at your age, can be difficult to see through."

 As I drove away, singing the song on the radio, I made a mental note to tell all women mammograms are easy.  I was in and out of the Breast Center in less than 20 minutes.  By the time I got home, I had already forgotten all about the exam.

A week later, while I was running around getting ready for work, my cell phone rang. 

"I'm looking for Lorettajo," the voice said.

I groaned.  Why did telemarketers have to be allowed access to cell numbers? Isn' t anything sacred anymore? "This is Lorettajo.  Can I help you?"  I fought to keep the aggravation out of my voice.

"Hello.  This is "M" and I am calling from the Breast Center."

I froze.  This was not a telemarketer.

"Now don't panic, but we need you to come back for closer examination of a thickening we found on your mammogram."

"Okay...."  I inhaled deeply.  I was NOT going to panic, because she told me not to.

"Are you available next Wednesday?"

"Next week isn't good for me.  How about the following?"

She cleared her throat.  "Um, there is no need to worry, but we would like to see you next week."

Okay, now I might panic, but I can't because she said so.  "Fine, yes, Wednesday 9am is fine."

"We will see you then.  And Lorettajo?  Don't panic.  Have a good day."

As I hung up the phone, I nodded, even though no one was there to see me.  Glancing at the clock, I realized I really needed to get going so I wouldn't be late for work.  I threw on some clothes, ran out the door and began the 20 minute drive to work.

Somewhere between home and work, pictures began flashing in my head.   First, I saw the diagram of the breast that my doctor had not mentioned.  Then I thought of my friend "J" who had also been told not to panic.  He (yes: HE) has been breast cancer free for 11 years now.  My kids, husband and entire family danced in my mind.   And then, my chest began to ache.  Deep breaths did not make the feeling better.  I reached for my cell phone with no idea who to call.  My husband was away on vacation with his friends and if I called anyone, I would most certainly panic.

I was not going to panic.

But then, I did.  Sobs of fear wracked my body as tears flowed freely down my face.

I am an ER nurse.  Someone who is trained to always prepare for the worst case scenario.  Someone who is witness to both triumph and tragedy on a regular basis.  Someone who has told many not to panic when indeed the worst was yet to come.  

Somehow, I pulled myself together and walked into work with a smile on my face.  Secretly, I Googled a few websites for more information and found great comfort in knowing that this WAS, in fact, very common.  The wave of panic that had surfaced slowly ebbed away.  My only hope was to keep it there until I had concrete answers.

Stay tuned to find out the results of my repeat mammogram.

I have been following the first season of Nurse Jackie closely. Not only am I enjoying the show, but I also find the heated debate around it very interesting. Ainsley Maloney's  coverage of the show at Advance Perspective has had great comments, as well as Suzanne Gordon's website.  

The show has brought the reality of drug addiction right to the forefront of my mind, as well as the many alleged drug related deaths that have happened this summer, including Michael Jackson, Billy Mays and now DJ AM (Adam Goldstein).

But what really blows my mind is the number of medical professionals abusing Diprivan/Propofol.  I was shocked when I saw a clip about it on CBS.  I had no idea that anyone would use this drug on themselves, so I began doing a little research myself.

According to one article from Anesthesiology News in 2007, the fatality from even one time use is as high as 40%.  And the numbers of professionals using the drug was even more alarming.  And apparently, the numbers are rapidly climbing. 

So how come I didn't know about this?  I administer the drug on occasion and am scared every time I do.  Not only does it decrease respiratory effort, but it can drop blood pressure and heart rate.  I am required to have resuscitation equipment near by at all times, just in case something happens.

Maybe Nurse Jackie is happening at the right time.  We should no longer hide the fact that drug addiction is real and dangerous.  By talking about it, maybe we could find some answers. 

 Have you had experience with a drug addicted co-worker?  Was the situation talked about in your place of employment? Is there a way for us to support each other in times of distress?

Most insurance companies require a copay for different types of appointments, including ER visits.  This seems reasonable enough, and most of the rules, depending on the particular policy make sense.  But now that the hospital I work in attempts to collect these copays before discharge, the inequalities of our health care system are becoming more clear to me.

Every ER has what staff call "regulars."  These patients come in day after day, sometimes more than once a day for something-usually pain medication.  Other regulars seek food, shelter or want human companionship.  And still more come in under the influence of drugs or alcohol.  They do not have a copay because they are uninsured.

Now, take the family who has brought their son in after he fell off the swing.  It's swollen, bruised and painful to the touch.  It may be broken or sprained.  Most doctor's offices do not have X-ray machines or the ability to fix a broken bone.   This family needs to be in the ER.  They will be asked for a copay prior to discharge.

Why does this bother me?  Well, for one, I see so many parents stressed because they can't pay the copay.  They weren't planning on visiting the ER, unlike a doctor's visit that is scheduled.  And many didn't know that their insurance company requires a copay for visits to the ER.  They assumed that because they have insurance, everything is covered.  Now they are starting to worry that none or little of the visit may be covered.  Forget the broken kid...how are they going to pay for this?

And it delays discharge.  Everything about the ER is waiting, something many people don't realize.  During busy times, everyone waits to be triaged, and then to be seen, and then to be treated.  After treatment, we discharge the patient home, if appropriate.  Prior to discharge, however, I now have to wait for the copay to be collected.  Again, the families wait.

On the hand, if people knew they had a copay to visit the ER would they take it more seriously?  Would they begin to redefine reasons to come in?  I doubt it.  The ones who abuse the system rarely have to pay for it.  And the purpose of the copay is not punishment, but a way to help offset the cost of care delivered.  Collecting copays is one way for our department to increase revenue.  And I am hearing that it's working.

I think what bothers me is the fact that I am a nurse, not a cashier.  No, I am not responsible for the exchange of money, but I do have to let the families know why they are waiting.  And the look of additional distress on their faces rips me to shreds.  The ER, for most is not a pleasant experience and now they have a financial burden to bear, on top of a health related one.  It does not make sense to me, especially when I see so many people flow in and out of that ER without needing to fork over one dime. 

I wonder, how many other ERs collect copays?  And how does it work for them?  How do you feel about it?  And if you are a patient, do you expect to be charged while still in the department?  I'd love to hear thoughts on the subject.

I ran through the door at 3pm, a few minutes late.  The hallway was filled with stretchers and wheelchairs holding patients that had been waiting for hours.  The air was warm and thick; the air conditioner had apparently malfunctioned again.  I swallowed my urge to run out the door into the fresh air and weaved through numerous EMTs/Medics and ER staff to read my assignment.

On this day, I was placed in a smaller section of the ER.  It has a wall that blocks off much of the chaos in the surrounding department.  I sighed with relief when I entered and saw it looked somewhat manageable, at least for the moment.    Plastering on a smile, I forced myself to believe that today was going to be a good day.

 It did not start that way.  Right away, I felt my body tense with the pressure of many tasks.  One admitted patient had a low blood pressure.  Another needed treatment for chest pain.  Yet a third need to go to the bathroom.  Within minutes, my smile was gone. I wanted to throw my hands in the air and quit, but I didn't.  I trudged through, as best I could, knowing that everyone in the department felt the same way: frustrated. 

And then, a hush fell over the department.  The only thing that could be heard were the muffled words of a paramedic via our radio system.  Everything stopped for one split second.  The charge nurse then rolled into action and prepared the trauma room for a pediatric cardiac arrest.  The most senior nurses were pulled into action.  I was one of them.   

Over the years, for one reason or another, I have managed to avoid such a situation.  So, here I was, an experienced nurse, doing something for the first time.  Everyone prepared for the worst case scenario, because  when when the medics are busy working on the patient and don't have time to give a full report, we don't get a lot of information.  So, we get every possible piece of equipment ready, just in case.

I wasn't nervous; I was ready.  (I think that's the bonus of experience.)  When the child arrived, everyone jumped into their designated role.  The team was a well oiled machine, working on a tiny patient who never really had the chance to live.

 After all efforts were exhausted, the pediatrician called the end of the code.  The family was brought over to the bedside. 

Piece by piece the equipment was put away.  Paperwork was completed.  The trauma room emptied out.  I took a deep breath and returned to my assigned patients with damp eyes and a heavy heart.  

As I rounded the corner, pats on the shoulder and words of encouragement gave me strength.  I couldn't help the child, but I could help those who lay in the beds nearby.  So I took a deep breath and smiled. 

"What do you think of that book you're reading?" I asked the patient who had been irritable just prior to the event. 

She began talking.  By the time she left, she was happily thanking me for the great care she had been given.  Even the patient next to her thanked me a million times after discharge.

I don't know if the knew what transpired in the trauma room; I doubt it, because they didn't ask me about it, as patients frequently do. But they certainly responded to my change in demeanor.

And that's when I realized why I haven't yet thrown up my hands and quit.  I love what I do.  So many departmental changes have left me frustrated.  Overcrowding in our ER has taken its toll, but I can't yet walk away.  I have to believe there is hope, especially in the face of tragedy.

There are few TV shows or movies that I can watch and not writhe in my seat at the way medical drama is portrayed.  Even ER got on my nerves after a while; but My Sister's Keeper did not.  I was swept away by emotion and nearly forgot that I was a nurse watching a movie.  And, as an avid reader/aspiring writer, I also tend to notice the obscure things about storytelling as well.  But the only thing I noticed with this movie was the unbelievable way it made me cry.

 I am not a professional movie critic, but I do know the "look" that the dying wear.  Sofia Vassilieva, Kate, hit it right on.  Her eyes echoed the sentiment that many people today are unable to recognize.  She didn't say much, but that's because she didn't have to, or maybe, like those dying around us today, couldn't. 

Actually, silence was a powerful tool throughout the entire movie.  Many scenes were not heard. You watched them.  It reminded me of how often I avoid being quiet and that noise covers up so much that I don't want to feel. 

Later that day, I went to work. I was still fuming at my inability to do something that so many people had expressed as easy. I received report only to find out that this one family was refusing to allow us to perform any procedures on their ill child. I shook my head and sighed. I didn't know if I had the energy to deal with this after my frustrating ordeal at home.

It took a lot of effort, but I put it all aside, forced a smile and entered the room. The air was thick with hostility. Both family members glared at me. The child was alert, her cheeks flushed with fever. She was sick, but holding her own. Her fussiness was apparent, as was the fatigue the mom was feeling. My heart softened and I knew we had to find a way to help this family.

I began speaking and was bombarded with questions of why and how come. I tried very hard to explain the rationale of the ER team. It didn't work, at first. So, instead of just walking out, I sat down on the bed next to the primary caregiver. We talked, a lot; I explained big medical terms and acronyms repeatedly. We compromised by discussing what she was comfortable with allowing and what I was comfortable with letting go. It wasn't going to be the ideal care situation, but it was most certainly a place to start.

The next day, when I sat down at my computer to again try to make sense of web design, I thought of this family. I remembered their frustration and anger and realized it was no different from mine. I speak the medical terminology language. They don't. So, essentially, they were hearing big words and acronyms they did not understand. I was experiencing the same thing, just in the computer world.

They came back a few days later. I was happy to see them, despite their higher level of frustration. But this time, I approached the situation differently. I understood their anger; I had felt it too. I realized that they didn't even know how to ask questions in regard to their feelings, because they couldn't vocalize what they needed to hear. The hospital was a foreign land; they were lost, and unable to navigate. It was my job to act as an interpreter and give them a few tools to find their way around.

In the end, I used an interpreter too. My brother is a computer software engineer. He helped make sense of the terms I was seeing. My website is up and running. I understand more than I ever thought possible. And, I realized that the culture of nursing is so integrated into everything I know that, at times, I forget to act as an interpreter. It sounds basic, but I think that is one of the hazards of experience. I am so fluent in hospital lingo that I assume everyone is, until a ‘difficult' family challenges me.

So, the next time I am faced with hostility I know I will be different. As hard as it can be, I will try to hear what they are saying before I attempt to translate what I need to say. And, I will be easier on myself. Learning a new language is hard, but worth it. And maybe, just maybe, I can make a difference in how someone perceives the foreign land of hospitals.

Earlier this month, I wondered what it was going to be like in the ER without being able to divert ambulances. Right after I wrote that post, I went to work. It was a Monday. According to the nurse in charge that day, we had the highest acuity and census ever, and we survived.

I walked through the door that day skeptical and concerned. Quickly, I was filled with pride. A Physician's Assistant (PA) was in the waiting room. He was seeing, treating, and discharging patients behind a screen. It seemed, at first, so antiquated to me, but it served a purpose of moving patients through quickly.

The afternoon progressed and in the end we needed to resort to "Code Help." This is our version of a hospital wide response to high census in the ER. So, instead of depending on other hospitals to bail us out, we look into our own facility. Administrators become involved. Beds are forced open and nurses from ICU/Intercare are floated to the ER to care for critical patients that have no beds.

From an ER point of view, "Code Help" is a godsend. Barriers that we had become so used to dealing with have now been obliterated. Floor nurses can no longer refuse report. Beds can no longer be hidden. Other staff from within the hospital will see why ER patients come up to their floor in the state they do. The ER is no longer silently suffering.

The change can even be felt on ‘normal' days. Our patients are moving to their rooms faster than ever before. It doesn't feel like we are holding as many patients, either. I know they are happier; as am I. This change has freed me up to do what I love best: Emergency Nursing.

But, still, it all leads me to wonder what it must be like now on the floors. I was once an inpatient nurse. I remember dreading a patient from the ER and the amount of work that came with it. I remember a time when I never wanted to function in the emergency an environment. And, yet, at times, that is exactly what they, the floor nurses, are going to be forced to do.

The other night, I worked with an Intercare nurse who was floated to the ER. She said she felt useless. She didn't know where we kept supplies, how we got our medications, or even how to go about charting. It was in that moment that I realized a little bit of planning on the administration's side could maybe have softened the blow. If we were going to force nurse's to work in our area, wouldn't it make sense to help them?

I tried my best to make this nurse as comfortable as possible. I wanted her to know that I appreciated her presence. Her knowledge of inpatient care was a relief to me. I did what I could to help ease her anxiety, but I don't think it helped her all that much.

Cautiously, I am breathing a sigh of relief. Maybe the horror of ER overcrowding can be changed. Maybe the answer can be found in the form of a law. And maybe, just maybe, the patients I'm nursing will get the care they deserve. I guess only time will tell.